What We Know—and Don’t Know—About Access to Long-Term Services and Supports Programs

Long-term services and supports (LTSS) cover a range of services—including nursing facility care, personal care assistance, homemaker services, adult day care, home-delivered meals, and other supports—that help people with functional limitations carry out everyday activities. As of 2015, nearly one million Medicaid beneficiaries used LTSS provided through managed care at a cost of $22.6 billion. The costs of these services are significant, but so is having access for those who need them most. Disruptions in access to LTSS can lead to declines in health and quality of life. 

As state Medicaid agencies increasingly contract with managed care plans to deliver LTSS to older adults and people with disabilities, the ability to accurately measure access to these services has become increasingly important.

In the context of managed LTSS (MLTSS) programs, researchers can measure access along six dimensions:

1. Availability addresses whether participating providers, provider networks, and other resources are adequate to meet the needs of enrollees.
2. Accessibility involves geographic distance and physical barriers that influence whether enrollees can get to their provider or, for services provided in a home or community setting, how far the caregiver has to travel to get to the enrollee.
3. Accommodation reflects the extent to which facility-based providers have operating hours, appointment policies, equipment, and communications technology that meet the constraints and preferences of enrollees.
4. Acceptability captures whether enrollees and providers are comfortable and relate well to one another.
5. Affordability is determined by the costs faced by consumers relative to their ability and willingness to pay. MLTSS enrollees do not typically face cost-sharing requirements, so affordability is less of a concern than other dimensions of access.
6. Realized access is what we would expect to see when the primary dimensions of access come together and result in good access to care.

With support from the Centers for Medicare & Medicaid Services, Mathematica Policy Research and Truven Health Analytics recently published important findings on the implementation and outcomes of MLTSS programs that inform our understanding of realized access and availability in MLTSS. Specifically, they found the following:

• Measures of long-term care service and hospital use in two states provide mixed evidence that MLTSS programs improve realized access. In New York’s Managed Long Term Care program, MLTSS enrollment from 2009 to 2012 was associated with positive trends: less use of institutional care; more use of home and community-based services (HCBS), especially personal care; and less use of hospital care compared with fee-for-service. In Tennessee’s CHOICES program, however, service use trends from 2010 to 2014 were mixed: MLTSS enrollment was associated with increased use of personal care but more hospitalizations, and trends in institutional care use were inconsistent.
• HCBS waiting list data from eight states present a mixed picture regarding availability of HCBS. Though six states either reduced or eliminated HCBS waiting lists after implementing MLTSS programs, variation in how states report wait list data raises questions about their ability to reflect access to HCBS.
• Discussions with Medicaid officials from four states suggest that certain program design features— network adequacy standards, transition of care policies, provider reimbursement levels, and level of care criteria—strongly influence access to care. But the magnitude of their effects on MLTSS are not yet known. States are only beginning to use new measures of network adequacy for LTSS that address realized access (for example, initiating HCBS in a timely manner and providing HCBS according to a care plan), a trend that will likely increase in response to the 2016 Medicaid managed care regulations.

However, these findings inform just two of six domains of access. Future MLTSS evaluations might use newly available data—for example, Transformed Medicaid Statistical Information System (T-MSIS)—to calculate more sophisticated measures of realized access, such as potentially avoidable hospitalizations, risk-adjusted for the characteristics of the HCBS population in each state. Or, they might use new findings on enrollee experience collected through the National Core Indicators-Aging and Disabilities (NCI-AD) survey or the Home and Community-Based Services Consumer Assessment of Healthcare Providers and Systems (HCBS CAHPS) survey to inform domains and questions not yet examined across states or over time. For example, they might inform accessibility (can enrollees reach their case manager/care coordinator when they need to?), acceptability (do paid support staff do things the enrollees want when they want them done?), and accommodation (do homemakers usually or always come to work on time and work for as long as they are supposed to?).

These new data sources and measures will help round out our understanding of how MLTSS programs support access and quality of life, which may in turn shape how LTSS is delivered to the people who need them.