Community services reduce long-term costs

NATIONALLY, MORE THAN 10 million people rely on long-term care (LTC) services, according to the Kaiser Commission on Medicaid and the Uninsured. On average, Medicaid spending is $26,096 for each person receiving services in a nursing facility compared to $9,459 for home and community-based services for each older person or adult with a physical disability.

However, the Medicaid program has a built-in bias toward nursing-home care, which is an entitlement. Home- and community-based services are an additional option that may be available through a waiver.

A recent report from the UnitedHealth Center for Health Reform and Modernization suggests that national savings from modernizing LTC Medicaid, and substituting home- and community-based care for nursing home admissions, could be as high as $140 billion over the coming decade. Some $60 billion of that sum would accrue to the states.

While the debate continues at the national level, some MCOs are developing innovative programs to demonstrate that coordinated long-term care can offer better outcomes and lower costs.

"There are a variety of creative contracts, based on outcomes or shared risk, for medical care delivery," says Thomas von Sternberg, MD, HealthPartners medical director for geriatric services. "Community services are generally not risk-based, they're simply contracts for specific services."

The dual-eligible elderly population tends to have a heavy disease burden. The challenge for the health plan is in linking together the many community services available, Dr. von Sternberg says.

"Under MSHO the health plan's biggest responsibility is to combine those two uncoordinated, very complicated arenas into one approach to care, so they support each other," he says.

HealthPartners assigns each MSHO member a personal care coordinator who is responsible for ensuring their medical and LTC needs are met at an appropriate level. The plan also relies on hospital-based nurse case managers, who partner with community care managers.

"Our goal is to have the care coordinator aware within 24 hours whenever one of their patients is hospitalized," Dr. von Sternberg says. "They then collaborate with our inpatient case managers to prepare for the transition out of the hospital."

MSHO has demonstrated decreases in long-term nursing home placements, lower emergency room usage, and improved HEDIS measures.