- Managed care payers and state Medicaid agencies are finding it difficult to find personnel to administer long-term support services (LTSS) within home and community-based settings (HCBS), says a new GAO report.
Currently, Medicaid spends $167 billion a year to cover LTSS through state Medicaid programs and managed care organizations (MCOs) in either institutional settings or HCBS.
As patients age, they are more likely to need long-term care support, and are increasingly expressing a preference for receiving that support in their own homes, GAO found.
“Medicaid spending on LTSS is significant, representing about 30 percent of total Medicaid program spending in fiscal year 2016, and the percentage of LTSS spending used for HCBS has grown over time,” GAO said.
“According to a 2018 CMS report, 24 states had implemented 41 managed care LTSS (MLTSS) programs as of August 2017, and there were about 1.8 million Medicaid beneficiaries enrolled in MLTSS programs.”
Recruiting and retaining professionals to administer HCBS LTSS has proved extremely challenging for managed care payers.
Managed care payers told GAO that low wages contribute to workforce shortages and make it hard to retain workers to assist beneficiaries with daily living activities. Payers noted that many direct care workers can earn more money working at fast food restaurants or accepting other employment opportunities.
State officials and MCO officials from Montana and Mississippi also told GAO that workforce shortages are also extremely common in rural areas. The officials explained that it is difficult to get direct care workers to travel long distances to only work a few hours for a low wage.
Managed care organizations and state governments are trying to address workforce challenges by increasing provider wages, GAO said.
In 2017, the Montana legislature approved a new spending provision that increased reimbursement rates for HCBS providers to create a more competitive wage. The increased wage may be particularly beneficial to rural care provider organizations.
Managed care payers are also addressing workforce shortages by allowing family members to become paid caretakers. Beneficiaries enrolled in HCBS services for LTSS can ask friends, family members, or neighbors to become caretakers, which may reduce provider turnover and ease financial burdens for those devoting time to previously unpaid care.
Many MCOs and state Medicaid programs experienced high participation rates in these programs during 2017.
“Arizona officials said that roughly half of beneficiaries in its HCBS program who were receiving personal care services got their care from family members, including spouses and parents of adult children living in the home,” GAO said.
For beneficiaries with significant mental or behavioral healthcare challenges, providing care can be an even more problematic task.
Conditions such as dementia and traumatic brain injury are common among LTSS beneficiaries and create additional stressors for providers, managed care payers told GAO.
Payers have responded to these challenges by developing condition-specific LTSS programs, training providers to manage behavioral health conditions, and increasing care coordination within HCBS.
GAO found that one MCO worked with nurses in a community setting to develop adult foster homes as an alternative to institutional care. State officials in Montana reached out to assisted living facility owners and educated these owners about best practices for providing care to members with traumatic brain injuries.
MCOs can also send behavioral health specialists into assisted living facilities to train staff on how to manage a patient’s mental health issues. Managed care payers emphasized a need for a care coordination model that integrates medical and behavioral healthcare under a single managed care contract.
“Officials from one MCO said this model of care will help better identify and coordinate care, for example, for children with autism and a co-occurring behavioral health condition,” GAO explained.
In addition to these challenges, organizations pointed out that limited funding for HCBS programs can prevent the delivery of quality care.
States including Arizona, Mississippi, Oregon, and Florida said that state legislatures did not budget properly for HCBS, leading to shortages in HCBS beds, services, and staff. In addition, state governments also found that sometimes Medicaid budgets fail to cover the total cost of HCBS.
States responded to budgetary challenges by using federal waivers to secure new funding sources. For example, GAO said some state governments rely on the Money Follows the Person demonstration to receive extra funds for transitioning beneficiaries from institutionalized care to HCBS settings.
MCOs and states are hopeful that wage growth, federal funding, and integrated care can address HBCS staffing concerns. However, MCOs and states may need to rethink their entire HCBS programs if staffing issues still remain, GAO concluded.
“Given the variety of options available for providing HCBS and the wide variation in HCBS spending among states, questions arise about how states are structuring their HCBS programs, as well as challenges they may face in providing access to these services,” GAO said.