Authors’ Note: During the past year, the aging network and the world of gerontology suffered the grievous loss of Dr. Rosalie Kane, a tireless investigator, author, speaker, and advocate, who concentrated much of her work on care management. When this edition of Generations was originally conceived, Dr. Kane had agreed to write this article. Both current authors were longtime friends and collaborators (sometimes co-conspirators) with Rosalie, and we have been asked to take on the impossible task of trying to fill her shoes.
In addition, we are to try “channeling” (a little insider humor for those of us who have been around this topic for a long time) Rosalie’s thoughts into the discussion. It should not be too hard, because Rosalie was an unforgettable person to know and work with. Our article is written as a dialog, in which we tried to include Rosalie as our third participant. We all wish she was still here to bring her invaluable perspective to the discussion.
Richard Browdie (RB): My experience is that care management has always been a topic that engendered conflict and passionate debate. Going back to the early 1980s and the National Channeling Demonstration, the appropriateness of having any professional other than a nurse perform assessments and care plans generated concern and argument. As things have evolved, and largely as a consequence of the introduction of commercial Managed Care Organizations (MCOs), care management functions have been broken into component roles, and debate remains about what should be included in care management practice and who should do what.
I would bet Rosalie would have been opposed to this development for a couple of reasons. First, fragmenting the functions of care management, such as separating assessment from care planning or separating an ongoing relationship of care manager and plan monitor, could lead to quality concerns. Second, separating those advocating for the interests of the consumer from resource allocation could compromise the decision-making process. Third, Rosalie would likely have been concerned with role continuity problems, which would end up negatively impacting the consumer. And, Rosalie always worried that the pursuit of profitability would inevitably threaten care quality.
Another big issue is what should be the organizational setting for care management? For many years, care management was seen as so complex it required highly skilled, experienced people to do it. Further, it needed to happen in a context where no incentives beyond the consumer’s well-being (in balance with government policy limitations), would weigh on the work of the care manager.
This school of thought recognized the role of care management as being a hub in the system, where the constraints of resources, ever present in the public domain, would be wrestled with by the care manager, whose mission was to do as much as a person needed without spending more than was required. Perhaps even more important, the organizational context for that work permitted and anticipated continuous scrutiny by government funders to assure that the sought-after balance was always pursued to the greatest degree possible.
Tension existed from the beginning between those advocating for community-based agencies like Area Agencies on Aging to perform care management as it related to accessing services they funded, as opposed to those who felt that because those agencies managed such services funding, it gave them a reason to underserve consumers and stretch their services further to reach more people. Of course, state budget offices saw this as a good thing. But consumer advocates, especially advocates for consumers with severe lifelong disabilities acquired before the traditional markers of old age, lobbied vigorously for a different approach.
‘Rosalie would be incensed to learn that one of the most important roles in the entire LTSS system has been reduced to “secret sauce.” ’
Advocates for all kinds of consumers came to realize that the main problem was that access to these services was limited by available funding. At the time, most often funds came from the Older Americans Act and a range of other state and local sources, with a few federal sources where discretion was available, such as Title XX of the Social Security Act. Once achieving an entitlement through expanding eligibility criteria under Medicaid became common purpose, the role played by care management became even more important, and pressure became even greater to move it away from community-based agencies. The drive to create broader entitlements to Medicaid services led to an even greater interest in giving control of Medicaid funds over to agencies that could take the risk of negotiating rates for large populations over a year or more. Thus, the role of commercial entities, used to doing this sort of thing profitably in the health insurance field, began to grow in the long-term services and supports (LTSS) arena. And because of its resource-allocation role, care management began to go with it.
Rosalie viewed all of this with concern and even distress. Rosalie was a great believer in transparency, particularly into the machinery and the results of care management operations. She knew how important they were to the mission of matching resources to needs for people who, for a number of reasons, may have difficulty articulating their needs and preferences, which is the essence of the care management role. In today’s managed-care environment, regulators care about eligibility operations and the ability of a plan to stay within its contractual limits across its contract. Over-serving is not of concern because regulators believe, probably correctly, that no commercial enterprise is going to do more for a consumer than is necessary to satisfy that consumer’s needs as expressed in the contract. Further, if consumers are unhappy, they are free to complain and the MCOs are expected to satisfy them. How MCOs accomplish this is not really of concern to the government. Plus, in many states the clinical and statistical methods used to guide care planning are considered proprietary, which shields them from public scrutiny. Rosalie did not, and would not, approve.
Larry Polivka (LP) Rosalie and I generally agreed upon many issues, especially the significance of the comprehensive Aging Network–based Oregon and Washington LTSS systems as a model for what LTSS should become in other states. And for a national LTSS policy formulated by Congress and executed through the Centers for Medicare & Medicaid (CMS). Such a model would center on consumer-, (person)-centered, community-based, relatively autonomous care management of the kind that had by 1990 been implemented in Oregon and Washington in LTSS systems, which included all publicly funded LTSS programs from Home- and Community-based Services (HCBS) to nursing home care.
The effectiveness and efficiency of these two state systems inspired a 1994–1995 effort in Florida to develop a managed-care LTSS model that would combine Medicaid HCBS and nursing care programs under a single capitation-based rate and be administered through the Aging Network that had for several years already been administering Medicaid HCBS waiver-funded programs. The Aging Network veterans planning this new LTSS model wanted to emulate the comprehensive state systems of Oregon and Washington through the Aging Network–based nonprofit model. This model used a capitation approach to administrative consolidation properly incentivized to shift Medicaid resources from nursing home care to HCBS programs. Political opposition to this new model of nonprofit LTSS led to defeat of proposed implementing legislation, and a variant of the model, the Wisconsin Family Care (WFC) program, is now one of the country’s best state LTSS programs.
Rosalie had several concerns about this development and its longer range implications for the future of cost-effective, person-oriented, community-embedded, and comprehensive long-term care (LTC) programs. Foremost among them was the fate of care management, which she had done so much to teach the LTC community, policymakers, and the media to understand and appreciate over the course of her decades of conducting research, teaching, mentoring, presenting papers, and leading conference discussions.
‘The challenge to avoid unnecessary institutionalization is a constant, and the key to effectiveness and efficiency is care management.’
As Richard notes, she thought that effective care management was fundamentally essential to avoiding conflicts of interest between service providers and those who should be able to decide the kinds and amounts of services LTC recipients needed and could most benefit from in meeting their LTC needs.
Rosalie also felt that the march to managed LTC would not just undermine effective, person-focused care management, but also could well end up drawing other critical policy and program matters into the Health Maintenance Organization (HMO) black hole and away from the policymakers and administrators normally expected to be responsible for policy and accountability.
We have good reason to believe that Rosalie’s concern was well-founded, based upon what we know about the impact in states with extensive Medicaid Managed Long-term Care (MLTC) programs. Florida, for example, has since 2014 had a statewide corporate MLTC program, and across that time period the many energetic and continuous debates that had characterized the legislative LTSS policy process for years gradually disappeared. The perception that all such matters, from the kinds of services provided, in what amounts, and to whom, to ensuring effective accountability for delivering cost-effective services, were now the responsibility of the HMOs rather than policymakers.
The only or at least overriding policymaker concern was that the MLTC model would make the annual budget more predictable and gradually lower than the traditional fee-for-service model of LTSS services. At this point there is little evidence that the MLTSS model is reducing Medicaid LTC costs. In Florida, annual LTC appropriations aren’t any lower with MLTC. We have clear evidence, however, that the number of Medicaid-eligible persons with unmet LTC needs are increasing by 5,000 to 10,000 annually. This may change now, however, as the state moves to alter the criteria for being placed on the Medicaid waitlist for services, which will reduce the waitlist immediately by several fold.
RB: Broad consensus has been hard to reach over what constitutes quality in care management and which factors are more important than others. For a number of years, quality was associated with extensive training and consistent oversight of the people asking questions of consumers, assuring the questions asked met assessment requirements for completeness and internal consistency, and then discussion of a person’s needs before finalizing a care plan. Built upon long-standing best practices in nursing and social work, quality in care management was seen as a matter of the amount of time and the kinds of professionals that were involved in the process of decision making, and assuring that the process was accomplishing everything that was required.
Over time, this deliberative and time-consuming process ran afoul of budgetary concerns as demand for services grew, and the demands began to grow to make care management itself less expensive and faster. Some places began to place greater emphasis on what we would now call machine learning, after it was observed that even with the discussion of individual detail, the service plans that resulted looked quite a lot alike. Analysis led to the development of paradigms that led to the creation of norms for what to do based on categorizing the number and intensity of needs observed, resulting in the algorithms that MCOs claim in today’s market place as their “secret sauce.”
Now, care management quality is seen more as an internal organizational matter, with oversight concentrating on documentation and to monitoring the credentials of the people doing the work, much like home healthcare. This is not to say that a lot of good services are being provided. What this does say is that the care management process itself is opaque to payors and to the public.
What would Rosalie say? I think Rosalie would be incensed to learn that one of the most important roles in the entire LTSS system has been reduced to “secret sauce.” She really saw the importance of doing care management as well as possible to best serve those who needed care on an ongoing basis, particularly in a field like LTSS where the objective and statistical measures of success and quality were so few and far between. And to rely upon consumers to complain enough to be heard by regulators was something she would see as a fallacy, given the well-established difficulties experienced by frail older people, particularly those who have no co-dwelling family or friends to speak for them.
What’s In Store for Care Management?
RB: So, what does the future hold for care management? it would be easy to simply say that care management as it was known in the Aging Network is dead and not likely recover, except that there are still places where care management is being delivered at a very high level on behalf of payers other than Medicaid, including MCOs in Medicaid Managed Care companies around the country. And, while it is well known that those states that have evolved that way did so because of vigorous and shrewd advocacy by their Area Agencies on Aging, sometimes with the help of and sometimes in spite of their State Units on Aging, they are performing well and are not going to be easily displaced by the plans or their Medicaid “partners” in state government.
At the same time, the interests MCOS have in having as few as possible other non-commercially controlled interests involved with their work in managing Medicaid funds is not going to change, either. Having community-based agencies involved in care management constitutes a check on their ability to exercise discretion in benefit management, which in LTSS means the management of consumers, and they are never going to want it.
'Rosalie really believed in the good intensions and good work of the social workers, nurses, and others.'
There is no evidence that having care management performed inside an MCO is better, or that it saves money for anyone but the MCO. The states considered most successful in managed LTC or comprehensive care thus far have compelled MCOs to use Area Agencies on Aging as care management partners. However, the fact remains that there is not much evidence based on real evaluation on Managed LTSS at all. So, this remains a topic for debate and opinion.
On this, I think Rosalie and I might say the same thing, but for different reasons. Rosalie really believed in the good intensions and good work of the social workers, nurses, and others who wanted to do this kind of work. You must be well-intended to do it well, because it is hard, and you have to care about the people you’re serving. So for her, getting the other incentives and obligations out of the way and situating care managers in the communities where their consumers live was so important that any other kind of agency and practice model would always be less effective and less responsive.
I, on the other hand, believe that organizational incentives matter. Commercial MCOs exist as commercial enterprises that must be profitable to survive. They must manage LTSS services as a way of finding that profit. Having care management done by a community-based agency makes that harder to do in some people’s minds, but it also resolves a lot of the dilemma about accountability so that the public can have confidence that this work is being done as well as possible. Community agencies will advocate for resources for clients, and MCOs can watch the community agencies and manage the budget if the states don’t want to do it. I am much more comfortable with that model because while I am fine with the government getting out of the business of managing health payments as they don’t want to keep up with the technology to do it well (a reality in many states), I don’t think state Medicaid and aging services authorities should give up on assuring accountability in how these resources impact individuals. Nor do I think the federal government should let them. Everybody needs somebody watching what they do with the public’s money. I think Rosalie would agree with me on this.
LP: I think we know enough to see that Rosalie’s deep concerns about the HMO policy and practice black hole were well-founded as states hand off responsibility for policy and practice to corporate (insurance companies) entities managing their MLTSS programs. As Richard points out, this trend is not occurring in every state with Medicaid MLTC programs. For example, in Ohio, the area agencies on aging have been able to carve out a critical front-end role in the state’s MLTSS program, including an important care management role. In Wisconsin, the highly effective Medicaid MLTSS program is administered through the area agencies and county government agencies rather than through corporate HMOs. The general trend, however, in MLTSS states is toward the marginalization’s of the nonprofit Aging Network in the administration of LTSS services. The Aging Networks’ role in LTSS is increasingly being reduced to community service programs funded through the Older American Act and state general revenue, which together constitute a small fraction of the state Medicaid funds. I think this is precisely the scenario Rosalie feared might occur with the spread of MLTSS programs across the states.
RB/LP: What will happen in the long run? We think the issues discussed here are fundamental enough to have an influence on how things evolve. In the short run, governments, both state and federal, are so beset by problems and challenges of a budgetary and operational nature that it will take time for thinking to come around. The budgetary problems states will face already are becoming severe, and it will not take long for the Medicaid system to arrive at a funding crisis. This could lead some states to explore even more wholesale delegations of responsibility to private insurance companies. But, LTSS has never been particularly profitable, meaning the best reason for an MCO to be involved is to also be able to manage Medicare benefits to the beneficiaries. If government financial conditions become bad enough, they will turn to MCOs to limit costs, and make profitability harder. Many states have seen MCOs come and go. LTSS consumers remain. The challenge to avoid unnecessary institutionalization is a constant, and the key to effectiveness and efficiency is care management. Community-based agencies, like Area Agencies on Aging, have been there for almost fifty years and are fighting hard for the privilege of doing it. They don’t require profitability.
Rosalie would think that was a good thing.
Richard Browdie is founder and principal at Browdie Consulting. Previous to consulting he spent 17 years as President and CEO of the Benjamin Rose Institute on Aging in Cleveland, and about four decades advocating for older adults. Larry Polivka, PhD, is the executive director of the Claude Pepper Center and scholar-in-residence with the Claude Pepper Foundation, at Florida State University in Tallahassee.