Good Morning! First and foremost, thank you to the committee for taking the time today to hear important information, comments and concerns regarding the state’s plan to implement Managed Long-Term Services and Supports, referred to in Pennsylvania as “Community Health Choices.”
My name is Kelly Andrisano, and I am the Executive Director of PACAH, the Pennsylvania Coalition of Affiliated Healthcare and Living Communities, which is an affiliate association of the County Commissioners Association of Pennsylvania (CCAP). We exclusively represents the 23 county nursing homes as well as 120 other nursing facilities and related entitieswho provide services in the long term care field.
We remain supportive of Governor Wolf’s efforts to improve Pennsylvania’s Long-term Care system. The implementation of Community Health Choices (CHC) will transfer the delivery of long-term services and supports (LTSS) through capitated Medicaid managed care programs as opposed to the state. The Managed Care Organizations (MCOs) will receive capitated payments for LTSS and are accountable for the health and welfare of participants. We recognize that there is room for vast improvements in the ways we serve those receiving long term care services, including opportunities for increased innovation, collaboration and quality improvement.However, a program change of this magnitude raises a lot of questions and issues, and should be done cautiously to insure success. We thank you for the opportunity to provide some commentary on how these changes will impact our members and the long-term care arena in general.
First I would like to emphasize that Pennsylvania’s counties have a vested interest in the long-term care system and have oversight and control of several long term care programs as well as other human services programs that impact long-term care. Counties are also on the front lines of insuring that those who are most needy are provided with necessary care and support to live healthy and independent lives. While all counties are organized differently, some counties in Pennsylvania have oversight of Area Agencies on Aging (AAA), county nursing homes, waiver programs, behavioral health choices programs, local mental health and developmental services programs, Medical Assistance Transportation programs and others. We hope that through this system implementation the counties’ role in the long term care continuum and their choice to provide services not be limited or impacted negatively, and that the state continue to see the counties as partners in providing these services moving forward.
Below is more detailed testimony on specific service areas, with our main focus being the impact on skilled nursing facility care.
Impact on Skilled Nursing Facility Care:
Pennsylvania has over 700 total nursing facilities with approximately 88,000 beds. Of those facilities, 23are county owned nursing facilities with approximately 8,000 beds. Nursing facility care will be one of the areas of care most significantly impacted by implementation of CHC, since all nursing home eligible individuals will automatically be enrolled in CHC. In Pennsylvania, county nursing homes have historically served the safety-net population, a fact which is supported by numbers and not just rhetoric. Not only are county homes required to take Medicaid patients on day one, but according to December 2014 cost reports, the average MA occupancy rate of county nursing facilities is over 80 percent while the average MA occupancy rate of all skilled nursing facilities in the state of Pennsylvania (including county homes) was just 65 percent . Because of this, county homes are not just providers of long-term care services, but instead, are partners with the state in insuring that the needs of the community’s most vulnerable individuals are met. While counties are supportive of the stated goals of CHC, including increased innovation and coordination of care, there are a few issues that we encourage the state and MCOs to explore more closely to insure continuity and quality of care while undergoing large-scale system changes.
Adequate Reimbursement Rates:
One of the biggest changes in a Managed Care environment is the process for setting Medicaid rates. As CHC is implemented in Pennsylvania, providers, which include the county nursing facilities, will have to negotiate their Medicaid rates with the CHC MCOs. In the past, to encourage and support county homes taking on the role of the safety-net, they have been carved out of the traditional skilled nursing facility payment system. Their rates are not based on their Case Mix Index (CMI) as private nursing facility rates are, and instead, only fluctuate if there is an increase in rates as part of the state budget. With rates having been set almost ten years ago, and after several years of flat-funding in the state budget, county homes have continued to serve Medicaid clients through rates that have fallen significantly below the rising cost of providing care over the last ten years. Recently, PACAH was able to show, through an independent study, that if these homes were all to privatize, there would be an increased cost to the state in terms of Medicaid reimbursements of almost $30 million per year. This would indicate at the very least that county homes are providing safety-net care in an extremely efficient manner and county homes have continued to serve as the safety-net with costs that far exceed what they are being reimbursed.
Because of the unique type of individuals served within the county homes, many questions arise as we transition to CHC, particularly around payments and reimbursements. First, as safety-net facilities, how will the new payment system recognize this and support this? With rates being set by MCO’s, how will the high Medicaid population of these homes and unique history of county payments be reflected? Where will the incentive be for county homes to continue to fulfill this role of safety-net facilities? How will unique payments available only to public facilities continue to be maximized (the IGT, CPE, etc.)?
We are concerned that if counties are expected to negotiate rates in direct competition with for-profit nursing homes who already have existing relationships with managed care entities and experience in a managed care environment will jeopardize their ability to continue to provide much-needed services. In addition, the costs of providing service within the county nursing homes are unique for the following reasons, and we feel as though this should be recognized through the establishment of rates:
a. Medicaid populations nearing 85%-95%
b. Significant population without any Part B type coverage
c. Of those that have Part B type coverage, it is rare that any coinsurance coverage exists
d. Unionized facilities
e. High cost of care factors that cause non-county homes to avoid similar admissions
f. Expensive specialty units that service specific populations.
We have continued to recommend and request that there be incentives included in rates (prior to any negotiations) for county facilities due to their status as safety-net providers. We have concerns that without some provisions in place to account for the differences in funding county nursing facilities and the unique population involved, it will be difficult for the counties to continue to serve in this role.
In addition to the concerns county facilities have with rates, all nursing facilities (private, non-profit) need to be assured of adequate rates. Across the board, the cost of care far exceeds the current Medicaid reimbursement rates in Pennsylvania. Reducing rates even further would have a significant impact on the ability of providers to adequately serve this population. We are strongly suggesting, and have seen in other states, rate floors where the negotiated rates are not allowed to fall below the pre-existing rates. If there is not a rate floor implemented in CHC, many providers will struggle to continue to serve this population. There should also be assurances that current funding streams, such as the Nursing Home Assessment program, are not jeopardized.
Provider Network Concerns:
In addition to the change in rate setting for providers, another significant system change with the implementation of CHC will be the requirement for all providers to be considered “in-network” by the MCOs in order to serve the CHC population. CHC is providing for a six month continuity of care period, where any willing provider will be able to continue to serve the Medicaid population, however, after six months this is no longer a guarantee.
While we believe the county homes provide quality services in the most efficient manner possible, forcing them to operate successfully in a managed care environment in just six months with a unique population is unrealistic and has the potential of forcing the remaining county homes out of business. When they have operated as the state’s safety-net for decades, not enabling them the time needed to be successful in this large scale system change does not seem to align with the stated policy goals of CHC.
County homes are not equipped with consultants at the ready to prepare them for managed care and their focus has never been on providing for-profit care but instead has been on serving as the safety-net facilities in the long term care continuum. In addition, county nursing facilities serve a unique population compared to the other skilled nursing facilities. Many of their residents do not have a support system in the community, would be considered homeless with no financial means of support, or have corresponding behavioral health issues. They also often serve a low CMI population who would not be accepted by other nursing facilities due to the differences in reimbursements.
Ideally, county homes would be considered in-network providers indefinitely, in order to maximize their collaborative potential and to reduce the risk of eliminating core safety-net providers. It would be difficult to have sufficient networks without the inclusion of county nursing facilities who have operated for decades as the community safety-net provider.
County homes are not the only providers who could potentially struggle with becoming in-network providers in such a short time-frame. It is not clear at this point what criteria will be used to determine which providers will be in-network, and with the implementation of CHC happening in part of the state in just one year, it may be difficult for providers to align themselves with the goals of MCOs in such a short time-frame. In an already overburdened system with a growing aging population, we should be allowing those willing provides ample time to align themselves with the goals of this brand new system. In other states where managed long-term care has been implemented, there have been longer continuity of care periods, for example – two years in New Jersey, or any provider who served Medicaid consumers previously was considered in-network (Texas). Many of our non-county members are small, non-chain nursing facilities who provide quality care in a small community. These smaller for-profit providers are not necessarily equipped to function in a managed care system overnight. There are also concerns that ancillary providers (pharmacies, therapists, etc.) will not be considered in-network and existing relationships with facilities will have to be severed and new providers quickly found to replace ones that residents are used to and that have historically provided services.
Determining Eligibility of Consumers for Care:
Other issues that are often seen in managed care environments are associated with the eligibility determinations for consumers. In a managed care environment, the MCO will play a large role in determining what type of care an individual is eligible for. We are concerned about additional pre-authorization requirements that could be placed on nursing facilities who admit individuals that are otherwise deemed eligible through the current CAO eligibility process. Timely processing of determinations is also a concern, as is who bears the financial burden during the MA pending process? Or if an individual is not deemed eligible back to day of admission.
Safe and Orderly Discharges:
Not only will the MCO have a large responsibility in determining eligibility, but they will also be involved in discharging residents from facilities. Nursing homes are required under state and federal regulations to ensure “safe and orderly” discharges, but in a managed care environment, the MCO will naturally play a significant role in determining an individual’s care in accordance with their care plan, including whether or not they should be discharged from the facility and placed elsewhere. This, however, raises multiple questions. For example, who is responsible for ensuring this is followed? What if a family does not want the resident to be discharged? What if the MCO and facility differ on whether discharge is appropriate and the resident is ultimately readmitted? What is the role of the ombudsman in this process? Who bears the responsibility of the discharge is deemed not to be safe and orderly.
Additional Reporting and Paperwork Requirements:
A change in process including an additional layer of oversight from the MCOs could result in more paperwork and reporting requirements. We are hoping instead that this process not lead to additional reporting and paperwork requirements, and instead leads to streamlined reporting. Several reporting mechanisms already exist, we should not be adding to the process and creating duplicative and unnecessary work.
Coordination with Licensure Standards:
Nursing facilities are currently licensed by the Department of Health. There are clear policies and goals that tied to licensing. Through the process of determining what quality standards will be utilized and which facilities will be deemed “preferred providers” there should be as much alignment with the goals of the Department of Health and the licensing regulations as possible. To have an alternative set of quality standards or measurements that diverge from existing regulations and policies would lead to confusion and would not improve the quality of care. In addition, the Department of Human Services should be working closely with the Department of Health to insure that there is coordination.
Availability of Community Housing:
One of the goals of CHC is to increase the placement in home and community based settings of those currently in facilities. We commend this, and are supportive of this initiative. However, there is a concern that the availability of community housing is not sufficient. For years there has been a focus to transition low Case Mix Index (CMI) patients into communities; however, in many counties there is little to no housing available for safe placement of these individuals. Also due to criminal and/or credit histories many of these low CMI patients could not be placed. We would suggest and like to see a more concrete plan for increasing this housing availability to align with the goals of CHC.
Further, we know there are residents within skilled nursing facilities that cannot safely be placed back in their home in the community and cannot afford the private pay Personal Care or Assisted Living facilities in their area. Finding a way to supplement payment for these settings would be ideal.
Behavioral Health:
In the area of behavioral health, CCAP appreciates the Department’s recognition of the viability of community mental health services currently provided through the Behavioral HealthChoices carve out. Establishing an integrated approach between the long term living and behavioral health systems will permit continuity of care for numerous individuals currently receiving behavioral health services and expand options for those newly enrolled.
The Request for Proposals underscores the need to coordinate care for individuals who will receive services through Community HealthChoices and Behavioral HealthChoices. Requiring information on approaches to integrate and coordinate at the system level in the Request for Proposals is appropriate and necessary in order to prevent conflicts in supports coordination and care management.
It is also important to note that changes in the current process could be extremely disruptive for consumers; not just aged or those living with physical disabilities, but persons currently undergoing assessments due to mental health and/or intellectual disability complications. As with capitalizing on the success of HealthChoices, we must not abandon that which is working.
Aging Services:
Area Agencies on Aging have a great deal of expertise in both conducting level of care assessments as well as in the provision of care management. They are connected to and part of the local community. They possess a unique and valuable awareness of both formal and informal supports that allow a person to remain independent and in the community—a stated goal of this effort. We must build on that expertise, not exclude it.