Demand for Care Spurs Action

Sunday, January 10, 2016
Recent growth in long-term care needs — and Medicaid spending to support it — prompted passage of a law in New Hampshire to turn to outside “managed care organizations” to rein in spending and improve care inside and outside of nursing homes.

That raises the question whether managed care organizations will be better able to coordinate those patients’ use of various services than the case managers and care coordinators who now play that role as state employees, said Steve Norton, executive director of the New Hampshire Center for Public Policy Studies.

New Hampshire, along with 37 other states and the District of Columbia, already has tapped managed care organizations to oversee most of the rest of the care and spending supported by Medicaid.

Managed care organizations, or MCOs, are similar to health maintenance organizations. They typically get paid a set amount for each Medicaid recipient whose care they manage, and organize networks of caregivers from which those recipients generally must receive care.

More than 160,000 Medicaid recipients in the Granite State now have care “managed” by one of two organizations: New Hampshire Healthy Families, a unit of the for-profit Centene Corp., and Well Sense Health Plan, which is part of the nonprofit Boston Medical Center Health Plan.

The changeover that would give the MCOs a role in managing long-term care tentatively is scheduled for July 1.

That date doesn’t seem realistic, but some sort of change is needed, Norton said.

“There is no question that a more coordinated system that creates incentives to keep people in high quality, low cost places” would help, he said. “You don’t want people in the hospital when, with two hours of nursing care a day, they could be home.”

The managed care structure — which seeks to assign to a single manager decisions about a patient’s health care needs and spending — could help with that, said Jennifer Farnham, a senior research analyst at the Rutgers University Center for the Study of State Health Policy. “I think the hope is that because they own the whole patients — acute care, long term care, behavioral health — they will do a better job of care coordination.”

But the change worries Charlene Harrington, a retired professor of nursing at the University of California San Francisco and long-term care expert. “Most of the managed care organizations have no experience with long-term care with older people and disabled people,” she said.

There are pitfalls, Farnham warned. Managed care organizations could seek to save money by cutting services, and nursing homes and other long-term care providers could be saddled with more administrative work, she said.

New Hampshire’s managed care organizations don’t yet have answers.

Boston Medical Center Health Plan, which also oversees Medicaid programs in Massachusetts, hasn’t had any prior experience overseeing long-term care, according to Lisabritt Solsky, executive director of its New Hampshire unit.

What costs Well Sense will incur overseeing long-term care and details of how it will be compensated still are being worked out, Solsky said.

Centene officials did not respond to requests for comment.

The hope is that the MCOs will “reduce the use of institutional services and increase access to home and community-based services, but there is little definitive evidence about whether the model saves money or how it affects outcomes for consumers,” Laura Summer wrote in a 2011 report for the Kaiser Family Foundation.

Farnham was an author of a July report from the Rutgers Center that found some early indications that a managed care program in New Jersey had increased the proportion of Medicaid recipients receiving long-term care at home or in communities. However, the report also warned that “given the vulnerability of many consumers ... there is concern about consumers who may be disconnected from resources and unable to communicate problems with their care.”

John Poirier, chief executive of the New Hampshire Health Care Association, an organization of privately owned nursing homes, remains skeptical. “Show us where the benefit is from having managed care come into long-term care,” he said in an interview. “Nobody’s been able to answer that question.”

In their quest for savings, the managed care organizations are likely to end up pressing to transfer patients out of nursing homes, he said. “The only way that the managed care organizations can make money with long-term care is to transition people out of facilities more quickly to less-restrictive settings, or less care settings, or reduce rates,” he said. “And we’ve been assured that rates won’t be reduced.”

Poirier pointed to experiences in mental health care systems in New Hampshire and other states where institutional care settings were shuttered but savings weren’t redirected to provide comparable services in communities. “You can swing that pendulum too far in the other direction, where people who really would benefit from institutional care don’t have the opportunity for that anymore,” he said. “I don’t want to see that happen to senior care.”

What is needed now, Norton said, is “getting started with the conversation about what a more integrated long-term care system would look like and where we need to go” to build one.

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