Indiana ‚— John is a 72-year-old retired farmer who spends his time painting, playing cards with his friends, and reading. He also lives alone, battles lung disease and has been in a wheelchair for the past year.
His children worry about him. They want him to consider a nursing home.
But John doesn’t want to move into a facility, and he won’t have to after the state launches a new program in July called Indiana Pathways for Aging.
John, whose last name was not provided, is just one example the state is using to show how Pathways will review and improve how Hoosiers age 60 and older with Medicaid will access and receive services.
The goal is to make it easier for residents to receive benefits that allow them to live independently for as long as they want before receiving care in long-term (and expensive) facilities like nursing homes, according to the Indiana Social and Family Services Administration, who is administering the program.
The FSSA says it anticipates that 75% of Hoosiers who join the program will be able to receive long-term care at home. That includes John, who qualifies for daily home health checks along with transportation to a local adult day center.
“Thanks to this support and more, John can continue to live life on his own terms,” the agency said.
HOW DOES IT WORK
Making this a reality involves the state transforming the way seniors receive Medicaid benefits and services.
The state now requires Hoosiers age 60 and older who receive Medicaid to enroll in Pathways. They will choose from one of three health plans offered by insurance giants Anthem, Humana or UnitedHealthcare for their Medicaid program.
Seniors must also complete a health assessment, which the health plan will use to create a personalized care path based on the users’ preferences and needs.
Health plan providers will oversee each patient’s overall care, a fundamental change in the way seniors currently interact with Medicaid. Providers are defined as managed care entities and each will be responsible for ensuring that users receive the specific type of care they need.
To do that, each entity will hire and contract workers to coordinate directly with each senior and their doctors, in-home providers, and Medicaid and state health programs to create integrated coordination among all involved.
The end result should be that seniors receive more appropriate care, primarily at home, in an easier and more efficient way, explained Kristen LaEace, executive director of the Indiana Association of Regional Agencies on Aging.
“The goal is for the person to be in the right environment and receive the right care at the right time,” he said. “There is great hope that it will help minimize the need for nursing facility confinement.”
‘IT MAKES SENSE FOR INDIANA’
Indiana agencies have been preparing for years to switch to Pathways, which Medicaid defines as long-term managed services and supports.
The programs, which are approved under federal Medicaid authorities, have existed since 1989 and can be operated in a variety of ways. Today, 25 states use one.
The focus has grown rapidly over the past decade as Medicaid costs have skyrocketed, leaving many states struggling to pay or budget for the growing number of people enrolling in the federal health program aimed at low-income seniors. .
By setting preset rates and reimbursements, states have more predictability about how much they will spend on Medicaid, explained Sarah Triano, associate director of the Center for Healthcare Strategies, which works with states to improve Medicaid outcomes.
This is especially critical in Indiana after the state’s Medicaid office last year discovered a forecast error that resulted in a nearly $1 billion budget shortfall. The agency immediately began looking to cut costs.
Michele Holtkamp, public affairs director for FSSA, said the Pathways program is “expected to help better manage or control the rising costs of providing health care to the growing aging population.”
Long-term managed care plans also have a history of allowing seniors to live at home longer before needing expensive care in a nursing facility, Triano noted.
This is desperately needed in Indiana, he said.
The state ranks in the bottom 10 in how much it spends on home services through Medicaid long-term care funding, according to the American Association of Retired Persons. Instead, most of that funding goes toward higher-cost institutional care.
Triano said Pathways “will help Indiana rebalance and really focus its resources so that people can stay in their community with their families in their homes.”
INNOVATIONS AND ERRORS
After more than 30 years of watching other states operate managed care programs, Indiana is implementing some innovative approaches that could make it a national leader, Triano said.
Pathways “will have seamless coordination of benefits” for those on Medicaid and Medicare, according to FSSA. Previously, Hoosiers had to deal with each plan separately. The move will reduce the confusion that often arises when navigating multiple benefit programs, FSSA noted.
Indiana is one of the few states that requires health plans to specifically describe how they will provide quality care management to their users to ensure positive health outcomes. The state has determined the program’s health outcome goals for the early years, FSSA’s Holtkamp said.
Managed care entities are financially liable if they fail to meet program requirements, such as completing initial health screenings or competently coordinating care plans for patients, he said.
Triano said that approach is a proven practice and establishes critical barriers to ensure that managed care entities do not provide mediocre service.
“Indiana requires that these plans not just say on paper that they are integrating care for people with Medicaid and Medicare, but that they are actually doing it in practice,” he said.
LaEace, of Area Agencies on Aging, said the initial success of Pathways will really depend on how well the state and managed care entities work with seniors to understand how to navigate the new system, which could be detrimental to adults. older people familiar with the previous system.
“They certainly hope to minimize some of that disruption and avoid difficulties that perhaps other states have experienced,” he said. “But no one is naive. There will be wrinkles and problems. “It’s just something people are going to have to work on.”
Holtkamp said that ahead of the launch of Pathways on July 1, FSSA continues to work extensively with providers to ensure they understand how to file their claims and receive payment for services provided.
All Pathway members have chosen or been assigned a health plan and should receive their welcome package in June from their managed care entity, he said.
With all the innovative approaches Indiana is implementing, Triano said, those involved in the world of managing Medicaid services will be watching the state closely to see how well the new program achieves its goals.
“I’m looking forward to seeing how Indiana does,” she said.
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