DOH Waiver Request Recognizes LTC as High Priority; LTC Funding Not Specified

The Department of Health (DOH) last week submitted a request to the Centers for Medicare and Medicaid Services (CMS) to extend and renew its 1115 Medicaid waiver. The proposed amendment requests a total of $8 billion over a four-year period, including unspent funds from the existing waiver and an additional $7.3 billion reinvestment of savings generated under the waiver. If approved, the extension would be for the one-year balance of the current 1115 waiver, and the renewal would extend the waiver for an additional three years from April 2021 to March 31, 2024. Thus, the proposed amendment to the waiver would be implemented in two phases – the one-year Extension Phase and the three-year Renewal Phase. While the submitted request includes long-term/post-acute care (LTPAC) elements and responds to aspects of LeadingAge NY’s advocacy, the funding available for LTPAC providers and programs remains largely unspecified, and the role of LTPAC providers and plans remains ill-defined. The Renewal Phase appears to be subject to further stakeholder input, and LeadingAge NY will continue its advocacy to promote an appropriate share of funding and role for LTPAC providers and plans.

The Extension Phase

The Extension Phase would continue the existing waiver activities in a “streamlined” fashion from April 1, 2020 through March 31, 2021, with $675 million in “rollover” funding that was not expended under the current waiver. The proposed amendment dedicates $605 million to "Waiver Performance," allocating 80 percent of the unspent funds to a base performance pool and 20 percent to a high performance pool. Performing Provider Systems (PPSs) would be ranked based on performance and would earn distributions from the pools based on relative rankings so that all funds would be distributed.

The Renewal Phase

The Renewal Phase intends to build upon the structures and promising practices developed in the first phase of the waiver while strengthening the framework to deliver value-based care. It would require the development of new, or reconstituted, entities to support service integration, care management, and social determinants of health (SDH) interventions. These new entities, dubbed Value Management Organizations (VMOs), would be "structured to support (and not replace) existing VBP [value-based payment] provider networks, including integrated delivery networks, accountable care organizations (ACOs), independent practice associations (IPAs) and Behavioral Health Care Collaboratives (BHCCs), as well as other provider network configurations...that have already been formed to engage in MCO and VBP contracting." They would be charged with leading the implementation of selected promising practices (see below). In addition to supporting the implementation of promising practices, each VMO would “have a longer-term purpose as a support or services organization.”

VMOs would have a stronger emphasis than PPSs on SDH and the engagement of non-clinical providers in population health activities and value-based care. They would serve as the mechanism for integrating managed care organizations (MCOs), Social Determinants of Health Networks (SDHNs), and local health departments in order to implement selected “promising practices.” SDHNs are networks of community-based organizations (CBOs) that would be approved within each region “to provide evidence-based interventions that address housing instability, transportation, food insecurity, interpersonal safety, and toxic stress.” The State would designate regions and select a lead organization within each region, which might be a CBO or a network entity (e.g., an IPA) composed of CBOs.

Each VMO would be required to implement five high priority promising practices:

Transforming and integrating behavioral health through peer outreach and expansion of crisis capacity;
Care coordination, care management, and care transitions hot spotting, development of transitional care teams, and leveraging telehealth;
Addressing social needs, community partnerships, and cross-sector collaborations through utilizing Community Health Workers (CHWs) and linking to SDHN high priority social care;
Addressing the opioid crisis through expansion of Medication-Assisted Treatment (MAT) to primary and emergency department (ED) care and peer bridging; and
Addressing high utilizers of care through rapid-cycle continuous improvement processes.

The proposed amendment allocates $4.3 billion to "Waiver Performance" and $1.5 billion to "Social Determinants of Health" in the Renewal Phase. It is unclear how these funds would be distributed. However, the amendment specifies that two pools would be established to support the waiver objectives in the Renewal Phase: (1) a VMO Performance Pool that would make direct awards to VMOs based on member attribution and potential performance in driving promising practices “and other high-need projects”; and (2) a VBP Incentive Pool that would provide incentive payments to MCOs (and by extension to providers and SDHNs) to promote "more sophisticated VBP arrangements." The amendment also allocates $1 billion to Workforce Development. The method of distributing these funds and the amount that would be dedicated to LTPAC workforce initiatives is similarly unclear.

Long-Term Care: An Additional High Priority Area

Like the draft amendment proposal, the final proposal identifies long-term care (LTC) as an additional high priority area, along with children and maternal mortality. The proposal provides that “VMOs chosen through the waiver will be required to place a considerable focus on practices that bridge acute and post-acute care and expand the best practices to include a component for LTC, both institutional and community-based.”

The amendment would add two new quality measure domains for VMOs: (1) Palliative and Hospice Care; and (2) LTC measures that relate to potentially avoidable hospitalizations (PAH) and nursing facility level of care (NFLOC) scores. The NFLOC score applies only to the community-based LTC population, not the nursing home population, and evaluates an MCO's performance in maintaining stability in (or improving) its members’ activities of daily living, cognition, continence, and behavioral issues.

The LTC components of the amendment include:

Workforce Recruitment and Retention:

The amendment outlines a number of proposals to enhance the training of the LTC workforce and improve retention of workers:

Training CHWs, resident assistants, and others to provide assessments and support care coordination in senior housing developments. Successful programs would be funded through managed long-term care (MLTC) VBP arrangements.
Training to expand the use of Interventions to Reduce Acute Care Transfers (INTERACT) in nursing homes.
Quality improvement training to be funded by VMOs aimed at reducing avoidable hospitalizations.
Continuing the Workforce Investment Program with additional funding to be allocated to continue those programs which have the greatest outcomes in recruiting, retaining, and training LTC workforce.
Developing a new Workforce Continuity Incentive Program in which the VMO would support financial incentives for LTC providers that implement practices to retain workforce. Providers would receive longevity payments when they demonstrate reduced staff turnover.

Integrating Care for Dual Eligible Beneficiaries:

The proposed amendment reiterates the State’s commitment to pursing the integration of Medicare and Medicaid services and financing for dual eligible beneficiaries. The State proposes to make additional investments to accelerate integrated care for duals over a two-year period. These investments would include consumer education about the benefits of integrated care, education campaigns focused on health care providers that serve dual eligible consumers across the continuum of care, and consumer and provider incentive programs that reward health outcomes and incentivize enrollment in integrated products. The amendment also proposes to make available funding to consolidate the current array of MLTC options into integrated MLTC programs and references “other initiatives such as arrangements between the state Medicaid program and CMS for those individuals who are not enrolled in a Medicare Advantage plan.”

Reducing Hospital and Nursing Home Admissions and Improving Discharge Planning:

The proposed amendment seeks to reduce hospital and nursing home admissions and improve discharge planning by:

Requiring each VMO to invest in evidence-based falls prevention programs; and
Leveraging VMOs and VBP arrangements to help transition nursing facility residents to the community and provide high quality transition supports and hospital discharge planning for duals (and other Medicaid members).

Increasing Access to Palliative Care and Hospice:

The proposed amendment would expand access to palliative care and hospice by requiring each VMO to sponsor community collaborations around end of life care and advanced planning. In addition, the amendment advances the following models:

Palliative Care introduced in primary care settings through the Patient-Centered Medical Home model.
Palliative Care administered through nursing homes.

Improving the LTPAC Information Technology Infrastructure:

Responding to LeadingAge NY's advocacy, the proposed amendment recognizes the importance of improving data sharing and health information exchange (HIE) in the LTPAC sector. It also acknowledges that connecting Medicare and Medicaid claims information is critical to improving performance in relation to care for beneficiaries dually eligible for Medicare and Medicaid. The proposal further notes that the LTPAC sector was not eligible for federal investments under the Health Information Technology for Economic and Clinical Health Act (HITECH Act), and as a result, it lags behind other sectors in data collection, analytics, and HIE. Accordingly, the proposed amendment charges VMOs with "encouraging the LTC providers in their area to invest in IT [information technology] infrastructure that meets standards developed by the State and generally based on the principles of HITECH.” Although funding for this initiative is not specified, the proposal identifies "eligible providers" as certified home health agencies (CHHAs), skilled nursing facilities (SNFs), hospices, and assisted living programs (ALPs).

Interim Access Assurance Fund

The waiver amendment proposes a second iteration of the Interim Access Assurance Fund (IAAF) that has been used to support safety net hospitals in financial distress. Under the proposed waiver amendment, $500 million would be made available to provide supplemental payments to ensure that viable Medicaid safety net providers “can fully participate in the transformation without unproductive disruption.” It is unclear whether nursing homes would be eligible for these funds. However, the IAAF payments would be limited to providers that serve significant numbers of Medicaid individuals and that have financial hardship in the form of financial losses or low margins.

LeadingAge NY will continue to update members as we advocate for sound public policies and appropriate allocation of available funds to promote access to high-quality LTPAC services for Medicaid beneficiaries.

The executive summary of the proposed waiver amendment request is available here, the body of the amendment is here, and the budget neutrality exhibits are here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124