Elaine Davies, 85 and widowed, spends much of her time caring for her younger brother, Albert Abbod, 76, who has polio and schizophrenia.
"Until you're in it, you don't really realize how much is involved in 24/7 care," Davies said from her home in Bay Point, near Richmond. "I only knew about problems [you get] with aging as I age. And until you're caring for someone who needs this kind of constant care, you don't really get it."
Davies said she wants to keep taking care of her brother, but that wouldn't be possible without the kind of help she gets from the Multipurpose Senior Services Program, which she said is a godsend.
"I don't know what I'd do without it. [The people at MSSP] enable us to continue," Davies said. "I have a hard time expressing how much I appreciate the services we get."
For seniors eligible for Medi-Cal, California's Medicaid program, MSSP provides a number of services, including care coordination and respite care. The tradeoff for the state is that Abbod can stay home and doesn't need to enter an expensive nursing home or long-term care facility.
"We view the MSSP program as a proven and cost-effective approach for supporting older adults," according to Lora Connolly, director of the California Department of Aging.
Connolly recently testified at a legislative hearing on the past and pending changes to MSSP and other programs.
Over the past five years, Connolly said, the state has cut about $5 million from MSSP; counting federal matching funds, that amounts to a $10 million reduction in funding.
Over the next two years, MSSP will undergo a different kind of change. The state plans to eliminate it as a stand-alone program, though it will keep all of its services under a new managed care model.
"It's one of the Medi-Cal services that can be administered by managed care plans," Connolly said. "The expectation is that [managed care plans] will contract with MSSP sites."
Incorporating MSSP services into managed care plans makes fiscal and administrative sense, according to Jane Ogle, deputy director of the Department of Health Care Services.
"In my mind it's not being phased out," Ogle said. "It's being integrated into the health plans. We're thinking of it as being expanded to the larger duals program."
The state's Coordinated Care Initiative combines resources and services for Californians who receive both Medicare and Medi-Cal benefits, otherwise known as "dual eligibles." Those who receive MSSP benefits fit that profile, Ogle said.
"When we think about MSSP, it's all about care coordination and case management," Ogle said. "When you look at the description of the Coordinated Care Initiative, it reads like MSSP. It's what plans are doing now with the duals population, [enacting] the intensive care coordination designed to keep people in the home."
The goal, according to Ogle, is that MSSP beneficiaries won't feel any change in daily care.
"Really, there won't be much of a change, in terms of delivery of services," she said. "It's more a question of how the MSSP providers will be integrated into that plan."
Concern Over Unique Services
Senior advocates are concerned that some services unique to MSSP won't be offered by managed care plans. For instance, Davies said MSSP workers arranged installation of grip bars around the house for her wheelchair-bound brother and gave him a Life Alert button to wear around his neck.
"Those are examples," Davies said. "Those are things you only get with MSSP."
Ogle agreed that MSSP offers some unique services that help keep people in their homes, but she doesn't think those services necessarily disappear with the switch to managed care.
"Home modification is one of those things that MSSP does that others don't," Ogle said. "But if I were a health plan, I might want to consider that as a service, because it works to keep people independent and in their homes. That's really at the core of this whole thing, that it's in the health plans' best interests to keep people in their homes and not have them go into long-term care."
The main concern for advocates is that a number of those kinds of services may be lost as the state makes the transition away from a small, successful program to the larger, relatively untested managed care program.
"Integration into managed care presents potential threats and opportunities to the integrity of the MSSP model," according to Ed Walsh, director of the Office on Aging and Senior Service Systems for Riverside County.
"The threat is that the model would be diluted to the point where it is no longer effective for those at highest risk. You take a small program, with a fixed amount of dollars, and drop it into a large lake [of managed care] -- and if you dilute it to a point where it's no longer effective for these high-risk, frail elders, it's no longer an effective model."
At the same time, Walsh said, he does see the opportunity to open up the MSSP care coordination concept to more people under managed care.
"In incorporating [MSSP] into managed care, there is the possibility of conducting an expansion of capacity of MSSP," he said.
Gary Passmore, executive director of the California Congress of Seniors, said he hopes current MSSP providers will be part of the new managed care network.
"It would be a terrible mistake to lose the capacity, the resources and the experience, the institutional memory of these organizations that have been around for decades," Passmore said, "by moving it into managed care and diluting the fine job it's doing today."
Changes Difficult for This Population
The big thing to remember, according to Davies, is that the terms "frail" and "at-risk" mean that people on MSSP have a difficult time tolerating much change. People like her brother with multiple health conditions deal with significant pressure just from living daily life. Even small reductions in care could create a tipping point that forces him and others like him toward institutional care.
You can have all of the good intentions you want, she said, but if her brother's health care providers aren't in the managed care network, or if the details of care are compromised, such as providing incontinence supplies or respite care, then the shoestring-thin lifeline to keep her brother home could break.
The California Legislative Analyst's Office has recommended that the Legislature take a broader look at MSSP in the managed care setting, and that it should evaluate the level of program control granted to those managed care plans.
Walsh asked legislators at a recent hearing to make sure all the steps toward managed care are carefully taken, since even small missteps have the potential to cause great damage.
"Go slowly. Go thoughtfully," Walsh said. "And look at approaches that have worked. Don't lose the heart [of MSSP] in managed care, and don't lose the heart [of MSSP] in capacity building."
Ogle said MSSP services won't be lost, they'll be expanded.
"It's all about the integration, it's the coordination," Ogle said. "And it's making those services part of the scope of services, and not just to that smaller population."