About 9 million Americans — mostly low-income seniors and those with disabilities — are eligible for both Medicare and Medicaid. These so-called “dual eligibles” make up less than a quarter of the total members of each plan, but because they’re also the sickest and poorest individuals, they account for a disproportionately high amount of the costs of the two programs — about 40 percent. Because Medicaid is run by the states and Medicare by the feds, there's little coordination between the two programs.
In 2010, the Medicare-Medicaid Coordination Office and Center for Medicare and Medicaid Innovation — both created by the Affordable Care Act and housed under the Centers for Medicare & Medicaid Services (CMS) — launched a program to improve that coordination. The State Demonstrations to Integrate Care for Dual Eligible Individuals awarded 15 states with up to $1 million each to “identify and validate delivery system and payment coordination models that can be tested and replicated in other states.”
CMS wants some states to start using these new models by January 2013. But that’s too fast, according to Patricia Nemore, a senior policy attorney at the Center for Medicare Advocacy, which works to advance fair access to Medicare and quality health care. I asked her why she feels the feds need to put the brakes on their coordination efforts in this edited transcript.
First, let me say that when you see the “9 million dual eligibles” figure, it’s really more like 7 million because about 2 million of them don’t get full Medicaid services. The current efforts to change delivery and payment systems for that population will affect somewhere between 2.5 million and 3 million of those. There is no other single factor that joins this population. It’s not like we are talking about a homogeneous population who all suffer from, say, heart disease or all need long-term care. It’s a very heterogeneous population — some use a few services, some use a lot of services. But most of the proposals coming from the states are looking to put the entire population in one demonstration.
The language of the initiative is all about demonstration, and one might think that would require a control group to see if the demo was or was not successful. But the proposals do not generally have control groups. Medicare and Medicaid don’t work well together. They have different rules, different appeals systems, so a reasonable control group would have the same coverage issues and have to overcome the issues that get in the way of people getting what they need.
Part of our concern is that there is a lot of vagueness, a lot of unknowns, many questions unanswered. You can’t talk about duals uniformly. You can’t even talk about a state uniformly; the infrastructure is different in city versus rural, one part of a state versus another part. We need to look at a more targeted approach. There is a lot of discussion in the literature looking at people who use a lot of services, the people you can help the most while possibly reducing costs the most. That kind of targeting would be a good place for states to start.
For example, one very common buzzword is “care coordination.” Everyone agrees that care coordination should happen, and for many duals, it is very much lacking. There have been demos of care coordination showing specific things can or cannot be successful. Telephonic care, for instance, is not successful; it has to be face-to-face between the coordinator and the patient. Another example: Wisconsin has been putting nurse practitioners (NP) in nursing homes to intervene when there might be some health issue developing that might end up sending the person to the hospital. The NP can intervene and prevent that, and that has proved successful.
So we know something about these things, but these proposals don’t talk about them in this specific way. The new delivery system models that are being proposed are not tried systems. The most common system being looked at is a capitated system, and those plans have little experience with very high-need, high-cost populations.
Another big concern is: How is the coordination process being monitored? Both the states and CMS are pretty strapped now, and monitoring will be a significant issue. Duals are first and foremost Medicare beneficiaries; most are paid into Social Security, and more than half of Medicaid money is also federal money, so there needs to be significant federal oversight. We believe that there needs to be strong ombudsman programs for these projects as they go forward, both to help people individually and to see the bigger picture. We are worried there may not be the resources for this kind of oversight.
Things are slowing down somewhat. Some states are already seeing there was a great rush to start in January 2013 and recognizing they are not ready to do that. That’s a good thing.
The June issue of Health Affairs focuses on this population and raises questions about how little we know about things that actually do work and whether we have the data we need. This issue is an indication of public awareness of the concerns we have.
But we also know that, at this moment, states with proposed January 2013 implementation [make up] about 2 million out of the 7 million duals. That is a lot of people. Many organizations, including ours, are trying to be part of the conversation.
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This story was originally written and published by Governing magazine.