Are dual-eligible demos succeeding? GAO says it will be hard to tell

The CMS needs to do a better job overseeing the 12 state-administered demonstration programs intended to improve care of people who are eligible for both Medicare and Medicaid, according to the U.S. Government Accountability Office.

The CMS is getting data from the the state programs that isn't comparable, making it difficult to assess whether the demonstration is achieving its goal of providing coordinated care to the population known as dual-eligibles, GAO says in a report released Tuesday.

The state programs are part of the federal Financial Alignment Initiative, which was called for in the Affordable Care Act because dual-eligible beneficiaries generally receive splintered care at extremely high costs to both programs. The estimated 9.1 million dual-eligibles accounted for about 35% of total spending by Medicare and Medicaid in 2011, according to the Kaiser Family Foundation.

The GAO specifically suggests that the CMS develop and require organizations participating in the demonstrations to report comparable core data measures. These measures should track the extent to which interdisciplinary team meetings are occurring and how often health-risk assessments are completed.

GAO also suggest that the agency align existing state-specific measures regarding the extent to which individualized care plans are being developed and designate them as a core reporting requirement.

For all but two of the state programs, HHS notes in a response included in the GAO report, the CMS is relying on the consumer survey (CAHPS) used in Medicare Advantage with supplemental questions specific to care coordination and related topics. The other two states are using a different survey because they are using a fee-for-service model rather than capitation, but the CMS has added similar supplemental questions.

HHS also said it is developing additional "consensus-based measures aimed at assessing care coordination by Medicare Advantage plans" that would be helpful in assessing the dual-eligible demos but may not be ready in time.

HHS said it would examine the feasibility of designating individualized care plans as a core reporting requirement.


Virgil Dickson

Virgil Dickson reports from Washington on the federal regulatory agencies. His experience before joining Modern Healthcare in 2013 includes serving as the Washington-based correspondent for PRWeek and as an editor/reporter for FDA News. Dickson earned a bachelor's degree from DePaul University in 2007.

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