Fed­eral demon­stra­tion shows sav­ings manag­ing care for dual-el­i­gi­bles

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Wash­ing­ton state saved Medi­care more than $60 mil­lion over two years as part of a fed­eral ex­per­i­ment to test bet­ter ways to man­age ben­e­fits and care for low-in­come and dis­abled Amer­i­cans.

But Wash­ing­ton and other par­tic­i­pat­ing states also need to show con­sid­er­able qual­ity gains in or­der to con­vince the CMS that it should con­tinue with the Obama-era demon­stra­tion.

Launched in 2013, the pro­gram aims to im­prove care for peo­ple el­i­gi­ble for both Medi­care and Med­i­caid. To date, there are 14 demon­stra­tions in 13 states, and all but one of the ini­tia­tives were launched un­der an Af­ford­able Care Act-cre­ated pro­gram.

“This is like care co­or­di­na­tion on steroids,” said Alice Lind, man­ager of grants and pro­gram de­vel­op­ment for Wash­ing­ton’s Med­i­caid agency. “We re­quire a very de­tailed as­sess­ment, in­clud­ing a per­son-cen­tered care plan, which means the client sets goals that are mean­ing­ful for them­selves.”

Na­tion­ally, dual-el­i­gi­ble ben­e­fi­cia­ries make up only 13% of the pop­u­la­tion but ac­count for 40% of all Med­i­caid spend­ing and 27% of Medi­care spend­ing.

But the vol­un­tary du­als demos have strug­gled with high opt-out rates. Some ben­e­fi­cia­ries skipped out of the pro­gram on the ad­vice of their doc­tors, who pre­fer fee-for-ser­vice pro­grams, the CMS found. In­sur­ers in­volved in the ef­forts have had trou­ble track­ing down en­rollees due to high rates of home­less­ness and fre­quent mov­ing.

While fed­eral sur­vey­ors re­ported on Wash­ing­ton’s Medi­care sav­ings, they didn’t have enough data to cal­cu­late Med­i­caid sav­ings un­der the demon­stra­tion. Fed­eral data show that the state has seen a $93 mil­lion re­duc­tion in Med­i­caid spend­ing on hos­pi­tal ser­vices, which in­cludes in­pa­tient, out­pa­tient and emer­gency room use from fis­cal 2014 to 2016. It is un­clear how much of the sav­ings stemmed from the demo.

In fact, many ob­servers are wait­ing for con­clu­sive ev­i­dence of sav­ings over­all.

“There has been a lag in the data, and peo­ple have been wait­ing to see this piece of it,” said MaryBeth Musumeci, an as­so­ciate direc­tor at the Kaiser Fam­ily Foun­da­tion’s pro­gram on Med­i­caid and the unin­sured.

The CMS will weigh whether the ex­per­i­ments have saved money with­out ad­versely af­fect­ing qual­ity of care, or if they saved money and im­proved care, as it con­sid­ers repli­cat­ing the pro­grams, she said.

Un­like most other demon­stra­tion states, Wash­ing­ton used a man­aged fee-for-ser­vice model to of­fer du­als a full range of ser­vices. Other states hired in­sur­ers to pro­vide care.

Wash­ing­ton’s health home model part­ners high-risk pa­tients with mul­ti­ple chronic con­di­tions with a care man­ager who uses mo­ti­va­tional in­ter­view­ing, ed­u­ca­tion in self-man­age­ment, and other as­sis­tance to im­prove health con­di­tions.

Mas­sachusetts’ pro­gram is slated for fed­eral eval­u­a­tion next. That state’s demon­stra­tion uses man­aged-care plans and also launched in 2013. CMS of­fi­cials pre­viewed the Mas­sachusetts eval­u­a­tion find­ings at a meet­ing last month and said they were pleased with the re­sults, ac­cord­ing to Stephanie An­thony, a direc­tor of Manatt Health, which has ad­vised states on du­als demos.

The CMS didn’t re­lease num­bers, but An­thony thinks Mas­sachusetts’ sav­ings could be higher than Wash­ing­ton’s since more ser­vices may be over­seen un­der a cap­i­ta­tion model ver­sus fee-for-ser­vice.

It’s still un­clear how much the states’ Med­i­caid pro­grams are sav­ing thanks to th­ese ex­per­i­ments, and fu­ture re­ports must ad­dress that, said Bar­bara Ed­wards, a for­mer Ohio Med­i­caid direc­tor and prin­ci­pal at con­sult­ing firm Health Man­age­ment As­so­ci­ates.

States bear the startup costs on get­ting the demo off the ground and some have al­ready com­plained to fed­eral eval­u­a­tors that launch­ing the pro­grams was more ex­pen­sive than an­tic­i­pated.

“If you can’t demon­strate cost-ef­fec­tive­ness for states, it won’t be sus­tain­able,” Ed­wards said.

“This is like care co­or­di­na­tion on steroids. We re­quire a very de­tailed as­sess­ment, in­clud­ing a per­son-cen­tered care plan, which means the client sets goals that are mean­ing­ful for them­selves.”

Alice Lind Man­ager of grants and pro­gram de­vel­op­ment for Wash­ing­ton state’s Med­i­caid agency

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