CMS dual-eligible demos called into question

Despite a recent report stating that CMS needs to do a better job overseeing the 13 state-administered dual-eligible demonstration programs, some stakeholders say the initiative is on the right track.

According to the report from the U.S. Government and Accountability Office (GAO), which examined care coordination under the demonstration intended to improve care of individuals who qualify for both Medicare and Medicaid (i.e., dual-eligibles), Medicare and Medicaid programs spent an estimated $300 billion on these beneficiaries in 2010. Dual-eligibles often have complex health needs, increasing the need for coordination across the two programs.

New integration

In 2013, as part of the Affordable Care Act, CMS began the duals demonstration, also known as the Financial Alignment Demonstration (FAD). The goal is to integrate Medicare and Medicaid services and generate savings for these programs, improve patients’ care coordination and outcomes, and bridge gaps.

Under the umbrella of the FAD, there are two main models: the capitated financial alignment model (C-FAD), and the managed fee-for-service financial alignment model. Thirteen demonstrations are under way across 12 states. New York is operating two demos.

“An objective of the capitated FAD is to streamline and coordinate primary, acute, behavioral, pharmacy, and long-term services and supports for this vulnerable population of seniors and individuals with disabilities,” says Tom Standring, vice president of Long Beach, California-based Molina Healthcare, a healthcare company with the most C-FAD contracts in the country.

Thus far, none of the states have withdrawn from the demonstrations. “In fact, we are planning for two-year extensions in most states,” says Tim Engelhardt, director, Federal Coordinated Health Care Office, CMS. “States have invested immense amounts of time and energy in the program. It’s a testament to the commitment of state leaders to better serve dual-eligible beneficiaries.”

Virginia is the only state that has signaled it will let the C-FAD expire after three years. “Enrollment is not high enough for the state to realize expected savings, and the state doesn’t have a lot of history with managed care-particularly Medicare-which made getting providers on board more difficult,” Standring says.

Next: Early results

Meeting patients’ needs

As a result of the duals demonstration, according to written comments from the coordination office at CMS, more dual-eligible beneficiaries are having their health needs assessed. “At Molina, we are seeing more dual-eligible beneficiaries connected to person-centered care teams and more duals are receiving medication consultations from pharmacists,” Standring says.

Margaret Murray, CEO of Washington, D.C.-based Association for Community Affiliated Plans, which has 14 member plans participating in the duals demonstration as Medicare-Medicaid Plans (MMPs), says the early results are encouraging.

“Our plans are finding success in several dimensions, such as making sure that primary care doctors and psychiatrists collaborate regarding patients with behavioral health diagnoses, putting members in touch with dedicated case managers, finding housing for members, connecting members with community resources, and assisting them with transferring out of nursing homes and back into the community, when appropriate,” she says. “Previously, much of that had fallen on the members themselves, or their caregivers or families.”

It’s also notable that demonstrations have taken big steps forward in helping more states move their long-term services and support programs into a managed care environment, and have better integrated them with behavioral health services and Medicare, Murray says.

What’s more, she says the demonstrations offer an improved level of coordination and access that is having a big effect on members. “Many of our plans reported significant unmet needs [among members] in their first year,” Murray says. “For instance, our plans reported that they enrolled far more members who were found to have behavioral health issues than they expected. Some of those diagnoses surfaced as the result of a health risk assessment of members of MMPs when they joined a plan; we’re finding diagnoses that had previously fallen through the cracks.”

Next: Mixed feedback

Mixed feedback

The Federal Coordinated Health Care Office has contracted with RTI International to independently evaluate the demonstrations. Over the next few months, it will receive its most robust analysis to date on demonstrations in Massachusetts, Washington, and Minnesota. Reports on several other demonstrations will follow in 2017.

Among the key issues that CMS has targeted for evaluation are member health status and outcomes; quality of care across care settings and delivery models; access to care; overall costs and savings; and beneficiary satisfaction with the program.

According to a preliminary report already completed by RTI International in January 2016, the demonstration in Washington saved the Medicare Trust Fund $21.6 million during its first 18 months.

Growing need

Standring says the title of GAO’s report, “Additional Oversight Needed of CMS's Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries,” overstates the breadth of the case for greater oversight. “CMS, and in particular the Medicare-Medicaid Coordination Office, are very engaged as are state Medicaid agencies,” he says. “The biggest reporting gap involves care team activity, and it makes sense for CMS to develop uniform standards.”

Pamela Parker, MPA, Medicare Medicaid integration consultant, SNP Alliance, National Health Policy Group, Washington, D.C., says GAO’s report indicated variation in care coordination models between demonstrations, and concluded that there is a lack of consistent measures being used to compare care coordination across all of the demonstrations.

“But there are few, if any, current nationally endorsed measures of care coordination appropriate for use in this field, and although some are being developed, they are largely separate for Medicare versus Medicaid and may not be appropriate for use in integrated programs,” Parker says. Furthermore, Medicaid is not designed to be the same across all states, and the populations served in the demos are not the same in all states. “Care coordination models need to be tailored to each population’s needs, so there may be good reasons why approaches and details differ and why some flexibility in the models is necessary. All of these issues complicate comparisons across states.”

Next: What the future holds

What the future holds

As federal and state governments face the significant fiscal and caregiving challenges of meeting the needs of increased proportions of elders and physically challenged individuals, the need for efficient integrated Medicare and Medicaid financing and service delivery models will only intensify, Parker says. “The investments we are making now to develop, implement, evaluate, and fine tune these demonstrations are essential to coping with the challenges of those very real and immediate demographic changes.”

CMS is on the right track with creating the dual-eligibles program, says Murray. “The previous system wasn’t serving people well, and it was time to try something new,” she says. “There are undoubtedly going to be challenges along the way, and that’s why CMS, states, and plans are continuously looking for ways to improve the program. It’s true that the cost savings haven’t come right away. But this level of delivery system reform, by its very nature, will take some time to bear that kind of fruit.”

The Federal Coordinated Health Care Office will continue to test the integrated care models and examine the results and the types of environments in which the models fare best, understanding that those findings may differ across states. “But as long as we continue to learn from the people we serve, we will end up with a system that is far better equipped to serve those of us with complex health and long-term care needs,” Engelhardt says.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.