LTC Bullet: LTC Prevention is Better than Cure
Friday, October 1, 2021
LTC Comment: The old saying “an ounce of prevention is worth a pound of cure” applies equally well in long-term care according to three experts in this promising field. Much more after the ***news.***
*** ILTCI CONFERENCE live and in person returns March 21-23, 2022 in Raleigh, NC. The organizers are planning the program and want your help. They say “Our Programs & Education Committee would like to know what YOU want to learn about next year.” Submit your session ideas and topic requests here. Additional information on the 2022 ILTCI Conference will be available soon. Check the website for details. Registration will launch in November. Exhibitor & Sponsor applications will be accepted beginning Oct 1st. As the program develops, we’ll keep you posted here as well. ***
*** WHAT’S NEXT AFTER THE WA CARES FUND? We thank Center corporate member CLTC and its Executive Director Amber Pate for inviting us to attend Wednesday’s webinar of that title. CLTC® Certification for Long-Term Care educates and certifies professionals in the fields of insurance, financial services, law and accounting in the discipline of extended care planning. Steve Cain emceed this 30-minute webinar for CLTC graduates with Melissa Steiner and Courtney Crenshaw commenting. Highlights follow.
*** RECENT MOSES COLUMNS:
In addition to the published columns listed below, Steve has two more articles accepted for publication soon and a third out for query. Watch for them.
“LTC Irony” in the November issue of Broker World.
“Long-Term Care’s Problems Are Bad, Getting Worse, but Fixable,” expected October 1, 2021 in McKnight’s LTC News.
“What’s better for senior living? The market or government?”
“Should Medicaid Protect $8 Trillion from Private Senior Living Costs?” for McKnight’s Senior Living, August 9, 2021
“The InLTCgentsia” for Broker World’s August 2021 issue.
“Panel Gives States Pass in Collecting Assets for Medicaid Long-Term Care,” by Stephen A. Moses, Health Care News, July 2021 (PDF version.)
“Government Violates the Long Term Care Social Contract to Your Detriment, by Stephen A. Moses, Broker World, June 2021. (PDF version.)
Find many more articles like these, plus scores of speeches and reports covering 35 years of long-term care policy analysis at www.centerltc.com. ***
LTC BULLET: LTC PREVENTION IS BETTER THAN CURE
LTC Comment: The Long Term Care Discussion Group is a “voluntary independent group that meets solely for the purpose of educating the policy community on all facets of long term care.” The group’s September 28, 2021 meeting discussed “How Wellness Programs Can Enhance Care for Long-Term Care (LTC) Insurance Policyholders.” The speakers were:
Chief Actuary, Bain Capital Insurance
What follows is a paraphrased summary of the program in case you missed it followed by the presenters’ professional bios.
Vince Bodnar opened the program asking “What is a wellness program?” It is foremost about getting people into optimal care settings and not only about saving claims dollars. To keep people well is good for everybody involved. There are two areas of focus: pre-claim and in-claim. Pre-claim is about interacting with policy holders before they need care, usually before age 75. Interventions increase as the covered population becomes more frail. The goal is to maximize “disability-free lifetime.” The claim is a critical event taking place over a week or so. Once on claim, the focus becomes initiating, prolonging and improving services at home in order to avoid nursing home intake by default.
The LTC insurance industry asks “does this stuff work?” about two common wellness models. CCRCs without walls (Continuing Care Retirement Communities) is one model. People contract with an organization, pay a monthly fee while still healthy, and receive care as needed. There are annual physicals; prior authorization required to enter a facility; annual visits by a care coordinator to monitor progress and ensure quality. The care coordinators often become almost like family members. Over 90% of people in these programs receive services at home as compared to 40% on average for the LTCI industry in general.
The other wellness model is Medicaid Long-Term Services and Supports programs. The MLTSS model involves commercial managed care companies receiving capitation fees from state Medicaid programs to manage care recipients’ long-term care. They require prescreening before institutionalization; mandate referrals; attempt to “repatriate” people from facility to home care. They may help people find a home who no longer have one. One-on-one caseworkers coordinate care as with the CCRC w/o walls model. The more advanced programs use data for sophisticated risk scoring. MLTSS programs keep 80% in home care compared to 40% for LTCI.
If home care claims are half of facility claims, a carrier can reduce claims costs by 12%. That’s a big number. Carriers save money while policy holders get better care and stay in their homes longer.
A long list of the kinds of interventions used to achieve these outcomes is included in the presentation materials. (The LTC Discussion Group usually archives program materials here. I don’t find them there yet, but it’s worth checking again when you read this.) For a tongue-in-cheek example of technology helping seniors, see the Saturday Night Live skit Alexa for Seniors.
How do companies collect and use data to guide caregiving? Big data collection; wearables; monitoring devices; data from assessments; risk scoring for people needing care. Learn what the early warning signs are that transfer to facility is imminent. Intervention scoring: what’s working?
Companies talked about wellness programs in the 1990s, but high cost and low results led the programs to be dropped. Carriers were afraid such programs would stimulate claims. We’re getting beyond that now. Instead of being limited only to rate increases or benefit reduction to confront the industry’s challenges, this is an honest attempt to save money while delivering better services. Interest in wellness programs is expanding geometrically, especially in the past year and a half. Some carriers have entire teams working on this. They’re beginning to see promising results.
But there are challenges. Vendor contracting processes with carriers can be frustrating. Is there rebating? Who should provide services? Can be viewed as discriminatory if not providing same services to all. Liability might attach to referring a policy holder to a certain provider. The regulatory community is quite interested in these programs. Mostly positive. Seen as beneficial if done right. NAIC working group concerns: data privacy, rebating, unfair trade practices model regulations, discrimination.
The LTC insurance business needs good news. The wellness approach is very positive. Deliver better care more efficiently. No more “grim reaper of LTC.”
The wellness focus is not just a funding issue. There is always the idea that a LTC insurance policy can provide a helpful service, not just dollars. We’re thinking about wellness, pre-claim, at-claim and on-claim.
LTCG is the largest claims payer. $4 billion last year. The business is all about claims now. After 25 years of adding policy holders, they’re now going into claim status. Previously, there was not enough interest. Now claims are growing rapidly and so are costs. We ask: what can we do besides raise rates and reduce benefits? Pursuing wellness is win/win because it benefits all stakeholders, carriers, policy holders and care providers.
Getting grounded in the claims process is challenging. We needed to make decisions, prioritize. We know we can’t be all things for all people. Three phases: pre-claim, the claim event, post-claim. The process usually lasts 2 to 3 years. LTCG made the decision to focus on at-claim and post-claim. Once someone makes a claim, what else can we offer to be sure the claim managed effectively?
The presentation material diagrams and explains the claim process. An interview is conducted at the point of claim so the process begins with more than just a claim form. We get them on phone, find out what has been done so far, what care received, face-to-face interview. Every time a claim is opened it creates a $250,000 cost (on average) for the carrier. We ask what are the needs? How can we manage those needs and arrange payments efficiently. Then loop around, reassess as needs change. Active management.
Make the right decision; use training; keep rules the same for all; same outcomes; collaborate with policy holders; the customer experience is important. Aim for recovery. About 33% recover, which is surprising; with right support, they get off claim. A lot of depression in this population, people spiral down. So we need to lean into recovery.
Pay benefits according to the approval. You need systems to vet claims. Don’t pay claims not covered by the policy. Catch any questionable activity; incredible what we see in fraud from seniors and providers. People are smart, savvy, if money is involved, people find a way to get it whether or not they’re entitled. Expanded programs and capabilities to address risk management, customer experience and administrative efficiency. This is a high touch business, but it needs to be efficient.
Best practices are important. You need an electronic way to view what providers are doing, including downloadable information on location, time in, time out. LTCG is launching a clearing house to take paper out of the process. Fraud detection using analytics. Interact electronically through a portal. 40% of the calls we receive are “where’s my check?” That information is available online so should not require taking phone calls. Care concierge service.
Post claim things we’re doing. There is a huge correlation with fraud when an agent is involved. We need to know and monitor the claim start date. High volume of unverified visits. Data tells more than a paper file. Important to stratify fraud risk.
LTCG partnered with Afik Gal and Assured Allies to expand our capabilities.
Pre-claim issues are important. Tighter integration of the value proposition. Go a step beyond. That is what Assured Allies does.
We have multi-disciplinary teams, with actuaries, medical staff and others. We bring together professionals not often brought together. Assured Allies was developed because of our long-term care experience with our own parents.
We’re looking at LTC insurance as one determinant for successful aging as a whole. Make sure people don’t decline prematurely. But recognize they will decline and need support. Families must fund it themselves or find a solution, such as LTCI. That’s what attracted us to this topic.
To summarize, we are about employing multi-disciplinary teams to achieve successful aging Make health care work from the lens of insurance and finances. For policy holders, live healthier in homes whenever possible. We’re bringing a win/win value proposition to this market. It is a rare opportunity to do the right thing for the policy holder, the provider, and the payer.
Pre-claim the focus is wellness, risk management. All financially positive if done right.
It is easy to help a lot of people by spending a lot of money. The bigger issue is efficiency. It is important to understand trade-offs. The system must be sustainable financially, not only socially good. Reduce costs of claims while improving care.
Real case study from policy holder standpoint. Reach out to engage people. See what their needs are. Do they want help? Do they want to change how they’re aging? That information translates into how much to spend on people. There is much on the Assured Allies website about how it works. Check out the videos there.
We use data to estimate how likely people are to claim and when. We must decide how much to invest to change or delay that. Depends on their desire to get help. Intervention, feedback loop, compare experience with others. Careful measurement mechanism. Is it working or not? 25,000 lives by end of this year. This market is notorious for poor data. We’re spending a lot of energy improving that to get well-validated data.
Interventions are various. Stratify policy holders by proximity to claim. Ask what is the right thing to do? Self-efficacy. How much effort? How much money? Careful monitoring. Predictive modeling. We don’t focus just on caregiving. Multiple of tools based on risk factors. For example: is the caregiver far away? Different discussion for the very sick. Are the caregivers fighting?, etc. We try to coach them into a solution. We only do things proven to be effective.
We’re not going to actually provide home care assistance. That would be a disservice to the carrier because not proven to deliver a positive ROI (return on investment). We find the right approach for the policy holder.
The goal is successful aging. At age 80 plus, the focus may be urinary continence and caregiver issues. Better to get an earlier start because we can do more at age 60. Build good relationship between all parties so that all parties have better outcomes.
Vince Bodnar is an actuary with Bain Capital Insurance. He has 37 years of experience with a broad array of insurance products. Mr. Bodnar has led projects related to product and distribution strategy, in-force management, capital optimization, reinsurance strategy, operational reviews and diligence, company rehabilitations and liquidations, and mergers and acquisitions. Prior to joining the firm, Mr. Bodnar had senior leadership roles at Genworth and GE Capital and led actuarial consulting practices at Milliman, Willis Towers Watson, Oliver Wyman and KPMG.
Peter Goldstein is CEO of LTCG, a leading provider of administrative and clinical services within the LTC insurance industry. His 25 years of leadership have helped LTCG adapt to a changing industry environment and have transformed the organization into a premier partner for LTC insurers. LTCG serves all of the top LTC carriers and is the largest third-party claims payer in this space. Peter’s strategic vision for the company has transformed LTCG from a TPA focused on processing capabilities into an organization dedicated to proactive, holistic risk management for its customers. Peter is a recognized thought leader on topics ranging from next-generation claims management to the public policy changes needed to ensure a sustainable future for this industry. He has been featured in a variety of wide-reaching business publications including the Wall Street Journal, Bloomberg, Mergermarket, Think Advisor, Business Week and many others.
Afik Gal is a physician and a co-founder of Assured Allies, an insur-tech company dedicated to making longevity sustainable. Afik has spent over 15 years bringing innovative technological care management solutions to life across healthcare and financial insurance industries. Prior to founding Assured Allies, Afik served as VP of Product Innovation at EviCore healthcare where he revolutionized prior authorization as a benefit to payers, providers, and patients. He also led the innovation lab at PwC’s healthcare advisory practice helping clients design and implement advanced analytics solutions with great impact on their business models. Afik has also served as a partner and advisor to numerous hospitals and startup companies developing technologies to improve patient care.