Where do senior care organizations fit under managed care?

(INDIANA CAPITAL CHRONICLE) — For one week in June, hundreds of senior Hoosiers in southern Indiana gather for the Senior Games and compete in the event hosted by LifeSpan Resources — their local Area Agency on Aging, one of 16 such AAAs across the state. 

For Rep. Ed. Clere, who usually emcees the opening ceremonies and dance contest, it’s one of the activities that AAAs offer that might not make waves statewide — or even at the local level — but are important to the population LifeSpan serves. 

“It’s an opportunity for seniors to get out and get active. It reduces isolation and loneliness,” said Clere, R-New Albany. “Same with the Angel Tree … Seniors who may not receive much else at Christmas or have much other human interaction receive a box full of gifts and goodies. And it’s a big deal for those seniors.

“Neither of those activities are things that (Managed Care Entities) are going to do.”

With just months to go before the state transitions to managed care, or PathWays for Aging, the state’s three Managed Care Entities (MCEs) are finalizing contracts with AAAs and other organizations. The three MCEs — Anthem Blue Cross and Blue Shield, United Healthcare Community Plan and Humana Health Horizons of Indiana— hired by the state will oversee services for aged and disabled Hoosiers under Medicaid at a flat fee for each participant rather than charging the state piecemeal for individual services.

So the state’s choice to intervene last month in the contract negotiations between MCEs and AAAs took some by surprise, especially when the state recommended rate of $112 came in roughly 41% lower than the current $189.56 rate AAAs get for different, but overlapping, services.

“We were just flabbergasted and shocked because how can you … take the work we’re doing now and add additional components on it? And it’s lower than what we make now?” said Ryan Keller, the CEO of Thrive West Central. 

Thrive is the AAA tasked with managing members in west central Indiana, based in Terre Haute.

“It’s such a low rate, we can’t even move forward. We can’t do the work for $112 because it would essentially crush the agency,” Keller said. “You’d earn such a deficit … you’d have to shut your doors within months.”

AAA services can vary from area to area in Indiana, with some expanding their reach beyond aged or disabled Hoosiers, but generally act as a go-between for senior Hoosiers seeking services and the providing programs. 

In a statement, the Family and Social Services Administration (FSSA) — which oversees AAAs, Medicaid and the managed care transition — said it recommended a case rate “to facilitate a swift negotiation” between the two. 

“(It) is the equivalent of the current Care Management service under the Aged & Disabled waiver, adjusted for the caseload in the PathWays program and with pay-for-performance measures to ensure quality,” said FSSA through a spokesperson. 

The higher, pay-for-performance rate comes to $128 for “to-be-defined performance measures.”

Senior Games and Angel Trees are just a fraction of the programs AAAs offer but some of the most meaningful for participants. Clere — who has served on LifeSpan’s advisory council and interacted with other AAAs through the state’s CHOICE board — said he worried such offerings, and more, would be lost with the transition to managed care.

“Those are some examples of the role the AAAs play and the void that would be left if the AAAs lose their ability to provide the programming and services that the MCEs won’t be providing,” Clere said. 

“I didn’t want the AAAs to be set up to fail and it feels as though that’s exactly what’s happening,” Clere continued.

What are AAAs?

The Older Americans Act of 1965 came at a time when the United States was reforming its approach to elder care and included several provisions aimed at supporting aging individuals in their homes, such as delivering food — commonly dubbed Meals on Wheels — and an ombudsman program. AAAs were added into the act in 1973 to act as local arms of those services. 

“The core purpose and the core function is for us to help older adults age in the setting of their choice but really to help them age in the community and age in place,” said Keller. 

For AAAs, their workload has grown in recent years as Hoosiers age. Roughly one in six Hoosiers now are 65 years or older but that portion of the population will grow and by 2030 an estimated 20% of Indiana’s population will be seniors. 

Since joining Thrive five years ago, Keller said that phone calls alone had grown from 15,000 to 62,000. In some areas, the need has tripled, he said. But the biggest role AAAs played was providing case management services for the state under the Aged & Disabled waiver.

“Case management is really helping guide that participant to ensure they have the right amount of home services needed to remain independent for as long as possible,” said Tauhric Brown, the CEO of CICOA Aging & IN-Home Solutions. 

CICOA is the AAA for central Indiana and covers just over one-quarter of the state’s population. 

For example, a social worker or another qualified staff member might visit a client and assess whether they’d be eligible for Medicaid, which can help pay for services, and help them apply. 

“Once we’ve gotten over that hurdle, we would then do that person-centered assessment that would move into a person-centered care plan … perhaps the individual might need a couple of hours of extended care. They might need a grab bar or a handrail hung in the bathroom. They might benefit from having a nutritious meal delivered daily,” Brown said. “From there, we are connecting that care plan and that participant to providers that would then deliver the services.”

That plan also requires follow-up appointments every 90 days to re-evaluate whether the current services are appropriate. Those plans are uploaded to the Division of Aging, part of FSSA, which reviews plans. 

The rate of $189.56 pays for one member for one month for case management, unless that individual is hospitalized or in a long-term care facility, currently. Brown said the cost for his facility came out closer to $192.71, slightly above the state’s rate and  higher than the suggested $112. 

Friction with MCEs

But AAAs will no longer handle case management, which will be overseen by the managed care entities, and instead will transition to “service coordination.” The problem with that designation change is that case management is a recognized billable service under Medicaid, according to the federal agency that oversees the administration of the low-income health insurance program. 

Service coordination is not, meaning that payments for the service will eat away at AAA’s administrative dollars under the multi-billion dollar contract.

“We are in this weird box where we’re no longer providers anymore. In functions where we work with the state, we have been shifted over to vendors,” Keller observed. 

The AAAs — contracting with MCEs under one group called the Community Care Hub of Indiana — will still meet with older and disabled Hoosiers and develop an initial assessment but they’ll have to work with the MCE’s care coordinator for approval of a service plan and to connect someone to a provider. Additionally, Brown noted that AAAs will also be responsible for assessing family caregivers and must maintain monthly outreach to clients. 

Brown, who is one of the leaders of the Community Care Hub, said that MCEs had varying reactions to the proposed rate and just one plan president had met with their group. But all seemed likely to use FSSA’s recommendation.

That left AAAs feeling like they needed to reach out to leaders themselves — including gubernatorial candidates, Brown said — who previously were called upon to weigh in on another FSSA issue surrounding changes to care for disabled children after a $1 billion misstep. 

The rate announcement comes after lawmakers adjourned for the year — meaning AAAs don’t have a hope for legislative intervention. 

Contractually, the MCEs must work with the AAAs for two years and split their service coordination caseload 50-50 — which FSSA said in a statement was “in recognition of the important role (AAAs) currently play in coordinating and managing waiver services for eligible members…”

“Service coordination is a critical aspect of the Indiana PathWays for Aging program design to ensure older Hoosiers have the supports they need,” FSSA said.

In response to a follow-up, FSSA said the Aged and Disabled waiver Care Management rate assumed a caseload of 1 care manager to 44 clients while the PathWays Service Coordination under managed care had a ratio of one manager to 65 clients.

“This caseload recognizes the shared role care coordinators will have in assisting the member and ensure their needs are met,” FSSA said. 

Care coordinators will be hired and maintained by the MCEs.

Moving forward

The transition to managed care has been a nationwide shift to change how state’s approach health care and, importantly, keep costs predictable as the average American gets older. But AAAs and their advocates have questions about Indiana’s rollout with just months to go before the July launch.

Still, Keller, Brown and even Clere all said AAAs had places to grow when it came to diversifying their services to fit with current needs.

“I think there are a lot of opportunities for the AAAs to do more, especially around prevention,” Clere said.

Two of the biggest contributing factors to hospitalizations for seniors are falls and medication mistakes — both of which can be prevented with the right precautions, he observed. 

“I think there’s an opportunity to work on that and take advantage of the community, knowledge and resources that the AAAs have.”

This isn’t Brown’s first experience with a managed care transition. Prior to CICOA, he worked as COO for Senior Services, Inc. in Kalamazoo, Michigan, according to his CICOA hiring announcement. There, the transition was “a disaster,” Brown said, for completely different reasons, including an ill-timed rollout. 

But in contrast to Indiana’s plan, Michigan didn’t contract with insurers as MCEs. Instead, they used so-called “waiver agencies.”

Brown expressed a long-standing concern about the involvement of an insurer’s approval in the long-term care of seniors and whether it would decrease current flexibility.

“When you move the plan review, approval and denial process over to an insurance company, I guess my question would be, ‘Do they have that member really top of mind? Or are there, maybe, some other factors — business factors — that are more top of mind for them?’” Brown said. “Over here on the AAA side, all we focus on is the member. Any surpluses we generate, we reinvest to serve more people that are low income, frail and vulnerable. 

“Do we really think that’s what that member experience is going to be with an insurance company?”

Importantly, any discussion about managed care doesn’t happen in a vacuum. Even before a $1 billion Medicaid shortfall FSSA publicized in December, Medicaid made up the fastest-growing portion of the state’s budget.

FSSA has long said that a transition to managed care will be expensive upfront but, over time, will be cheaper than fee-for-service, especially if it incentivizes state providers to pivot from expensive long-term care facilities to more home- and community-based services. 

But many have observed nationwide nursing shortages, especially for the home health workers needed for such a change, adding to overall health cost concerns.