Tuesday, January 3, 2012

Integrated Care for Duals

The “Alliance for Health Reform” founded by Senator Jay Rockefeller of West Virginia held a briefing December 12th on Capitol Hill to foster a discussion on the issues facing dual eligible beneficiaries. Under the CMS funded “State Demonstrations to Integrate Care for Dual Eligible Individuals”, fifteen states are in the process of designing new approaches to better coordinate care. Each state will receive $1 million to develop a model that will work in their state.

According to Suzann Gore, Director of Integrated Care for Dual Eligibles at the Center for Health Care Strategies, it is very important to keep stakeholders engaged to meet the needs of dual eligible beneficiaries, to learn how care can be improved, and to understand what is working.

To find solutions to integrating care for dual eligibles, Lindsay Barnette, a member of the Models and Demonstrations Group in the Medicare-Medicaid Coordination Office at CMS described how focus groups held by CMS in 2011 were productive. The focus groups held in five states helped to gain insight as to how Medicare-Medicaid enrollees make enrollment decisions, their experiences with the various types of Medicare and Medicaid service delivery combinations, and how to improve communications with enrollees.

The focus groups enrolled 156 people in 21 groups mostly 18 to 64 but three groups had participants 65 years old and older. People were in the group with physical disabilities, serious mental illness, developmental disabilities, multiple chronic illnesses, long term care needs, and individuals with no particular conditions were represented. In addition, there was one Chinese speaking group and one group with Navajo majority.

Basically, the participants are concerned with the physician and/or psychiatrist in the network that they will work with, understanding benefits, making the right dental and eye care choices, and understanding their prescription drug needs and costs.

Most enrollees find the information confusing and overwhelming as to what is covered, what is not, and the overall cost for their healthcare. They also want up-to-date provider directories with information as to whether the providers are taking new patients. Most participants have poor access to the internet and are frustrated with automated phone information.

Most participants in the groups are much more focused on coordination of benefits than on the coordination of care. The participants want better coordination of benefits, easier time in getting authorization for services, and they do not want to get the run-around between Medicaid and Medicare.

Lynda Flowers a Senior Strategic Policy Advisor for the Health Team in the Public Policy Institute at AARP, described the insights obtained from AARP focus groups that discussed what older adults want from their care.

The participants in the AARP focus groups were 65 or older, enrolled in both Medicare and Medicaid, receiving care through one of the specified delivery models, had no cognitive impairments, currently managing multiple chronic conditions, and roughly one-half of the participants had a recent interaction with a hospital.

The AARP heard that most of the participants in the focus groups were generally satisfied with their care although duals in this study group strongly preferred having the freedom to select their providers but most were willing to make trade-offs. However, some duals in some of the care models reported having problems accessing some services.

Most of the dual eligibles in the focus groups saw value in care coordination. They like having someone look out for their best interests and take care of billing issues. The things that they appreciated the most included frequent phone calls from their care managers, phone calls alerting them as to the availability of special health programs, and having people check to make sure that they had the things they needed to manage their conditions. It also gave most of the duals a measure of comfort knowing that their providers communicated with each other.

The focus groups talked about effective strategies to educate beneficiaries on the billing system and benefits, the options available, and how or whether to develop a single, laminated ‘smart” card that combines Medicare Parts A, B, and D for beneficiaries in fee- for- service.

Also needed are peer-to-peer discussions among duals with similar health conditions, a study to examine whether social isolation increased healthcare costs, and if and how the use of pharmacy transition coordinators could be an effective strategy to improve medication management.

Massachusetts was one of the fifteen states awarded a $1 million planning contract from CMS to help develop a design proposal for a state demonstration plan to integrate care for duals. The state’s target population is 115,000 dual eligibles ages 21 to 64 with full MassHealth and Medicare benefits.

Corrine Altman Moore from the MassHealth/Executive Office of Health and Human Services in the Commonwealth of Massachusetts recounted how the four focus groups assembled in 2011 felt about current benefits and an integrated model. From feedback gathered, the focus groups and other stakeholders want to see some improvements in benefit design especially related to dental services and eyeglasses and want more peer support related to nutrition and wellness provided by community health workers.

As for the enrollment process and outreach, they believe a neutral and impartial enrollment broker is needed along with sufficient time and clear information on how to make good choices for their care and they want to see current providers connected to their caregivers.

The Commonwealth of Massachusetts Executive Office of Health and Human Services (EOHHS), Office of Medicaid in December 2011, released a draft proposal that went to the CMS Center for Medicare and Medicaid Innovation on how the state could conduct a state demonstration to integrate care for duals.

The draft proposal gives ideas on how the demonstration would be managed, provides leadership under the leadership of the state EOHHS, and how the Integrated Care Organization (ICO) manager would oversee the daily program. The ICO contracting unit would handle routine contracting and procurements for managed care plans.

One of the major challenges would be to provide the specific information on the technology needed to enroll members, make global payments, collect and manage encounter data, manage federal reporting activities including MA-21 for enrollment and eligibility, MMIS for capitation payments, and provide a data warehouse to collect and analyze data. Data analysts would also be needed to aggregate, analyze, and report on encounter, quality, and financial data to be used for quality control and other purposes.

Go to www.mass.gov/eohhs/docs/eohhs/healthcare-reform/state-fed-comm/111207-draft-demo-proposal.pdf to view the draft proposal.

For more information on the briefing and the Alliance, go to www.allhealth.org.