Federal demonstration shows savings managing care for dual-eligibles
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