Formerly IGSW News | VOLUME 23 | WINTER–SPRING 2016

News and Views

Implications for consumers and the aging network

Managing Integrated Acute and Long-Term Services

By Robert Applebaum

These days we are seeing a strong push to integrate acute and long-term services, primarily through risk-based managed-care models. The push has come from the federal government, through the Centers for Medicare and Medicaid Services, and from the states themselves, to address concerns about the quality and cost of the health and long-term care system.

Fragmentation is at the heart of these concerns. Acute care, institutional long-term care, and community-based services, not to mention funding sources, are all in separate silos. Each organization typically is well-versed in the workings of its own part of the world, but less so for those of the other components. Negative outcomes, such as inappropriate hospital re-admissions, unnecessary nursing home placement, or overlapping in-home providers are the result. In many instances, fragmentation translates into an inefficient, irrational, and expensive delivery system—and poor quality of care.

Integrated care, on the other hand, is seen as having built-in incentives to do the right thing. These incentives could really help to create a more rational system. If all the health and long-term services entities funded by Medicare and Medicaid—the hospital, the skilled home-health agency, and the agency providing long-term services—are working for the same organization (usually managed care), that organization has a strong financial incentive to see that the providers all work together successfully. That will mean improved services for consumers—and, the thinking is, better outcomes at lower cost.

Risk-based, managed-care models are the choice of most states that are exploring strategies to integrate care for individuals eligible for Medicare and Medicaid. Rather than relying on fee-for-service reimbursement, these models rely on capitated payment (a set amount per person). This arrangement increases the incentive to integrate care, but also is a big change for most community-based service agencies. For them, the new environment presents challenges and some opportunities.

A new role for the aging network? Perhaps the biggest challenge for the aging network in an integrated care world is establishing a role for itself. For example, the aging network through the area agencies on aging has long been the leader in developing and managing home and community-based services. Will this role now be performed by managed-care organizations?

Similarly, since their inception, the area agencies on aging have been a source of unbiased information for consumers looking for assistance. Can a sub-contractual role with a managed-care entity threaten the neutrality of area agencies?

Another of the important responsibilities of the aging network has been to provide supportive and preventive services to a range of older people in the community through an array of local, state, and federal programs. Less than 10 percent of older people living in the community are eligible for the Medicaid program, but two-thirds of nursing home residents across the nation are supported by Medicaid. Through their involvement with home and community-based services, the area agencies are able to leverage Medicaid funds to support community outreach and information and referral services. A reduction or removal of the home and community-based services infrastructure support could have a wide-scale negative impact on the large number of older people served in today's aging network.

Opportunities. Of course, the rise of managed integrated care also provides opportunities for aging network and other community-based agencies. For example, some are marketing their expertise in care coordination and other services to managed-care organizations.

There are many issues to consider as the aging services system continues to experience change. What impact managed integrated care will have on the aging network and older consumers and their families is uncertain.

Robert Applebaum, Ph.D., is professor of gerontology and director, Ohio Long-Term Care Research Project, Scripps Gerontology Center, Miami University, Oxford, Ohio.

Photo of Robert Applebaum courtesy Scripps Gerontology Center

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