Recently, I had the privilege of attending a roundtable discussion to learn more about the work underway to develop integrated care plans for those who are dually eligible beneficiaries of Medicare and Medicaid, often referred to as "duals."
The nearly 9 million people in this group are among the most vulnerable in our society: To qualify, they typically combine poverty, age, and disability. The John A. Hartford Foundation was proud to co-sponsor the meeting in partnership with The SCAN Foundation, a long-time ally in health and aging. Attended by a broad range of stakeholders, the event was hosted by the Alliance for Health Reform, the non-partisan, non-profit group that serves to provide unbiased information to senior Congressional staffers, consumers, health advocates, the press, and the general public.
A core issue facing duals is the financial misalignment between Medicare and Medicaid. This has been a longstanding impediment to coordinated care for Duals. As Chris Langston wrote in an earlier blog post:
One of the long-standing concerns about providing good and cost-effective care for duals has been that they were getting particularly bad and overpriced care as the two programs essentially played “hot potato,” passing these vulnerable people back and forth for temporary advantage. For example, Medicaid pays for the costs of most long stays in nursing homes. However, Medicare pays if the person is admitted to a hospital and then discharged to a nursing home (and pays at a higher rate than Medicaid). This includes current nursing home residents. This likely contributes to admissions to hospitals from nursing homes that are higher than they need to be. This is exacerbated by Medicare payment policies that make it very hard for institutionalized or homebound beneficiaries to get the assertive primary care that they need to stay well. Coordinating the two programs so that they work together to limit total spending and maximize the benefit to each person has been the holy grail of aging and health for a long time, only glimpsed occasionally in programs like PACE (the Program of All-Inclusive Care for the Elderly).
With the recent enactment of health reform, the Centers for Medicare and Medicaid Services (CMS) have focused on two types of models to address the issue:
(1) a capitated model in which a state, CMS, and managed care plan enter into a three-way contract and the plan integrates primary, acute, behavioral health and long term services and supports; and;
(2) a coordinated fee-for-service delivery model in which the state would be eligible to benefit from shared savings.
Budgetary and fiscal pressures have led many states to pursue these models. To date, five states—California, Illinois, Massachusetts, Ohio, and Washington—have signed memorandums of understanding (MOUs) with CMS with plans to implement their models this year. Another 17 states have pending MOUs.
While good integrated care has the potential to improve health outcomes at lower costs, the tasks facing the states are enormous. The complexity of different coverage and administrative requirements, and the challenges involved in bringing health plans and providers together to meet the varied needs of the diverse population of duals, holds as much risk as promise. Vigilance must be taken to protect beneficiaries from service disruptions in the near term, and to prevent the real possibility of putting into place something that’s much worse than the status quo.
Consider, for example, the perspective of insurance firms that have entered into these contracts with the states and CMS. Contract development itself presents a puzzle. As reported recently by the Kaiser Family Foundation, some have found the development of three-way contracts much more challenging than initially expected. There is a concern that the contracts may “scotch tape” requirements across programs instead of providing true integration. Moreover, some have also found the absence of critical details in the proposals and contracts—such as benefit specifications, rate levels, and risk adjustment methods—to be an impediment to negotiations and planning.
Marshaling resources to serve the kinds of special needs presented by the subgroups that make up the duals group is also very challenging. Even experienced firms that recognize varying needs of duals, and the consequent necessity of different provider networks and care management techniques for key subgroups, point out that few organizations appear to have all the core competencies needed to address all of those needs.
Most observers surveyed by Kaiser agree that a coordinated effort to manage the challenges faced by duals holds the potential for better quality of service and outcomes and better cost management. However, most executives see that capturing these savings will likely require time, organizational development, alignment of interests, and a significant amount of work with providers to obtain their buy-in.
To enable the industry to make the right investment decisions, it’s important to communicate a clear vision of the structures, processes, and outcomes of care that will be rewarded. I was heartened to learn that The SCAN Foundation recently commissioned a white paper by the National Committee for Quality Assurance (NCQA) that addresses this very point. The strategy they have developed for evaluating the quality and person-centeredness of integrated care has two parts:
1) a “roadmap” of structures and processes that describe the capabilities needed by states, health plans, and other entities responsible for the integration of care and services;
2) a method of building onto these structures and processes outcomes and other types of performance measures for accountability and quality improvement.
Because structure and process measures can specify the minimum standards required as a starting point for these plans, the proposed roadmap offers a way to monitor implementation and to shape quality improvement. With clearly defined performance measures and organizational feedback loops, and appropriate government oversight and consumer engagement, firms can make the right decisions regarding investing in program refinement and improvement.
While the path ahead remains complicated, there is commitment to confronting the challenges facing duals and to improving the care they receive.