Libby Powers, a 29-year-old disability rights counselor born with spina bifida, understands the state’s pending Community HealthChoices program better than most of the other 80,000 southwestern Pennsylvanians soon to be affected by it.
To the Sewickley resident whose mobility problems already enable her to receive government-funded home care and transportation assistance, this new managed care program that starts Jan. 1 sounds like a good thing.
“It’s going to make everything more streamlined for everyone,” with potentially better communication among health care and in-home providers, said Ms. Powers, an independent-living coordinator for the Disability Options Network, a private, nonprofit agency.
Efficient streamlining and coordination of services for aged Medicare and Medicaid recipients or younger adults with disabilities is indeed the stated thrust of the Wolf administration’s Community HealthChoices initiative. Those goals may not be apparent at this stage, however, to the affected population, which is being asked to select one of three new managed care organizations by Nov. 13. Even consumer advocates supportive of the program’s intent — and many are — say it’s difficult for a vulnerable constituency of sometimes-limited mental abilities to easily grasp its bureaucratic terms, new conditions and sweeping concepts.
These three MCOs are supposed to have service coordinators working with clients in a more comprehensive way than what is possible under current guidelines limiting the work done for them by Area Agency on Aging staff or another government-contracted service coordinators. For instance, in the period after hospital patients are sent home — a time now viewed as having major care gaps — coordinators will be expected to work closely with the consumers, their doctors and home care services to ensure that they get everything they need to avoid costly readmissions, emergency home visits or nursing home stays.
Multiple mailings were sent by the state in recent months to those automatically enrolled in Community HealthChoices, but many remain either unaware of the new program, confused about it or fearful that it’s going to disrupt services to which they have become accustomed.
“Some people are angry about it,” said Fran Chervenak, Pittsburgh senior attorney for the Pennsylvania Health Law Project, which counsels consumers. “We do a lot of easing people’s fears, explaining what it means. … The fact is, it’s not an easy population for whom to make a change, and [it’s not easy] to have them really understand and not be afraid of it.”
The Department of Human Services is hoping to better educate the public with community meetings at 21 sites through Nov 3, including one at 6 p.m. Monday at the Jewish Community Center in Squirrel Hill.
Attendees will hear Community HealthChoices described as a mandatory program for people whose age, income or disability entitles them to government-funded Medicaid services for long-term care support — such as home aides, home modifications, day care services or nursing home stays. Most also qualify for Medicare for their health needs, which Community HealthChoices does not replace; thus those affected still have a separate decision to make concerning private health care coverage such as an Medicare Advantage plan.
Community HealthChoices is being rolled out in 14 southwestern counties at the start of 2018 before being expanded to the rest of the state in phases, with about 420,000 Pennsylvanians a year expected to fall under it.
Here are some key points that will be explained at upcoming meetings in each of the counties, for which consumers received a schedule by mail:
- Those affected are encouraged to use either phone, mail or the internet by Nov. 13 to choose one of the three managed care organizations: UPMC Community HealthChoices, PA Health & Wellness or AmeriHealth Caritas.
- If individuals don’t choose an MCO, the state will assign them to one on an equally distributed basis before Jan. 1, although people can change their plan at any time. State officials say they would prefer that people pick their own plan, but acknowledge that fewer than half have done so in other states with similar programs.
- The three MCOs each have created a network of wide-ranging health and home care providers with whom their service coordinators will work on behalf of consumers. If consumers have an existing relationship they like with a home care agency or primary care physician, they are encouraged to ask that provider which MCO they are part of, as that may influence their decision (though providers can be affiliated with more than one MCO).
- Employees of a state-contracted independent enrollment broker, Maximus, are available at 1-844-824-3655 to answer questions about the MCOs and their networks and help people make their decisions. The MCOs each supplement state-mandated coverage with their own special services — such as dental benefits or, in some cases, rent assistance — that help differentiate them from one another.
- The state is using a six-month transition period through June 30 in which people may continue working with their existing service coordinators and retain all of their current services, even if a provider of home or medical services is not part of their selected MCO’s network.The more than 11,000 Medicaid-funded nursing home residents in the 14 counties may stay in their current facilities as long as they wish, although coordinators will also offer them special assistance to move back into the community if they want.
- Pennsylvania follows more than 20 other states in adopting a managed care process for its delivery of long-term care services, which are paid for on a shared basis by the state and federal government for those who qualify under Medicaid. Those costs amount to $6 billion annually in Pennsylvania, primarily for nursing home care and home services offered under a group of waiver programs that are being consolidated into Community HealthChoices. That $6 billion is now being funneled to the MCOs, who receive what’s known as a “capitated” per-client rate from the state to manage all of those individuals’ needs that are Medicaid-covered.
Some states’ managed care programs have experienced criticism for cuts in services to clients, based on decisions by MCOs. Jen Burnett, overseeing Community HealthChoices as deputy secretary of the state’s Office of Long-Term Living, said that has more commonly been the case in states that adopted managed care with intent to reduce Medicaid spending, unlike Pennsylvania, which she said is only trying to stabilize it.
“If [MCOs] cut services and people decline and end up in the emergency room, that’s not helpful to their bottom line at all,” Ms. Burnett said.
If a client ends up in a nursing home, the MCO likely ends up paying far more for care than that client could have with services delivered at home.
“It’s really about getting people the resources they need to thrive in the community,” said Ray Prushnok, a senior director for UPMC Health Plan. “This isn’t the type of program where we succeed in trimming people’s care plans. Their health is our No. 1 success metric.”
Community HealthChoices will have appeals rights to both the MCO and the state for individuals unhappy with their services, and the state plans detailed assessments and comparisons of the quality of the MCOs’ performance.
In other states’ programs, there has been a “mixed bag” of benefits and harm for consumers, according to Alice Dembner, a senior policy analyst for Community Catalyst, a national health advocacy organization, but she said Pennsylvania in many ways has learned from mistakes made elsewhere. She praised the 180-day transition period during which no one will have to change services, for example, but noted Pennsylvania could also do more to ensure consumers’ rights, such as giving them independent ombudsmen to turn to for help with problems.
And she, Ms. Burnett and Mr. Prushnok all concurred with local consumer advocates that many affected people lack any clear sense yet of what Community HealthChoices will mean to them.
“There’s a lot of apprehension because it’s close to launch time and there’s still so much to know,” said Brenda Dare, an independent living supervisor for Transitional Paths to Independent Living, based in Washington, Pa. “A lot of people are happy with the services they have, because this is what they know, and I think change is difficult for everyone.”