Medicaid has long been the primary payer of long-term services and supports (LTSS) in the United States, with each state designing its own LTSS delivery system. Over the last decade, states have been increasingly moving the delivery of LTSS services away from the traditional fee-for-service (FFS) payment model and toward managed care. States contract with managed care plans because of the plans’ potential to improve care quality, increase access to home and community-based services (HCBS), and control per-person costs for Medicaid beneficiaries requiring LTSS.
Despite the growing use of managed care, evidence on the merits of using it to deliver LTSS has been scarce, and what has been published is largely limited to single-state programs that are difficult to generalize. Oversight agencies, including the Government Accountability Office, have also raised important questions about managed care plans’ ability to ensure timely access and high quality care to enrollees in managed LTSS (MLTSS).
To build the evidence base on MLTSS delivery models, Mathematica conducted a cross-state evaluation of MLTSS programs under a contract with the Centers for Medicaid & Medicare Services (CMS). This evaluation built on a previous study by examining additional states and data sources, including data on access to care and beneficiary experience and quality of life from the National Core Indicators - Aging and Disabilities (NCI-AD) survey. Our findings included the following:
- The effects of MLTSS on nursing facility use, HCBS use, and hospitalizations varied over time and across states and populations. We found favorable effects for some service use and quality of care outcomes—that is, some indication of lower nursing facility use, greater use of some types of HCBS, and fewer hospitalizations—but the effects were not consistent across states and populations.
- Previous state-specific studies have also found mixed results on the impact of MLTSS for similar measures. The mixed findings could be the result of many factors, including differences in state program design, differences in the level of functional need or other characteristics of enrollees in the study and comparison states, data quality problems, and difficulty identifying comparison groups for certain states.
- However, averaged across the NCI-AD survey questions we examined, MLTSS enrollees rated their experience of care and quality of life more favorably than FFS beneficiaries. This finding held across all the survey domains we examined, but the advantages of MLTSS were greater in questions related to access to needed services, peoples’ control over their lives, and maintaining relationships with family and friends.
- Although few prior studies examined MLTSS’ impact on these domains, a 2017 survey aligns with our findings demonstrating favorable impacts of MLTSS on beneficiary quality of life and satisfaction.
- CMS and states should work toward improving data to enable future evaluators to construct a comparable set of measures and outcomes across states. Such data might help advance knowledge on the effects of MLTSS—operating in different states and for different populations—relative to FFS.
“States implementing MLTSS models need to weigh the potential benefits of these programs, such as budget predictability and enhanced beneficiary experience, against potential harms, such as restricted services where managed care plans have financial incentives to reduce LTSS use,” said Senior Researcher Andrea Wysocki and lead author on the report. “Our results suggest consistently favorable impacts for beneficiary experience, including in domains that would be impacted by reduced or restricted LTSS use, potentially mitigating this concern. Our results also provide motivation for improving existing data to build more conclusive evidence on the impact of MLTSS programs on beneficiary outcomes across a range of important measures.”
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