A Comprehensive Analysis of MLTSS Programs: Challenges, Opportunities, and Best Practices

Learn about how states are grappling with finding the balance between expanding and optimizing MLTSS programs while navigating recent health care reforms and tightening budget constraints in this recent interview with guest expert Gary Jessee. 

Please share your name, title, and a brief overview of your professional experience. 
My name is Gary Jesse, and I'm currently senior vice president of Sellers Dorsey. I lead the firm's national consulting practice, but I spent over 2 decades in state service before coming to Sellers Dorsey. I began my career working in aging services in Texas. As our agencies moved toward consolidation, I was appointed to lead services for aging, intellectual developmental disability, and physical health. 

Texas was keenly focused on expanding managed care and long-term care within long-term services at the time. I was appointed as the Chief Deputy for Medicaid and was responsible for various functions, including oversight of policy, program design, and implementation of managed care. I served as the State of Texas Medicaid Director before being appointed over medical and social services, which was a large division responsible for every health and human service benefit in the state.

During my time in state service, I also had the privilege of serving on the board of directors and then as president of the National Association of States United for Aging and Disabilities, now referred to as ADvancing States. 

Please share a brief overview of Managed Long-Term Services and Supports (MLTSS) programs, what types of services they provide, and what role they play in ensuring care quality and continuity for Medicaid beneficiaries, particularly those with aging complex healthcare needs. 

When you think of managed care, most people think about acute care: your doctors, your specialists, your pharmacy, going into the hospital. But when we talk about managed long-term services and supports, we mean the intersection of acute care and long-term services and supports. If you've seen one Medicaid program, you've only seen one Medicaid program. If the wording is different, programs and benefits are different. Typically, at the core, you find a combination of support for individuals who need help at home, which might include long-term services and support provided within an institutional setting. But when we talk about MLTSS, we're talking about those states that have decided to integrate acute care coordination and coordination of long-term services and supports. 

This can vary by population. You mentioned specifically older people, but we also think of individuals who have physical disabilities and, increasingly, individuals with intellectual developmental disabilities. States approach these programs, whether a state plan benefit or waiver benefit. Services like attendant care or habilitation might include home-delivered meals, modifications to somebody's home, adaptive aids, medical supplies, etc. All those services and supports that make it possible for an individual to remain in their home. And if they can’t remain in their home, the least restrictive setting available for that individual. We also include opportunities for individuals to transition from institutional care within our MLTSS framework. One of the core goals of managed long-term services and supports is the state's efforts to focus on rebalancing. Rebalancing is the ability of individuals to access services within a community that otherwise would be in an institutional setting like a nursing facility or an intermediate care facility. 

Last month, Sellers Dorsey released a state of MLTSS report. Are there any innovative approaches or best practices within MLTSS programs that you've noted in the research, particularly related to improving access to care and coordination among aging populations? 

Sellers Dorsey is a small health care consulting firm founded over 23 years ago, and our focus is Medicaid. Our efforts aim to improve our system of care and especially focus on access, quality, and equity. Our team includes former Medicaid directors, former policy staff, former managed care executives, and lots of other bright and talented individuals. Within Medicaid, we focus on state Medicaid agencies, managed care organizations, and service providers within the long-term services and support space. Also, solution partners that are bringing innovations to states and managed care organizations, associations, and foundations, and we do a fair amount of work in private equity. We’ve been working on a series of reports in partnership with the Association for Community Affiliated Plans (ACAP), Medicaid Health Plans of America (MHPA), and the National MLTSS Association to bring knowledge and information about the nature of managed care. 

Many states’ typical approach to managed care is organizations pitted against each other instead of what they’re really trying to achieve. Managed care is also often misunderstood as privatization. Through our partnerships, we’re seeking to highlight the benefits and goals of managed care and, most importantly, the impact of managed care. 

This last report discusses the connection between long-term services, support, and acute care. Because it is impossible to issue a report that addresses everything happening in the country, we highlighted some specific states, including Delaware, Pennsylvania, and Indiana, who's just recently moved to MLTSS. We also surveyed the 25 states in the country that have implemented managed long-term services and supports to get their feedback on a variety of areas. This report brought attention to what these states have undertaken in terms of their service delivery strategies around MLTSS.

Having been around this industry for a long time, when I think of MLTSS, I think about bringing innovation to service delivery. When you have an organization that's specifically directed to manage both acute care and long-term services and supports, a tremendous opportunity arises to focus on how to best coordinate care, how to bring innovation to care, and how to focus on whole-person care. 

We’ve got programs designed to just support informal caregivers. We recognize that informal caregivers are the backbone of our service delivery system, and addressing their needs and providing them with timely information is a meaningful way to affect direct outcomes for the individual they care for.

As I mentioned, many states are considering how to address workforce challenges and increase value-based care and alternative payment models within long-term care. We've seen increased adoption of value-based care or alternative payment models targeted to acute care with physicians and hospitals, and we're seeing broad adoption of these strategies within community-based service providers. This is helping them take an active role in benefiting from the care that they're providing and certainly how they are leaving individuals better than perhaps they even found them.

We're seeing specific adoption in innovations around the national social isolation and loneliness epidemic. We’ve found that there are innovations that we can bring to market that address these needs, improve health outcomes, and reduce spending by health plans. 

We’ve also noted a focus on transitioning from institutional care to community care. Managed care organizations have created some impressive strategies to ensure that individuals are supported to be successful when they transition from a hospital, nursing facility, or Intermediate Care Facilities (ICF) back to home. This support can reduce recidivism back to an institutional setting. We've seen a continued prioritization of community over institutional care. Health plans across the country have stepped up to this challenge and have supported thousands of individuals transitioning out of institutional care communities. 

What are some key challenges and opportunities facing states as they navigate the expansion and optimization of MLTSS programs, especially considering recent health care reforms and budget constraints? 

We have had a lot of transitions, certainly with the recent public health emergency, and we have the opportunity for individuals to maintain their eligibility for several years. However, as the public health emergency ended, we saw significant numbers of people no longer eligible for Medicaid. While we're typically not talking about individuals who might be older or disabled or those who have an intellectual developmental disability, just the fact that there were fewer people within a managed care system created some concern for health plans. On the one hand, you have a reduced population. On the other hand, the ARPA (American Rescue Plan Act of 2021) spending and what we would refer to as our home and community-based services spending initiatives was also coming to an end. Now, there are health plans that have been delegated responsibility for the coordination of care for complex populations.

When most people think of Medicaid, they think of children and pregnant women. But if you dig into managed care, while most individuals within a program might be pregnant women and children, the most complex coordination of care falls to those individuals with disabilities, who are older, and who have intellectual and developmental disabilities. In this way, the smallest percentage of individuals within managed care contribute to the highest cost. 

States are focusing on how to contain costs. Instead of reducing or limiting access to services, they need to provide services in the most meaningful and effective way that individuals can access. Unnecessary acute care utilization can be avoided if preventative care is available when needed most. 

Another challenge in the expansion of MLTSS is the incorrect notion that “one size fits all”. When you think of the unique needs of populations, you think of managed care in general being built around a medical model. However, in populations such as those with intellectual and developmental disabilities, the focus changes. For those individuals, it's a social model that focuses on supporting independence through employment assistance. We need to create and diversify programs and models that allow everybody to access the types of services they need. 

There also have been changes to how services for duals are supported. Many states were early adopters of MMP (Medicaid and Medicare programs). Many states are moving away from those demonstrations and trying to figure out how to solidify models within managed care that can support individuals who have both Medicare and Medicaid. Some states adopt strategies that mandate Dual Eligible Special Needs Plans (D-SNPs) within counties they support.

The goal around this is not to affect choice. We want individuals to be able to choose the plans that coordinate care on their behalf, whether it be Medicaid or Medicare. But, we also want to look out for individuals who do not need care and have the opportunity to align their services under one payer. When one organization is managing care, it can eliminate fragmentation. 

Another key challenge facing states is workforce challenges. For all the years I spent in state service, we knew workforce challenges were ahead of us because of increasing needs and demand for services without enough workers to meet them. I think all states are struggling with how to incent managed co-organizations to try to address workforce challenges, whether it be aligning with community colleges or institutions to try to attract, retain, and train workers or just test out different models like self-direction to empower individuals to take control of their care. Workforce challenges are present in many scenarios and MLTS has done well at focusing on workforce challenges.  

States also need help with their budgets. Appropriations are often considered reduced federal dollars coming from the public health emergency, the ARPA spending, and the HCBS (Home and Community-Based Services) spending. States are struggling with the increased demand for benefits and have limited general revenue to meet the needs of individuals. When discussing budget pressure, I want to make sure people don't think we mean ratchet down on care and ensure people don't get anything. Budget pressure means aligning standards, contract principles, and oversight so that people receive what they need at the right time and in the right amount.

Can you highlight any success stories or notable outcomes resulting from MLTSS programs that demonstrate their value in improving the lives of Medicaid beneficiaries?

As I mentioned, we've seen a lot of improved health outcomes. The data shows reduced acute carry utilization. We've seen successful implementation of alternative payment models, home health agencies, private duty nursing companies, and other providers are now putting skin in the game. They're bearing risk, supporting managed care organizations, and ensuring that services are being provided. This can either result in associated shared savings or an increased reimbursement because of being the eyes and ears of managed care organizations and connecting back into that service coordination process. 

Part of this resulted from what we saw during the public health emergency. Still, we've seen a significant expansion of food insecurity support, expansion of nutrition, and adoption of food as medicine programs. We’ve seen direct caregiver support programs are driven to ensure the success of informal caregivers and their ability to sustain their important role as caregivers. We've seen the expansion of self-direction precipitated by workforce challenges. Through managed care expansion of self-direction, an increased number of individuals are managing their own care and an overall increase in person-centered planning. 

In your opinion, what does the future of MLTSS look like and what steps are necessary to enhance its effectiveness and sustainability in Medicaid managed care?

I don't have a crystal ball, but I've often pretended I did. First, we'll continue to see adoption and growth within managed long-term services and supports. An exciting expectation we have is to continue seeing opportunities for innovation and flexibility for states, managed care organizations, and service providers to try things out that go all the way up to federal partners. We’ve never seen these high rates of innovation before. For those of us who've been around this industry for a long time, it's just been over the last decade that we've seen organizations take on an entrepreneurial spirit and try new things. We must create an environment where people are not guinea pigs, but we know what people want and how they respond. These notions of innovation and flexibility are key at the federal, state, management, provider, and consumer level. 
Individuals need an active role in deciding what works best for them and trying things out. Also, with so much adoption of MLTSS, we must focus on improving measures for long-term services and support. We have a suite of health and outcome measures focused on specific acute care needs, diagnosis, management of A1C, etc. But haven't adopted national measures that focus just on LTSS. It's hard to compare state to state if you all use different measurements. 

Having been a Medicaid director, I know how important it is that the contracts we secure and execute with managed care organizations are packed with standards. Many states are taking a timely choice to reflect on and update standards. Sometimes we assume managed care organizations are going to do things just as we hope they will. Even though they know as much as we do about these populations, providing training and support and an opportunity for stakeholders, providers, advocates, and families to be at the table when we're designing these programs is the only way to ensure that the unique needs of these populations are addressed. It's much easier to take time and get it right at the beginning than for a state to move forward, have a failed experience, and lose credibility and the trust of people with the greatest need. 

Have you and your team encountered any unique challenges and opportunities when advising clients on managed or long-term care initiatives, especially in the context of evolving health care policies and regulations?

Our mission as a firm to ensure that we're paying attention and digging into federal and state policy. When it comes to clients, everyone believes their product is special. We've seen lots of products and we've seen lots of solutions. An important question for clients is how can we keep them innovative. How do we craft a message not just tied to data and outcomes but that tells a story? We want to be aligned with solutions with the greatest potential to serve as a disruptor and to effect positive change. 

Managed care organizations have tremendous pressure and stress. I always say that many states have tried to manage care as well as they could for many years without great success and then moved to manage care, expecting someone else to figure it out. We help managed care organizations meet the basics then also think outside of the box to test innovations. The Medicaid of today is not our grandparent's Medicaid. It is a different dynamic of financial and political pressures that create new challenges for providers, organizations, and the people who rely on these programs. We try to work in the competitive nature of the managed care business to help our partner organizations tell their story. Don't just talk about what you want to do, talk about what you have done and demonstrate the value you've already been bringing to Medicaid systems. 

Finally, could you share your perspective on the potential for MLTSS programs to drive health care innovation and promote independence among aging populations in the United States?

I care deeply about these programs across the country and for the people they are designed to serve. To any Medicaid director contemplating this shift, I would say this is an opportunity to integrate both the acute and long-term services and supports in a meaningful way. States who have made it through this process would tell you that, because of those efforts, they've been able to serve more people. They've been able to expand waiver programs and ensure all individuals who are trying to access state plan benefits can do so.  

Managed care creates a great opportunity to focus on rebalancing through MLTSS and what we're trying to drive in terms of health care innovation and promoting independence. We don't give managed care organizations all the credit for our rebalancing efforts, but they certainly play an important role in ensuring that individuals access care where they want and how they want.

We’ve been able to install plans to keep that momentum moving and ensure people are accessing community care. I'm most excited about the opportunity for managed care organizations to partner with community service providers. At the end of the day, they are the organizations that are directly impacting people's lives. It is exciting to help establish an alternative payment model, support providers, and bring innovation to community partners.