Rebalancing in Capitated Medicaid Managed Long-Term Services and Supports Programs: Key Issues from a Roundtable Discussion on Measuring Performance

Medicaid is an important source of health insurance coverage for seniors and non-elderly people with disabilities who rely on the program for essential long-term services and supports (LTSS) to assist with activities of daily living and maintain their independence in the community. Although the program has an historical bias toward funding institutional care, states have been working to rebalance their LTSS systems by devoting a greater percentage of spending to home and community-based services (HCBS). There is increasing state interest in managed long-term services and supports (MLTSS) delivery systems, and states indicate that incentives in MLTSS programs are expected to increase beneficiary access to HCBS. To explore issues related to how rebalancing progress in capitated Medicaid MLTSS programs is measured, the Kaiser Commission on Medicaid and the Uninsured convened a roundtable meeting on November 13, 2014 with a group of federal and state officials and other experts.

Key issues related to measuring performance in rebalancing identified by the roundtable participants include:

Including and using existing measures to assess current MLTSS programs.

Formulating a strategy for how MLTSS will further rebalancing and including detailed measures to assess progress are important parts of state implementation of MLTSS programs. Because beneficiaries presently are receiving services through MLTSS, it is important to assess current MLTSS programs’ impact on rebalancing. In addition to yielding insights on the performance of existing MLTSS programs, rebalancing measures may help to inform more standardized approaches to assessing system performance.

Further developing measures to assess MLTSS programs’ effect on rebalancing.

While some measures exist, rebalancing remains a current gap in assessing MLTSS quality, and states are interested in further developing this area. Additional work on measures is needed to both assess the extent of rebalancing and evaluate the quality of HCBS provided, including the development of uniform or standardized measures to consistently assess the extent of rebalancing and evaluate HCBS quality in a way that allows meaningful comparison by stakeholders. Performance measures also can assess the impact on beneficiaries of delivery systems that integrate LTSS with medical services. A set of core rebalancing measures could facilitate comparisons across states and health plans, although barriers to their development would have to be addressed.

Using MLTSS performance measures to examine beneficiary functioning and account for the diversity of the population with LTSS needs and the settings in which services are provided.

Unlike clinical measures, rebalancing measures focus on beneficiary functioning and therefore require a different approach to data collection, measurement, and reporting for health plans. Rebalancing measures also need to account for the diverse needs and preferences among beneficiaries who rely on LTSS. For accurate comparison, it is important that measures are risk adjusted to account for differences in populations served by health plans that may impact rebalancing performance. In addition to tracking where services are provided, performance measures can account for differences in the degree of community integration offered by various settings.

Basing MLTSS performance measures on data that is available at the individual service level, accurate, and transparent to stakeholders.

Health plan data at the individual service level, allowing for adjustments to measures impacted by different populations served, is a key part of assessing rebalancing. Data collection systems that are designed to capture information relevant to rebalancing are important to inform MLTSS performance measures. Data is most useful if it is transparent to beneficiaries and other stakeholders.

Employing MLTSS performance measures to hold health plans and states accountable for achieving program goals and inform policymakers responsible for overseeing and funding these programs.

State and federal policymakers can use performance measures to monitor and evaluate MLTSS programs and ensure that public dollars are being spent to achieve the program’s intended goals. Measures should clearly define the processes and outcomes for which health plans will be held accountable to achieve. Data from MLTSS performance measures can be an important factor in an era of federal and state budget pressures and potential cuts.


Although work is needed to further develop MLTSS performance measures, there also is a need to assess rebalancing progress now, to determine whether current MLTSS programs are achieving their intended goals. Challenges in assessing rebalancing in MLTSS programs include the diversity of the population receiving LTSS; how to define what is being measured; different reporting requirements associated with different authorities authorizing MLTSS and HCBS; determining the services for which health plans are accountable; health plans’ learning curve in moving from a medical model to meeting beneficiary’s functional needs and supporting beneficiary choice, independence and community integration; ensuring the availability of data about services provided by health plans; and the speed at which capitated MLTSS programs are implemented. Revised Medicaid managed care regulations expected to be issued by CMS also may inform efforts to assess MLTSS programs. Continued focus in this area by federal and state policymakers and other stakeholders is important to evaluating the success of MLTSS programs in promoting LTSS rebalancing.


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