America Wants Equity. VBP in Healthcare Can Deliver

The research gives us a place to start, although it does not tell us what any one person needs. Race and ethnicity cannot tell us a participant’s diagnosis, preferred language, or family situation. We also need to be careful about the populations being studied: findings about adults generally are not estimates of how common these conditions are among older LTSS participants.

For Black older adults with disabilities, hypertension, diabetes, and mobility-limiting arthritis warrant attention. Census research among adults 40 and older found higher levels of disability associated with these conditions among Black than White adults. NIA also identifies vascular conditions and healthcare barriers as contributors to dementia disparities affecting Black and Hispanic Americans. Care should connect chronic disease management with mobility support and, when indicated, cognitive assessment.

For Hispanic and Latino older adults, diabetes alongside hypertension or kidney disease deserves attention. Census findings identify disparities in disability associated with diabetes and hypertension. NIDDK reports higher rates of diabetes-related kidney disease among Hispanic, Black, and American Indian populations. A program could pair kidney monitoring with needed language assistance, medication support, and nutrition counseling that respects food preferences.

American Indian and Alaska Native communities face a disproportionate diabetes burden, including kidney, cardiovascular, and nerve complications. States and plans should work with tribal health organizations and older adults to design services, including transportation and home support where access is limited. Those partnerships must respect tribal sovereignty and differences among communities.

Asian American populations should not be treated as one clinical category. CDC found substantial differences in diabetes prevalence, with higher rates among Filipino and Indian adults than several other Asian subgroups. Native Hawaiian and Pacific Islander populations also warrant separate attention; federal data identify disproportionate diabetes mortality. These findings can guide outreach to older adults with diabetes and cardiovascular or kidney disease. Individual needs must determine care.

Pain, depression, changes in cognition, and hearing or vision loss also deserve attention across communities, including among White older adults. These needs can complicate an existing disability and affect whether a person can manage at home. Eligibility for a service should follow the individual assessment. Looking at racial and ethnic differences helps us find people we may be missing and understand why they are not getting appropriate care.

A state or plan developing a program should begin by talking with older adults who live with these conditions and the providers who serve them. Where does care break down? What help is needed but cannot currently be paid for? For someone with diabetes and limited mobility, meal preparation may need as much attention as the next clinical appointment. For someone with cognitive impairment, a familiar worker and support for the family caregiver may make it possible to continue living at home. Those conversations should help determine what the program funds and how it measures success.

Treating co-occurring conditions may reduce emergency visits, hospitalizations, or complications. Those medical savings support an LTSS VBP business case only when physical health and LTSS financing are integrated, or an explicit agreement shares savings across payers. For dual-eligible participants, Medicare must be included. Coordination by itself does not bring hospital savings into an LTSS-only budget. CMS’s Financial Alignment Initiative shows why the financing matters.

There is still work worth funding in a stand-alone LTSS program. The savings calculation must stay within the services the program pays for. I would look at the following areas:

One is preventing avoidable nursing facility admission. A participant with dementia and mobility limitations may be able to stay safely at home with timely personal assistance, respite, and caregiver training in the family’s preferred language. Community partners can help reach families who have had difficulty obtaining those services. If that support prevents an unnecessary placement, the LTSS savings would come from the nursing facility days avoided, after accounting for the added cost of care at home.

Another is helping someone return home from a nursing facility. A participant may want to leave but still be waiting for accessible housing, a home modification, or a reliable personal assistance schedule. Transition staff who understand the person’s circumstances and can communicate effectively with the family can help resolve those barriers. CMS’s Money Follows the Person program supports this kind of transition. A VBP arrangement could reward a successful return to community living and continued support there, counting the full community service package when calculating savings.

I would also look at the reliability of existing home services. Starting care promptly, providing backup when a worker is absent, and making reassessments accessible can help prevent a home arrangement from falling apart. This matters for underserved participants with arthritis, sensory loss, or cognitive limitations who may have difficulty getting a problem resolved. Reward the provider for dependable support and progress toward the participant’s goals. To claim savings, however, the program must demonstrate lower covered LTSS costs; fewer hospital visits do not establish that.

The financial details matter. When nursing facility care is outside the LTSS contract, the avoided expense benefits a different payer or the state. The incentive needs to account for that. Better access may also increase spending at first because people finally receive services they needed all along. That can be a good outcome, even without shared savings. States can pay for better access and quality directly. Missed care, pressure on families to provide unpaid help, and denial of necessary institutional care must never be counted as savings.

The larger opportunity, however, extends beyond facilities. CalAIM has incorporated value-based payment through several mechanisms, although relatively few are specific to LTSS. The CalAIM Incentive Payment Program rewarded managed care plans for building capacity, expanding Enhanced Care Management and Community Supports, and improving quality and utilization, including in LTSS-related areas. More broadly, the state’s Quality Withhold and Incentive Program now links a portion of managed care capitation to quality and member-experience measures.

For consumers, the goal should not simply be to place more benefits under an MCO contract. Greater integration has value only if it makes access easier, strengthens transitions back to the community, and creates clearer accountability when services are unavailable. California already gives managed care plans responsibility for costly institutional care. The next challenge is ensuring those plans have both the tools and incentives to help people avoid unnecessary institutionalization in the first place.