State plans for dual-el­i­gi­bles face tough chal­lenges

Modern Healthcare - - NEWS - By Vir­gil Dick­son

On a bone-chill­ing day in Jan­uary, Jennifer Turpin vis­ited a wheel­chair-bound pa­tient named Olivia Richard at her small apart­ment in Bos­ton. Turpin, a care co­or­di­na­tor, was con­duct­ing a home in­spec­tion for Richard, who had just joined One Care, a state pro­gram for low-in­come, chron­i­cally ill people who are du­ally el­i­gi­ble for Medi­care and Med­i­caid.

Look­ing around the apart­ment, Turpin, who per­forms in­de­pen­dent liv­ing as­sess­ments for the not-for­profit plan Com­mon­wealth Care Al­liance, was hor­ri­fied at what she saw. Richard’s sheets and dishes hadn’t been washed in months, and her floor was black with dirt. Be­fore she joined One Care, Richard did not re­ceive con­sis­tent vis­its from home health aides.

“I didn’t re­al­ize how bad the level of care I was get­ting was un­til that visit,” said Richard, who is 30. “If I were to get a sore on one of my legs and am ly­ing on filthy sheets, I could get a lifethreat­en­ing in­fec­tion.”

Since late last year, 10 states have launched or are about to launch dualel­i­gi­ble ini­tia­tives un­der the CMS’ Fi­nan­cial Align­ment Ini­tia­tive to im­prove care for more than 9 mil­lion dual-el­i­gi­bles by in­te­grat­ing Med­i­caid and Medi­care ben­e­fits. They hope bet­ter care co­or­di­na­tion will re­duce costs for this very ex­pen­sive pop­u­la­tion, cur­rently to­tal­ing about $350 bil­lion a year. It’s es­ti­mated that about 2 mil­lion are el­i­gi­ble for the pro­gram in those 10 states.

But some ex­perts ques­tion how many dual-el­i­gi­ble ben­e­fi­cia­ries will vol­un­tar­ily en­roll in the new man­aged­care pro­grams and whether pri­vate health plans par­tic­i­pat­ing in the demon­stra­tions will get enough physi­cians and other providers to serve these chal­leng­ing and time-con­sum­ing pa­tients. In ad­di­tion, there are ques­tions about the qual­ity of the plans them­selves, and whether the demon­stra­tions will pro­duce cost sav­ings.

While most dual-el­i­gi­bles are 65 or older, around 40% are younger. Many duals un­der age 65 have mul­ti­ple chronic health con­di­tions, in­clud­ing men­tal-health and sub­stance-abuse is­sues, or phys­i­cal or devel­op­men­tal dis­abil­i­ties. Some are home­less, while oth­ers live in res­i­den­tial care fa­cil­i­ties. Of­ten the health­care and other sup­port ser­vices that they re­ceive are frag­mented be­cause duals fall through the cracks of the two pro­grams. Many duals need home- and com­mu­nity-based sup­port in ad­di­tion to med­i­cal and be­hav­ioral care.

While 26 states ap­plied to par­tic­i­pate, so far only Cal­i­for­nia, Colorado, Illi­nois, Mas­sachusetts, Min­nesota, New York, Ohio, South Carolina, Vir­ginia and Wash­ing­ton have re­ceived federal ap­proval to start their pro­grams. Mas­sachusetts and Min­nesota are the far­thest along, hav­ing launched their pro­grams last year. Illi­nois be­gan en­roll­ment in March, and the rest of the states are start­ing en­roll­ment be­tween April and Oc­to­ber. Some states are tar­get­ing all their duals, while oth­ers are fo­cus­ing on a sub­set, such as those un­der 65 or those need­ing long-term care.

“I’m glad they’re mov­ing slowly,” said Judy Feder, a Ge­orge­town Univer- sity pro­fes­sor of health­care pol­icy who has closely fol­lowed the duals demon­stra­tion. “Tak­ing a large, frag­ile pop­u­la­tion and mov­ing them into an un­tried new sys­tem is a gam­ble. Slow is bet­ter.”

Most states are con­tract­ing with pri­vate man­aged-care plans to serve the duals. But as the plans gear up, there are con­cerns about get­ting enough par­tic­i­pa­tion from physi­cians, both pri­vateprac­tice doc­tors and those em­ployed by provider or­ga­ni­za­tions, given the time com­mit­ment needed to treat duals un­der the demon­stra­tion’s model.

That model re­quires doc­tors to work closely with a mul­ti­dis­ci­plinary team of clin­i­cal and non­clin­i­cal staff to man­age both med­i­cal care and so­cial ser­vices for ben­e­fi­cia­ries. This may be too much for some physi­cians, said Christo­pher Palmieri, pres­i­dent of VNSNY Choice Health Plans, one of the plans that will serve duals in New York state’s demon­stra­tion when en­roll­ment be­gins Oct. 1.

It’s not yet clear whether it’s fea­si­ble for doc­tors with dozens of dual-el­i­gi­ble pa­tients to spend that much time on their care, said Dr. Ju­dith Stein­berg, deputy chief med­i­cal of­fi­cer of Com­mon­wealth Medicine, a con­sult­ing arm of the Univer­sity of Mas­sachusetts Med­i­cal School. Still, af­ter years of treat­ing dual-el­i­gi­ble pa­tients her­self, she ar­gues

that co­or­di­nat­ing these pa­tients’ med­i­cal and so­cial needs is the best way to keep them sta­ble and out of the hospi­tal and emer­gency depart­ment.

Nurs­ing home oper­a­tors also are eye­ing the demon­stra­tions with cau­tion. They may stay away if the re­im­burse­ment isn’t ad­e­quate, said Scott Hale, ex­ec­u­tive di­rec­tor at Sym­me­try Health­care Man­age­ment, which owns and op­er­ates sev­eral nurs­ing homes in Wash­ing­ton state. The man­aged-care demon­stra­tion pro­gram there be­gins en­roll­ment in July. Par­tic­i­pat­ing plans have not yet re­leased their nurs­ing home pay­ment rates.

An­other ma­jor ques­tion is how many dual-el­i­gi­ble pa­tients will choose to en­roll, since duals can opt not to sign up. Un­less they ac­tively de­cline to join, though, they gen­er­ally will be au­to­mat­i­cally en­rolled. Al­ready there are in­di­ca­tions of prob­lems. In Mas­sachusetts, it’s es­ti­mated that nearly 94,000 res­i­dents are el­i­gi­ble for One Care. But as of Feb. 1, only 9,541 had signed up, while 16,642 had opted out. State and health plan of­fi­cials say they aren’t wor­ried be­cause duals have time to change their minds.

Pa­tient ad­vo­cates say duals may opt out be­cause their pre­ferred physi­cians or other providers are not part of the plan net­work. Oth­ers may sim­ply be un­com­fort­able with the new man­aged­care sys­tem.

Re­mon Jour­dan, 39, a One Care en­rollee liv­ing in Bos­ton, said he’s happy with the care he’s re­ceived through the Com­mon­wealth Care Al­liance, which started work­ing with duals long be­fore One Care. But he said he’s talked with other en­rollees who have ex­pressed buyer’s re­morse be­cause they didn’t like the careteam ap­proach.

In Illi­nois, which is a month into en­roll­ment, there are con­cerns about how many of its 132,000 dual-el­i­gi­bles will opt out, said Jim Parker, the state’s deputy ad­min­is­tra­tor for Med­i­caid. “Opt-out could be higher in Illi­nois than in other states be­cause (the state) does not have high man­aged-care pen­e­tra­tion in many mar­kets,” he said. Duals un­fa­mil­iar with man­aged care may stick with the fee-forser­vice model, de­spite its many in­ad­e­qua­cies, he said.

In Cal­i­for­nia, Nancy Becker-Kennedy, 62, of Los Angeles, said she plans to opt out of the state’s Co­or­di­nated Care Ini­tia­tive when en­roll­ment be­gins April 1. That’s be­cause she’s heard hor­ror sto­ries about the par­tic­i­pat­ing plans, sev­eral of which pre­vi­ously were par­tic­i­pat­ing in the state’s Medi-Cal pro­gram. She has heard about prob­lems with cov­er­age de­nials for needed ser­vices and an in­ad­e­quate ap­peals process. “The state claimed that switch­ing to man­aged care would lead to more co­or­di­nated care, but it’s been a dirty bomb on the qual­ity of care we had,” she said.

Her con­cerns are not with­out some ba­sis. CalOp­tima was cho­sen by Cal­i­for­nia to of­fer a plan for duals in Or­ange County as part of the demon­stra­tion. But when the CMS con­ducted a readi­ness re­view of the plan, it found prob­lems in how the com­pany was over­see­ing care for the dual ben­e­fi­cia­ries it al­ready was serv­ing in OneCare, its Medi­care spe­cial needs plan that has 16,000 ben­e­fi­cia­ries.

“Vi­o­la­tions re­sulted in en­rollees ex­pe­ri­enc­ing de­lays or de­nials in re­ceiv­ing cov­ered med­i­cal ser­vices or pre­scrip­tion drugs, and in­creased out-of-pocket costs,” the CMS said in a Jan. 24 let­ter to CalOp­tima of­fi­cials. “CalOp­tima’s con­duct poses a se­ri­ous threat to the health and safety of Medi­care ben­e­fi­cia­ries.” Un­til those is­sues are ad­dressed, the CMS said, the plan could not par­tic­i­pate in the duals ini­tia­tive.

The CMS has blocked an­other Cal­i­for­nia duals demon­stra­tion plan called L.A. Care from sign­ing up ben­e­fi­cia­ries through pas­sive en­roll­ment, which in­volves ran­domly as­sign­ing ben­e­fi­cia­ries to a plan if they don’t se­lect one and don’t opt out. That’s be­cause L.A. Care has a Medi­care Ad­van­tage qual­ity rat­ing of 2.5 stars, less than the three stars—on a five-star scale—re­quired to par­tic­i­pate in pas­sive en­roll­ment.

De­spite these is­sues, Cal­i­for­nia is stand­ing be­hind the eight plans it chose to serve Los Angeles, Or­ange, San Diego and San Ma­teo coun­ties for the demon­stra­tion. “We are con­fi­dent that (L.A. Care and CalOp­tima) will be able to re­solve these is­sues and will then be able to par­tic­i­pate and pro­vide mem­bers with the high level of qual­ity care they need and de­serve,” said Anthony Cava, a spokesman for the Cal­i­for­nia Depart­ment of Health Care Ser­vices.

The big, over­ar­ch­ing con­cern is whether the dual-el­i­gi­ble demon­stra­tions will in­deed re­duce costs for the federal and state gov­ern­ments in serv­ing these very ex­pen­sive pa­tients.

In 2011, Medi­care and Med­i­caid spend­ing on duals in Mas­sachusetts to­taled $3.85 bil­lion on care for 21- to 64-year-olds, the age bracket One Care is serv­ing. As a re­sult of the ini­tia­tive, the CMS ex­pects a 1% spend­ing re­duc­tion by the end of 2014, with twice as much sav­ings in 2015 and four times as much in 2016.

But some ob­servers think that’s un­re­al­is­tic, at least partly be­cause pro­vid­ing high-qual­ity care to duals who have not been well-served pre­vi­ously could cost more ini­tially if pa­tients have pent-up needs for pri­mary and be­hav­ioral care. “We think (federal and state of­fi­cials) may be ag­gres­sive in what the cost sav­ings will be,” said Leanne Berge, se­nior vice pres­i­dent of One Care at Com­mon­wealth Care Al­liance.

VNSNY Choice Health Plans so­cial worker Sherri Zabko con­sults with Choice mem­ber Janet Whit­more.

It’s not yet clear whether it’s fea­si­ble for doc­tors with dozens of dual-el­i­gi­ble pa­tients to spend that much time on their care, ac­cord­ing to Dr. Ju­dith Stein­berg, deputy chief med­i­cal of­fi­cer of Com­mon­wealth Medicine.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.