1. Reorganizing LTSS in 2017: The 4 Pillars
Rodney L. Whitlock
Vice President, Health Policy
ML Strategies

2. 2017: Not What We Were Expecting

3. Major Programmatic Reform is on the Table

4. What is the goal of programmatic reform?
Improve efficiency or save money?

6. How do you provide care most efficiently?

7. The Problem in LTSS
Two programs providing coverage with disparate incentives.
Medicare provides acute care.
Medicaid provides LTSS for a specific population.

8. The 4 Pillars for Reorganizing LTSS
Care Across the Continuum
Provider Risk
Assignment
Full availability and participation

9. When can you reduce the intensity of LTSS utilization?
Once in LTSS versus before LTSS utilization begins.

10. Care Across the Continuum
Segmented programs necessarily face greater challenges to be efficient.
Programs with artificial limitations face greater challenges to be efficient.
In the current system, some of the greatest success stories are those that break down barriers and limitations like PACE and iSNPs.
To be more efficient, the system needs to move to cover across the full continuum of care.

11. “We are moving Medicare and the entire health care system toward paying providers based on the quality, rather than the quantity of care they give patients."
– Sylvia Burwell

12. Provider Risk
Many have argued for years that provider risk drives efficient behavior in a way that cannot occur under fee-for-service.
Through the ACA and MACRA, the federal government has now charted a course to move away from pure fee-for-service.
Through ACOs, MIPs, CPC+ and other programs, CMS is moving in the direction of provider risk.
Providers can be traditional insurance plans or risk-bearing health system arrangements.
Providers need to bear financial risk across the continuum of care.

13. Assignment If providers provide care across the continuum …
If providers bear risk for doing so …
Then having some level of assignment is critical.
Assignment allows risk-bearing providers to control data and quality.
People retiring today have spent much of the insured lives in some degree of assigned relationship, either through an HMO or a PPO.

14. Full Availability and Participation
Medicare provides acute services to seniors.
The program works because it is available to all and has incentives to cause all seniors to participate.
Any efficient program will work under the same principles as the existing program.
Low-income only strategies encourage gaming and therefore inefficiency.

15. Putting the Pieces Together
Acute and LTSS need to be under the same roof.
Coverage under that roof needs to be provided by risk-bearing providers.
Those providers need to have some level of dependable assignment of the population.
The population needs to have incentives to participate similar to existing Medicare.

16. The Worst Thing Congress Could Do …
Would be to further silo acute and LTSS through a block grant or a per capita cap reform to the Medicaid program.

17. A Future Medicare
Currently the Medicare Advantage program provides Part A, Part B and Part D services to Medicare beneficiaries.
Currently risk-bearing provider-based ACOs deliver Part A and Part B services to Medicare beneficiaries.
A future Medicare could have risk-bearing providers deliver Part A, Part B, Part D and LTSS (Part E) services to Medicare beneficiaries.