A Chronicle of New York's Medicaid Redesign Project for Home Care
Fundamental shift in service delivery, payment, and regulation has reshuffled billions of dollars in reimbursement and transitioned thousands of home care patients into managed care, with more change to come
By Roger Noyes
Over the past two years, New York State’s Medicaid program — particularly its home care sector — has undergone some of the biggest changes of any state health care program in the nation.
These changes include a fundamental shift in service delivery, payment, and regulations, involving the state’s reshuffling of billions of dollars in reimbursement and, to date, the transition of nearly a hundred-thousand home care patients into managed care — with more patients transitioning every month.
As other states’ Medicaid programs grapple with similar policy reforms oriented toward new care-management models, shared risk arrangements, and a realignment of payment incentives, New York’s Medicaid Redesign offers an interesting case study and a possible sign of additional shifts on the horizon nationwide.
Medicaid Redesign panel
The vast majority of New York’s home care policy changes stem from the state’s development of a Medicaid Redesign Team (MRT) in 2011. The MRT is a panel of health care stakeholders who were tasked with considering an array of health care delivery proposals affecting all sectors of the state’s Medicaid program. The wide-ranging MRT recommendations were ultimately adopted in the state’s 2011-12 fiscal year budget on April 1, 2011.
If viewed as a two-cycle process, the MRT actions affecting home care first involved constrictions to the existing home care system. This included major payment changes such as a global cap on Medicaid spending that applies to virtually all sectors of health care, provider-specific spending caps for certified home health agencies (CHHAs), and a home health aide wage mandate in the New York City area. (The global cap is particularly noteworthy for its precedent of restricting expenditures in a program that remains an open entitlement with steadily increasing enrollment.)
This first phase of program cuts was followed by a second phase of initiatives involving structural changes to the home care system as a whole: its flow of reimbursement dollars, the management and authorization of home care services, the placement of patients in new service models, and other changes as the state now pursues near-universal Medicaid managed care plan enrollment for its long-term care populations and many other service levels. These changes have mostly been subject to federal review through the State Plan Amendment (SPA) process and home and community-based waivers.
To get a sense of this overall policy trajectory, take, for instance, the MRT changes for CHHAs. These agencies are licensed to serve Medicare and Medicaid patients and typically provide post-acute home care services, usually for a shorter duration.
The state’s cap on CHHA expenditures was a first-year spending limitation in advance of an entirely new CHHA reimbursement system for Medicaid services. This new reimbursement system, now in effect, is modeled closely after the Medicare home health prospective payment system (PPS).
Like Medicare PPS, New York’s Medicaid episodic payment system (EPS), which went live on May 1, 2012, reimburses CHHAs with a single risk-adjusted rate that — with certain exceptions — covers a 60-day “episode” of care, regardless of how many times the provider visits a patient or how much care the patient ultimately requires. Importantly, the EPS methodology is in effect only for Medicaid patients needing fewer than 120 days of care. (Certain populations, like children, are exempted from EPS, too.)
This transition from spending caps to a risk-based EPS model of payment is emblematic of the state’s effort, as a whole, to approach its Medicaid reforms in home care by first capping or restricting Medicaid payments and then overhauling the entire method of payment and finance incentives.
Thus, while CHHAs have now moved to an episodic system for patients needing fewer than 120 days of care, a whole separate branch of policy changes is being implemented for programs serving “longer-term” Medicaid populations (i.e. patients needing more than 120 days of care), again with an emphasis on shared risk.
The vast majority of these “longer-term” patients are now being moved to managed care plans under a process called “mandatory enrollment,” which is perhaps the biggest change to New York’s home care system in decades, affecting all of the principal types of home care programs in the state.
Background on New York’s Mandatory Managed Care Enrollment Policy
First, some background … Traditionally, patients at or above the 120-day service threshold in New York State were referred to 1) a provider-led program of care-management and services, where the home care provider billed Medicaid largely on a fee-for-service basis; or 2) a Managed Long Term Care (MLTC) plan which: functions as the vehicle for care management, is the recipient of Medicaid payments from the state, and establishes contracts with a network of home care providers to do the actual service delivery to patients.
The state’s Managed Long Term Care Program was authorized in 1997 based on several demonstrations operating at the time and, until very recently, had grown to serve approximately 30,000 patients in New York State (an enrollment number that has since quadrupled).
With some variation, the aforementioned models — a home care provider-led model and an MLTC-led model, along with a “consumer directed personal assistance program” model — were the options for patients. Ultimately, the decision on which model to choose depended on the level of services needed, the type of program overseeing the patient’s care, oversight by municipal social service districts, and other factors.
Skip ahead to 2012 … At the same time that the state began transitioning to a new CHHA payment system for shorter-duration cases, it also initiated an ambitious project to move more than 100,000 longer-term home care patients (again, 120-day-plus) from direct home care provider enrollment to enrollment in managed care insurance plans.
For patients who are enrolled in managed care, the plans authorize and coordinate home care and certain other services either directly or through contract (largely under contract with home care providers). The plans receive a monthly Medicaid premium payment from the state for doing so; and the home care provider operates as a subcontractor, delivering and/or coordinating in-home services to managed care enrollees under contract with — and paid by — the MLTC or managed care organization (MCO).
To participate in this system and continue serving the Medicaid long-term care population, home care providers in New York State must now negotiate a service or care-management contract as well as rates of payment from the MLTC or MCO; and these rates can vary significantly from the amount a provider would have traditionally received when it was directly billing the state under fee-for-service.
Indeed, a recent survey of providers conducted by the Home Care Association of New York State (HCA) found that, on average, home care providers who have already negotiated MLTC contracts under this new paradigm are receiving Medicaid payment rates at 7.45 percent below their previous fee-for-service rates. Much of this rate constriction is attributable to global financing issues under Medicaid that have constrained the system overall. Indeed, 42 percent of MLTC plans had negative premium incomes in 2012 — a shortfall that financially squeezes both the MLTC plans and their rates of negotiated payment to downstream providers.
This overall process of mandatory MLTC enrollment began in New York City in 2012, where managed care penetration was already deemed adequate, and is being extended to other regions of the state on a phased-in basis as the state encourages MLTC plans to extend their service footprint. To date, many patients in the New York City metropolitan region have already been enrolled in managed care plans. Mandatory enrollment into MLTCs has begun in other areas of the state, and will continue for the duration of 2014.
Continuity of Service Issues
This change has altered service delivery for eligible patient populations served by virtually all types of home care agencies and programs, particularly patients in certain specially designed programs in New York, like our state’s unique Long Term Home Health Care Program (LTHHCP) and Personal Care Program, both of which serve the elderly and persons with disabilities.
At present, the Personal Care Program has been entirely transitioned over to managed care. This means that home care providers who previously received a Medicaid fee-for-service rate for personal care services provided to these patients are now operating in a negotiated contract arrangement with the managed care plan to deliver services for the patients.
The transition of personal care also means that components of the program which were formerly handled by municipal-based departments of social services (e.g. assessments and authorization of services) are now the purview of the managed care plan.
Long-term home health care programs (LTHHCPs), also known as “nursing homes without walls,” are specially licensed by New York State to provide a nursing-home-level of care to nursing-home-eligible patients in their own homes through a service package that has been enhanced over the past three decades by federal waiver authority. These programs have traditionally served 25,000 to 30,000 patients, many of them dual-eligibles, at half the cost of nursing-home care, although program costs are statutorily capped at 75 percent of the nursing-home rate. An LTHHCP is traditionally sponsored by a Medicare-certified home health agency, a nursing home, or hospital.
As of today, this 30-year-old care-management program may no longer enroll new Medicaid patients in certain counties where mandatory managed care enrollment is in effect, and LTHHCP-licensed providers may only continue to serve their patients in these areas if they are able to contract with a managed care plan in that region.
Faced with an uncertain future, LTHHCP providers have already begun to discontinue or substantially downsize these programs. In fact, a recent survey of providers conducted by HCA found that 53 percent of these programs plan to close their doors as a result of new home care policy changes.
In addition, important specialty services like home telehealth are also substantially affected by the managed care transition. Many home care agencies have adopted these technologies and clinical protocols in ways that have greatly enhanced patient care and reduced unnecessary hospitalizations. Indeed a 2012 study by Simione Healthcare Consultants found that innovative care-transitions programs for a defined group of high-risk patients at just five of New York State’s approximately 230 Medicare-certified home health agencies saved $1.2 million in averted hospital expenses annually by reducing each agency’s 30-day readmission rate, mostly through the use of home telehealth.
In 2007 and 2008, the state Medicaid program, with advocacy from HCA, adopted a special program structure and Medicaid rate for home telehealth under the fee-for-service system. However, as the state now moves enrollments and payments to managed care, it has yet to migrate this home telehealth program so that it is continued under the managed care structure. Without a carryover of structure, funding, or aligned incentives, most managed care plans are not paying for home telehealth services; as a result, providers are already reporting that they plan to discontinue their home telehealth programs.
The state has developed some requirements intended to ensure continuity of services. These requirements specifically mandate that a patient’s caregivers and level of home care service must remain in effect during a defined 90-day transition period for patients already receiving services before the transition. However, once this continuity-of-care period ends, a patient will receive services only from those specific home care providers who are under contract with the plan and in the health plan’s network. Those network providers may — or may not — be different from the ones who were previously serving the patient; and the level of services may also change depending on the reassessment of the patient by the plan.
As each month passes, more and more patients are being transitioned from fee-for-service, or direct provider enrollment, to managed long-term care. The state’s Medicaid expenditure and enrollment data reveal the magnitude of this shift in such a short period of time: between January 2011 and December 2013, MLTC enrollment grew 264 percent, from 32,602 to 118,615. In this same period, the state’s expenditures on capitated payments to managed care increased from $1.7 billion to $4.7 billion by the end of 2013 — a 176 percent increase. Meanwhile fee-for-service Medicaid revenue for home health has decreased by 64 percent.
Next Step – FIDA
This monumental transition is just one step among even bigger changes yet to come.
New York State is right now working with the federal government on a special demonstration project to enroll dual-eligible Medicaid/Medicare patients into special managed care plans for the coordination of both their Medicaid and Medicare services under the Fully Integrated Duals Advantage Program (FIDA).
To date, the state’s mandatory managed care initiatives have been restricted to Medicaid services, even in cases where a patient is eligible for both Medicaid and Medicare. However, under FIDA, the state expects to enroll 170,000 dual-eligible recipients — many of them having just enrolled into MLTC plans under the aforementioned transition — into specially approved managed care FIDA plans that will coordinate services paid both by Medicare and Medicaid.
Individuals will have the option of enrolling into a FIDA plan of their choice. However, eligible beneficiaries who do not actively enroll into a plan or indicate that they don’t want to enroll will be “passively enrolled” at a later time. For passive enrollment selection, the state has said it will rely on a process called “conversion in place,” under which dual-eligibles already in MLTC plans will see the Medicare benefit added to their MLTC coverage (in cases where the individual’s MLTC plan is FIDA-approved).
Preparing for these Shifts
One of the biggest and unforeseen regulatory changes to occur in the lead-up to mandatory managed care enrollment was the state’s decision to open up the home care certification application process in conjunction with other changes to the transitioning system.
To that end, in December 2011, the state issued an emergency rule lifting its long-standing moratorium that had barred any new CHHAs in the state. It also established an applications process that would allow existing agencies to apply for more capacity, new ones to enter the Medicaid market, and other existing providers to convert their programs.
So far, about 66 such applications have been approved by the state’s Public Health and Health Planning Council. This process has brought forth new players and market dynamics in an infrastructure already otherwise undergoing major transitions.
Providers now contend with deliberate infrastructure and market changes, continuity-of-care measures, oversight, and transition management efforts, and a range of other considerations that have commanded attention in this process. One can also imagine the litany of specific operational questions that providers and managed care plans have faced in their work to adapt to such major changes in care management, payment and, frankly, changes in providers’ relationship to their own patients and community services.
One of the biggest issues that our association has been grappling with is the need for regulatory streamlining to help providers and managed care plans work together and meet the goals of a transitioning system.
While the state has taken one big step down the path toward mandatory managed care enrollment for thousands of home care patients, the proverbial other foot remains firmly planted in a regulatory structure for home care that is designed for a much different fee-for-service Medicaid environment.
HCA is continuing its work with the state to sort outand articulate the lines of compliance responsibilities between home care and managed care, including such practical matters as billing/payment procedures for downstream providers, determinations as to who is responsible for obtaining required physician orders, conducting assessments and other administrative mandates, service contracting and delivery issues, the applicability of federal conditions of participation (CoPs) to contracting providers; and a near-endless list of other major issues that still have not been resolved several months into the transition process.
During last year’s budget, HCA appealed for legislative remedies in the area of regulatory streamlining under managed care. In response to our appeals, the state created a workgroup to streamline and properly align the regulations governing the interface of home care and managed care. The workgroup released a series of recommendations in March, but it is not yet known whether the state will act on any of them.
Unfortunately there is still much work to do, and there are many regulations that remain excessive, overlapping, not clearly delineated as to provider/managed care roles, and underfunded in this new paradigm.
Meanwhile, as a next major step, the state recently received word that the federal government approved its waiver application to invest $8 billion of federal Medicaid savings — a major share of the $17 billion that the state saved due to MRT initiatives over the past two years — for purposes of further supporting the state’s health system and Medicaid reform.
Consider all the major changes that have occurred in New York’s home care system over the past few years, the ongoing need for transition support, and, most importantly, home care’s well-established clinical and cost-savings track record that aligns with the goals of Medicaid Redesign. Given all that has taken place, HCA will be looking to work with state leaders on ways to support the home care system with waiver funds and other available investment dollars, along with appropriate regulatory change to ensure a strong infrastructure ready to meet the needs of New York’s citizens.
About the Author: Roger Noyes is Communications Director for the Home Care Association of New York State (HCA). He can be reached at firstname.lastname@example.org.