WAHSA advocates for several elements which we believe must be essential features within any new system. These elements will help ensure that the designed system will meet the Department's and WAHSA's goal to maximize an individual's choice of necessary services, providers, and care settings; establish a minimum level of quality standards; and adhere to cost-effective principles.3
Persons in need of publicly funded LTC services should be able to access the following services through a SEP:
The Department would contract with the SEP entities using a competitive bid process. The SEP entity would be responsible for a defined geographic area, which may or may not correspond to county boundaries. All SEP entities would be required to utilize uniform functional, acuity, and financial assessment screening tools to assure all citizens have equal access to defined services. Individuals would be free to access SEP services provided outside their current community (e.g., when seeking access to LTC services not available in their own community or when moving to live with a family member residing in a different location).
Unless a waiver is granted by the Department, the SEP entity (a not-for-profit, for-profit, or governmental organization) should not be a managed care organization but may be included as a participating provider under contract with the MCO. The SEP would not be responsible for completing a client's comprehensive assessment but would be required to share client screening data with the organization charged with that responsibility. Further, it should be stressed that the SEP screening process typically will not be performed in a traditional office setting. Many elderly and disabled persons in need of LTC services will require the SEP staff to visit with them in the hospital, clinic, nursing facility, senior center, or in their home. The SEP entity will need to be flexible and innovative in performing its screening functions.
These SEP services would be available to individuals who are not eligible or in need of public funding but these individuals would not be required to utilize SEP services as a condition to enter the LTC delivery system.
The cornerstone of any redesigned LTC system should be a comprehensive client assessment system. This assessment would include data on a client's health, socioeconomic, functional, and cognitive status. The assessment also should identify any informal support systems which may be available to the client. It is recommended that DHFS convene a multidisciplinary group of persons (internal and external to DHFS) with experience in assessing elderly and disabled clients to develop the assessment tool. The challenge will be to develop an assessment tool that captures sufficient client data without becoming unwieldy. Under the redesigned system:
WAHSA advocates a system which fully addresses the needs of an increasing elderly and disabled population and places greater emphasis on coordinating care and services throughout the spectrum of care. The future delivery system likely will integrate primary and acute care, long term care, and supportive services in order to provide, finance, and manage the health and long term care needs of clients. The traditional roles of diverse provider groups will be challenged, redefined and, in some instance, become blurred as policies begin to promote a "coordinated" versus "episodic" approach to the delivery of care and services to elderly and disabled persons. This new system will require unprecedented cooperation between all parties, including DHFS, counties, advocates, providers, and others, in order to most effectively serve elderly and disabled clients.
The Department has published its "preliminary views" on LTC redesign and apparently has concluded that creating a fully integrated system, one that includes acute care, hospitalization, therapies, and drugs, in addition to traditional LTC services, is not feasible, at least under current constraints. WAHSA members strongly believe a fully integrated LTC system must be the ultimate goal of redesign efforts and the DHFS must strive to achieve that goal. However, we also acknowledge there are significant state and federal legal and regulatory roadblocks to achieving a fully integrated LTC system. WAHSA members suggest the DHFS proceed on a parallel track: Pursue incremental redesign efforts while working to overcome any barriers to full integration.
Approximately two-thirds of all nursing home admissions are from hospitals; at the same time, hospitals annually admit nearly 46,000 patients over the age of 75 due to a chronic condition.4 Failure to move towards an integrated system will ignore the fact that "individuals with chronic diseases and disabilities move back and forth between physicians, hospitals, nursing homes, and other providers with great frequency over many years, even after a person requires ongoing residential care. Often conditions seen by nursing homes and alternate care programs are simply the final stage of a series of ongoing problems that have been seen by acute care providers for many years. Isolating chronic care to the long term care environment is simply not a reflection of reality and is a major impediment to integration."5 Thus, a redesigned system which ultimately does not include Medicare, Medicaid, waiver programs, and other community-based LTC programs will not fully address the problems evident with the current "system" and will create significant incentives to shift costs outside the redesigned program (i.e., managed program costs, not managed care).
As stated above, WAHSA recognizes that DHFS initially is likely to pursue a less ambitious redesign plan. Following an incremental reform pathway will produce needed changes to Wisconsin's LTC system and, therefore, should not be postponed until the regulatory and legal roadblocks to full integration can be removed. The models/programs identified in this paper are offered with this in mind.
As the Department pursues its LTC redesign plan, the following seem clear:
This discussion is included under this section of our paper for two reasons. First, the Department will need to perform an actuarial analysis of the cost of including LTC services covered under any future plan. This analysis must consider the increasing population in need of services and the range of services to be offered under its plan. In short, as is true under the current system, the budget will drive final decisions regarding eligibility and covered services.
Second, if the redesigned system does not include acute care services, rehabilitative and restorative care, and intensive skilled nursing services (subacute care), then WAHSA advocates that the menu of services to be rolled into any capitation rate exclude the first 100 days of skilled nursing care (Medicare benefit). Carving-out the first 100 days of skilled nursing care would: (1) Save individuals and the State substantial dollars by fully utilizing the federal Medicare benefit; and (2) Recognize that the future role of many nursing homes will be to serve residents with increasingly complex medical or behavioral symptoms and in need of a short term stay in a nursing facility.
In 1995, approximately 62% of all nursing facility admissions were covered by the Medicare program. This compares to Medicare-covered admissions of only 19% in 1985.6 The Department's redesign plan should not cause the State to unnecessarily shift current responsibility for certain LTC services from the federal Medicare program to the State Medicaid program. Should this happen, the State likely would be forced to make deep funding cuts within current LTC programs. In addition, many of today's nursing home expenditures actually result in programmatic savings because nursing home services are being substituted for more expensive acute care services. Carving-out of the first 100 days of nursing facility care from the capitation rate should continue as long as the redesigned system does not include all health services utilized by long term care consumers.
WAHSA also has concerns about the apparent interest by some to include all social services and supportive services for elderly and disabled persons within the capitation rate. There are certain programs which DHFS may wish to continue outside the capitated system. For example, home-delivered meals may be utilized by an individual only on an infrequent basis. Including meals within the capitated program could result in denying this service to persons who are in need of meal assistance but who do not qualify either functionally or financially for the more comprehensive, capitated LTC benefit. These carve-outs would offer a safety net to many individuals and retain certain necessary services as a county responsibility (other services might include protective services, establishing guardianship, some transportation services, counseling, and intervention). Further, many of these services are funded by the local property tax; it would be extremely difficult, politically and otherwise, to transfer these dollars to the State for purposes of funding the redesigned system.
As DHFS redesigns the LTC delivery system, it also should embark on the task of redesigning the LTC regulatory system. The new regulatory system should focus less on process and more on outcome. The Department's own strategic plan voices support for such an initiative.7
The redesigned system should extensively utilize multiple data-driven quality indicator measurements to evaluate the care and services financed under the new system. These outcome measurements should focus on quality of care, quality of life, performance measurements and cost-effectiveness8. Organizations should be encouraged to develop innovative methods to determine performance and client satisfaction. Measurements should include, but not be limited to:
The Department should assume a vital role in assuring the integrity of the new system. The role of the Department should include setting capitation rates, contract monitoring of all MCOs, reviewing the accuracy of client comprehensive assessments, prohibiting excess profit-taking, and responding to formal complaints voiced by clients, families, and providers. All clients should have a right to appeal care, service, and financing decisions to the Department. It is likely the Board on Aging and Long Term Care also would have an expanded role in this area.
Under any redesigned system, the DHFS should retain statutory responsibility for enforcing existing divestment prohibitions and the estate recovery and lien programs --assuming these laws continue under the new system. This is a governmental responsibility and should not be transferred to providers or MCOs. Under certain circumstances, it also may make sense for co-payment collection duties to become a DHFS responsibility.
WAHSA 204 South Hamilton Street Madison, WI 53703
Telephone: (608)255-7060 FAX:(608)255-7064