Managed Long-Term Services and Supports Programs Are a Cornerstone for Fully Integrated Care

Strong advocacy is critical as states move from fee-for-service models to managed long-term services and support programs.Across the healthcare system, many initiatives are being implemented to improve quality and lower costs for populations with complex needs (Center for Medicare & Medicaid Innovation, 2013). These initiatives reflect a growing consensus in the health policy community that people with complex medical and social support needs are often not well served by the existing healthcare system, and that more innovative care management models are needed to reduce costs and improve the population's health and care experience. While concepts like "more integrated care" and "better care coordination" are widely used to describe the care models needed to manage high-cost populations, their meanings continue to evolve, and solutions to complex care problems remain a work in progress.Medicaid participants receiving long-term services and supports (LTSS) are one important group that would benefit from better care management models. Such participants also have Medicare coverage, and they experience fragmented services that are poorly coordinated among care providers. Older individuals and people with disabilities who participate in Medicaid are low income and often have low educational levels and few social supports, all of which compromise their ability to manage their complex care.Until recently, Medicaid LTSS populations have generally been excluded from states' managed care initiatives for various reasons. States initially focused on transitioning children and families into managed care, because those groups were thought to be more similar to individuals with private coverage and could be well served by managed care organizations with commercial coverage experience. Those same managed care organizations generally lacked experience with LTSS.But in recent years, states have had more reason to pursue managed care strategies in LTSS systems. First, there is growing support for fully integrated care models for people dually enrolled in Medicare and Medicaid. Managed long-term services and support (MLTSS) programs are one component of these fully integrated care models.Second, there is increasing pressure to decrease the number of state government positions, making it difficult for states to sustain large cadres of utilization management staffand others typically engaged in operating large LTSS programs.Finally, state Medicaid programs are increasingly transforming themselves into "value purchasers" of healthcare services, moving away from the traditional role of authorizing services and paying claims. As other parts of Medicaid have moved in this direction, the pressure for LTSS to follow suit has increased.This article describes the recent growth in MLTSS programs as a cornerstone for the development of fully integrated care programs. We first lay out the early efforts in selected states to apply managed care approaches to LTSS. Then we review the rapid growth in MLTSS programs that occurred between 2005 and 2012, and the projected growth for 2014. Finally, we discuss how state implementation of MLTSS programs provides a foundation for fully integrated models that include all Medicare- and Medicaid-covered services, and the importance of advocacy to ensure programs are held accountable for improving quality and reducing costs.Early MLTSS ImplementersIn 1989, Arizona was the first state to adopt a large, statewide managed care approach to the delivery and financing of LTSS. Arizona was the last state to participate in the Medicaid program, and it implemented a managed care approach from the beginning under a Section 1115 demonstration authority. The Arizona Healthcare Cost Containment System was implemented in 1982, covering primary and acute care services. The Arizona Long Term Care System, implemented in 1989, covered LTSS services. Virtually all services provided under both programs were covered through managed care contracts- Arizona never had a Medicaid fee-for-service system. …