A Long-term Challenge for the State


By Stephanie Anthony, Keith Nevitt, and Carol Raphael


Long-term services and supports (LTSS) enable hundreds of thousands of people of all ages in Massachusetts to live with independence and dignity in their daily lives, participate in their communities, and increase their overall quality of life. MassHealth, the Commonwealth’s Medicaid program, is the largest payer of LTSS, spending $4.5 billion (including federal Medicaid matching funds) on LTSS in 2015, representing nearly one-third of all MassHealth spending and 12% of the state budget. Although the demand for LTSS is projected to skyrocket, few people are aware of the likelihood they will need LTSS in their lifetime, and few viable LTSS financing options exist beyond MassHealth.

The increasing demand for LTSS, rising costs, and building pressure on the workforce, coupled with a care-delivery system that is fragmented and lacks meaningful quality measures, creates an LTSS system in Massachusetts that may be providing suboptimal care while simultaneously creating serious budget pressures on the MassHealth program. Additionally, the fragmented LTSS system is difficult to navigate, and may be increasing avoidable hospitalizations and ER visits and replacing much-needed functional supports with more expensive medical interventions. While Massachusetts is widely recognized as a leader among states in healthcare reform, it is near the middle of the pack on LTSS system transformation.

Massachusetts has a unique opportunity to address these issues and become a bellwether state on LTSS transformation, as state policymakers and stakeholders are coalescing around LTSS reform more than ever before. Not only have stakeholders unanimously identified LTSS reform as one of the top five priorities facing the MassHealth program, but demographic trends predicting increased LTSS demand and spending are also propelling LTSS closer to the center of MassHealth policy debates. State policymakers are incorporating LTSS and LTSS providers into broader discussions about MassHealth payment and care-delivery reform, recognizing the interdependencies among medical care, LTSS, behavioral-health services, and social-support services in promoting health and well-being for some of MassHealth’s most vulnerable members.

To become a leader on LTSS reform, Massachusetts must establish a quality-driven, affordable LTSS purchasing and delivery system strategy. Implementation of the strategy will require a multiyear commitment and should result in a system that is person-centered, integrated, sustainable, accountable, and actionable.

The LTSS system of the future likely can be achieved through various models, but the best vehicle is one in which a single entity or network of entities assumes financial responsibility and performance accountability for coordinating and delivering comprehensive care to LTSS populations and is vigorously monitored by the state.

Regardless of the vehicle, community-based LTSS providers must be at its core, as they have the expertise needed to serve diverse LTSS populations. Such an entity, particularly one paid through a risk-adjusted global or shared savings payment arrangement and accessing Medicare financing for dually eligible populations, will have more flexibility than providers in the current system to creatively address people’s needs in a person-centered and cost-effective manner and to integrate and coordinate physical healthcare, behavioral healthcare, and LTSS.

To successfully design, implement, and oversee this transformation, the Commonwealth must designate a senior health and human services official to be responsible and accountable for the LTSS system. It must also invest in hiring highly skilled contract management and analytic staff in order to vigorously monitor integrated care programs and hold them accountable for providing high-quality, effective, and accessible care.

In addition, the state must monitor the financial performance of contractors, particularly those taking on financial risk and/or reward, to ensure effective stewardship of state and federal resources and instill a level of confidence that public dollars are being spent wisely.v

Stephanie Anthony, Keith Nevitt, and Carol Raphael serve as director, senior analyst, and senior advisor, respectively, for Manatt Health, which was commissioned by the Blue Cross Blue Shield of Massachusetts Foundation to study and report on LTSS issues in Massachusetts. For the full report, visit bluecrossfoundation.org.

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