Her concerns are not without some basis. CalOptima was chosen by California to offer a plan for duals in Orange County as part of the demonstration. But when the CMS conducted a readiness review of the plan, it found problems in how the company was overseeing care for the dual beneficiaries it already was serving in OneCare, its Medicare special needs plan that has 16,000 beneficiaries.
“Violations resulted in enrollees experiencing delays or denials in receiving covered medical services or prescription drugs, and increased out-of-pocket costs,” the CMS said in a Jan. 24 letter to CalOptima officials. “CalOptima's conduct poses a serious threat to the health and safety of Medicare beneficiaries.” Until those issues are addressed, the CMS said, the plan could not participate in the duals initiative.
The CMS has blocked another California duals demonstration plan called L.A. Care from signing up beneficiaries through passive enrollment, which involves randomly assigning beneficiaries to a plan if they don't select one and don't opt out. That's because L.A. Care has a Medicare Advantage quality rating of 2.5 stars, less than the three stars—on a five-star scale—required to participate in passive enrollment.
Despite these issues, California is standing behind the eight plans it chose to serve Los Angeles, Orange, San Diego and San Mateo counties for the demonstration. “We are confident that (L.A. Care and CalOptima) will be able to resolve these issues and will then be able to participate and provide members with the high level of quality care they need and deserve,” said Anthony Cava, a spokesman for the California Department of Health Care Services.
The big, overarching concern is whether the dual-eligible demonstrations will indeed reduce costs for the federal and state governments in serving these very expensive patients.
In 2011, Medicare and Medicaid spending on duals in Massachusetts totaled $3.85 billion on care for 21- to 64-year-olds, the age bracket One Care is serving. As a result of the initiative, the CMS expects a 1% spending reduction by the end of 2014, with twice as much savings in 2015 and four times as much in 2016.
But some observers think that's unrealistic, at least partly because providing high-quality care to duals who have not been well-served previously could cost more initially if patients have pent-up needs for primary and behavioral care. “We think (federal and state officials) may be aggressive in what the cost savings will be,” said Leanne Berge, senior vice president of One Care at Commonwealth Care Alliance.
Correction: In the article “State plans for dual-eligibles face tough challenges,” (March 31, 2014) Dr. Judith Steinberg's position was inaccurately presented. She said multidisciplinary coordinated care teams will ease the time burden on doctors by taking over some of the medical and social services tasks for dual-eligible patients.
Follow Virgil Dickson on Twitter: @MHVDickson