Abstract

Background: In the US, 21 states have embarked on a dramatic new approach to financing and delivering Long-Term Services and Supports using the private sector in innovative ways. These programs, referred to as Managed Long-Term Services and Supports (MLTSS), seek to align the incentives for improved quality and care coordination for people that require LTSS by shifting financial risk and operational management to private managed care plans. Privately run plans, whether for-profit or not-for profit, receive a fixed per-person-per-month payment to cover the LTSS needs for their enrollees as well as any medical care costs not covered under Medicare. These plans have an incentive to shift the locus of care away from expensive institutional settings, and toward less expensive and more preferred community-based care. In addition, they have an incentive to coordinate LTSS and medical care to improve health outcomes and prevent unnecessary utilization (e.g., reduce hospitalization and readmission).

Starting January 1, 2018, the Commonwealth of Pennsylvania began implementing a mandatory MLTSS program known as Community HealthChoices (CHC). CHC covers people fully eligibly for both Medicare and Medicaid, living in a nursing facility paid for by Medicaid, and everyone participating in the aging and physical disability home and community based services (HCBS) waiver programs. The program will be administered by 3 managed care organizations (MCOs) that are obligated to coordinate with Medicare Advantage and D-SNP plans.

The Community HealthChoices (CHC) program has 5 main program goals: Enhance Opportunities for Community Living; Improve Service Coordination; Enhance Quality and Accountability; Advance Program and Innovation; and Increase Efficiency and Effectiveness. The program covers the dual eligible population, which includes adults over age 21 who are physically disabled and receiving LTSS in the community or in a nursing facility, as well as duals not receiving LTSS. In addition, people who are receiving Medicaid financed LTSS but are not eligible for Medicare are covered. In 2019 and 2020, the program will expand from the Southwest region to the Southeast and then the remainder of the Commonwealth.

Methods: The multi-method, longitudinal evaluation will take advantage of the phased implementation to produce the first estimates of the causal effects of MLTSS on outcomes for program participants. We are conducting qualitative interviews with key informants representing providers, advocacy and trade groups, and government agencies as well as focus groups with consumers and caregivers. A longitudinal statewide prospective survey of program participants and caregivers was launched prior to the program implementation, and analysis of claims data from Medicaid and Medicare as well as the nursing home minimum data set.

Objectives: This presentation will provide an overview of the policy change, describe the evaluation, and provide a description of the outcomes and indicators that we are tracking.