Managed Long Term Services and Supports Committee Recommendations

Loren Anthes
Public Policy Fellow in the Center for Medicaid Policy
The Center for Community Solutions

October 15, 2018

The Center for Community Solutions is a nonpartisan think tank with the mission of providing strategic leadership and organizing community resources to improve health, social and economic conditions through applied demographic research, communication, nonpartisan policy analysis and advocacy.

Community Solutions is pleased to present its recommendations to the Managed Long Term and Services Supports Committee in advance of its report to the General Assembly. The following suggestions represent a high-level review of those issues which we think define the current fragmentation and challenges in the system, as well as the areas for policy development for General Assembly members and the administration to consider.

Remove Revised Code Protections for Providers
Long term services and supports (LTSS), in the multitude of settings and services represented by that term, is the greatest area of spending in Ohio’s Medicaid program. The long term care continuum also remains one of the most fragmented parts of the delivery system. In order to ensure that alignment takes place between the various settings and services associated with this benefit, finances need to support value, evidence and patient preference. For these reasons, leveraging laws to protect the interests of any single provider type maintains regulatory capture by the industry in ways that do not benefit the patient or the long term financial health of the state.

Develop a LTC workforce strategy
One of the major drivers of Ohio’s quality challenges is the shortfall of clinicians and medical professionals who work with the long term care population. Some states have mandated staffing levels in specific settings. While Ohio could consider similar measures, the state should also make strategic investments in its long term care workforce by developing a strategy that considers subsidizing the education and credentialing of individuals interested in the field. This strategy should look at those quality metrics that most depend on staffing as the priority.

Case Management
The ability to help individuals navigate the complexities of settings, coverage options, benefits and transitions in long term care is central to creating better value. However, this management currently happens in a number of settings with various individuals, including insurers, hospitals, family caregivers, Area Agency on Aging (AAA) coordinators, institutional staff and others. In some settings, this work is subsidized and medicalized. In others, it is informal or dependent on an individual’s personal efforts in directing their care. Policies should reflect and incent case management for the populations served in managed care, focusing on transitions of care.

Specifically, if the state is intending to carve LTSS into managed care, more should be done to ensure case management is taking place in settings that are most effective. In the case of MyCare Ohio, for example, the state reimburses AAAs for some of this function, seeking a waiver from the National Committee for Quality Assurance (NCQA) standards for this type of subcontracting with managed care. Depending on the level of need, the “who” of this may change, though it should be done in a manner consistent with the choices of consumers. Pursuant to federal regulations regarding managed care LTSS, the state should intentionally include consumers in this process. What’s more, the Ohio Department of Medicaid should engage LeanOhio to help determine the best way to process map the management of care along the continuum.

Reducing Provider Burden
While LTSS represents a significant investment by the state, providers are often faced with the difficulties of maintaining their services with current reimbursement. This is especially true as smaller, independent entities do not have access to the same resources as larger organizations to address their needs in an increasingly complex system. These needs include, but are not limited to, credentialing, electronic health records, staffing, revenue cycle management and other clinically-based documentation.

Beyond increasing rates, the state of Ohio should consider ways to reduce the expenses of providers delivering services. This can include examining scope of practice laws that may not improve the clinical efficacy of any given service, but make the process of delivering services more difficult (for example, medication administration). Other considerations could include more standardization of contract with managed care, subsidizing the purchase of electronic management systems and the cost of increasing and advancing certain credentialing.

Address Social Determinants
The health needs of individuals in the LTSS system are not addressed by health system alone. Many individuals in LTSS rely on the Supplemental Nutrition Assistance Program for food, public transit to make their appointments, subsidized housing to stay out of institutions and local senior services block grant dollars to address their most basic needs.

If the General Assembly would like to improve the LTSS system, it needs to look beyond the LTSS system and support policies proven to lower costs and improve outcomes and quality of life for individuals who rely on it for their care. This means the state of Ohio should improve access and functionality of each of these supports, and others, as ways to maintain independence and diminish the downstream need for clinical interventions in acute and institutional settings.

We would like to think Chairs Mark Romanchuk and David Burke for conducting a thorough review of Ohio’s LTSS system. We would also like to thank the various committee members and organizations who have contributed to the effort.

In order to ensure Ohio’s LTSS system is sustainable and effective, the system needs to fundamentally shift its priorities and how it’s designed. We are hopeful the final report includes and considers our suggestions and look forward to working on this issue in the future.

Please reach out to us with any questions or for additional information via Community Solutions’ Public Policy Fellow in the Center for Medicaid Policy, Loren Anthes ( Thank you for the opportunity to provide input.