Reform Update: Quality of life difficult to measure for dual-eligibles

State demonstration projects designed to coordinate benefits and care for people dually eligible for Medicare and Medicaid are lacking in how they measure quality-of-life indicators, as well as quality of long-term services and supports, according to a new policy brief from the Commonwealth Fund.

The report found that states participating in the demonstration are not widely tracking certain quality measures for issues outside the medical setting, such as beneficiaries' perceptions about whether they can choose their living arrangements and friends, whether they feel treated with respect, whether they feel they have good relationships with their caretakers, and whether they participate in community activities, according to the study.

The states also are not adequately tracking patient experience-of-care measures based on individuals' goals and preferences. In addition, there are few metrics for assessing whether states are making progress on keeping people out of long-term care facilities and allowing them to remain in home- and community-based settings.

Among the many challenges that states, managed care plans, and the CMS face in designing and implementing these demonstration projects is how to choose and apply measures that accurately track changes in quality and performance over time. The authors examined quality measures chosen by eight states with federally approved memorandums of understanding for their demonstrations as of December 2013: California, Illinois, Massachusetts, New York, Ohio, South Carolina, Virginia and Washington.

It's largely not the states' fault that they are not tracking quality issues adequately, said Sabiha Zainulbhai, a co-author of the policy brief and a health policy analyst at the National Academy of Social Insurance. On the core list of metrics the CMS has required states to monitor, these types of quality-of-life measures are not mandatory. That's because there are not adequate federal measurements for such issues, explained Lee Goldberg, study co-author and vice president for health policy at the National Academy of Social Insurance.

As a result, some states are voluntarily tracking particular issues, Zainulbhai said. For instance, Illinois is the only state studied that is tracking long-term care and hospital utilization related to urinary tract infection or bacterial pneumonia.

Goldberg said she hopes organizations like the National Committee for Quality Assurance will develop performance measures on quality-of-life issues for programs serving dual eligibles.

NCQA has begun working with several managed care plans that serve dual eligibles to identify best practices for treating this population. That research could lead to the creation of new Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, said Jessica Briefer French, a senior consultant for research at NCQA.

The demonstration projects are taking place under the CMS' Financial Alignment Initiative, a program established by the Patient Protection and Affordable Care Act. The goal of the program is to better coordinate care for the 9.1 million beneficiaries who receive coverage from both Medicare and Medicaid. These individuals cost the federal government around $350 billion a year. A total of 26 states applied to participate in the program, with only 10 states thus far getting the formal go-ahead to begin building programs.

Most of the state demonstrations have yet to launch, with the exception of Massachusetts, which began enrollment Oct. 1, 2013. The rest have begun or are just about to begin taking in patients.

New Hampshire's House voted Wednesday to expand Medicaid programs to cover an estimated 50,000 low-income adults eligible for federal subsidies under the federal health care overhaul law.

The House voted 202-132 to send a bipartisan Senate plan to the governor that uses federal Medicaid funds to buy private health coverage for adults making less than 138 percent of the federal poverty limit, about $15,856 a year for a single adult.

Democratic Gov. Maggie Hassan said she looks forward to signing the bill, which could be as soon as this week.

Republicans in Virginia's House of Representatives have told Democratic Gov. Terry McAuliffe “no dice” on his proposed two-year pilot to expand the state's Medicaid program under Obamacare.

The deadlock over expanding the program has kept the state from passing its 2015 fiscal year budget, which begins in July.

McAuliffe's proposal involves using federal Medicaid funds to buy private coverage on the federal insurance exchange for an estimated 400,000 state residents with incomes between 100%and 138% of federal poverty level.

House Majority Leader Kirk Cox (R-Colonial Heights) said McAuliffe was hurting local government agencies by holding up the budget. Cox said he wants the General Assembly to pass a budget and then take up Medicaid expansion in a separate special session.

But Virginia hospitals and some business groups are lobbying vigorously for the governor's proposal to expand Medicaid.

Ohio Medicaid officials are planning to petition the CMS to allow Medicaid healthcare coverage inside jails and detention centers for incarcerated teens and young adults.

Federal law currently prohibits Medicaid-funded services in public institutions where individuals are held against their will. These include people held in jails or detention centers.

Ohio, which has decided to expand Medicaid, will ask the CMS to “reconsider out-of-date law and interpretation,” specifically for youth in detention who are awaiting adjudication, Patrick Beatty, deputy director and chief policy officer of the state's Department of Medicaid, said in state documents. State officials did not respond to requests for comment.

Around the country, correctional institutions in states that are expanding Medicaid are enrolling their inmates in the program to pay for healthcare delivered outside the walls of the facilities. Medicaid does not cover day-to-day healthcare provided in jails and prisons, but it does cover external hospital stays beyond 24 hours.

Republicans and some Democrats around the country have criticized extending Medicaid coverage to inmates. It's unclear whether the Obama administration would agree to expand Medicaid coverage to cover healthcare services delivered inside the walls of detention centers and jails.

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