State plans for dual-eligibles face tough challenges

On a bone-chilling day in January, Jennifer Turpin visited a wheelchair-bound patient named Olivia Richard at her small apartment in Boston. Turpin, a care coordinator, was conducting a home inspection for Richard, who had just joined One Care, a state program for low-income, chronically ill people who are dually eligible for Medicare and Medicaid.

Looking around the apartment, Turpin, who performs independent living assessments for the not-for-profit plan Commonwealth Care Alliance, was horrified at what she saw. Richard's sheets and dishes hadn't been washed in months, and her floor was black with dirt. Before she joined One Care, Richard did not receive consistent visits from home health aides.

“I didn't realize how bad the level of care I was getting was until that visit,” said Richard, who is 30. “If I were to get a sore on one of my legs and am lying on filthy sheets, I could get a life-threatening infection.”

Since late last year, 10 states have launched or are about to launch dual-eligible initiatives under the CMS' Financial Alignment Initiative to improve care for more than 9 million dual-eligibles by integrating Medicaid and Medicare benefits. They hope better care coordination will reduce costs for this very expensive population, currently totaling about $350 billion a year. It's estimated that about 2 million are eligible for the program in those 10 states.

But some experts question how many dual-eligible beneficiaries will voluntarily enroll in the new managed-care programs and whether private health plans participating in the demonstrations will get enough physicians and other providers to serve these challenging and time-consuming patients. In addition, there are questions about the quality of the plans themselves, and whether the demonstrations will produce cost savings.

While most dual-eligibles are 65 or older, around 40% are younger. Many duals under age 65 have multiple chronic health conditions, including mental-health and substance-abuse issues, or physical or developmental disabilities. Some are homeless, while others live in residential care facilities. Often the healthcare and other support services that they receive are fragmented because duals fall through the cracks of the two programs. Many duals need home- and community-based support in addition to medical and behavioral care.

While 26 states applied to participate, so far only California, Colorado, Illinois, Massachusetts, Minnesota, New York, Ohio, South Carolina, Virginia and Washington have received federal approval to start their programs. Massachusetts and Minnesota are the farthest along, having launched their programs last year. Illinois began enrollment in March, and the rest of the states are starting enrollment between April and October. Some states are targeting all their duals, while others are focusing on a subset, such as those under 65 or those needing long-term care.

“I'm glad they're moving slowly,” said Judy Feder, a Georgetown University professor of healthcare policy who has closely followed the duals demonstration. “Taking a large, fragile population and moving them into an untried new system is a gamble. Slow is better.”

Most states are contracting with private managed-care plans to serve the duals. But as the plans gear up, there are concerns about getting enough participation from physicians, both private-practice doctors and those employed by provider organizations, given the time commitment needed to treat duals under the demonstration's model.

That model requires doctors to work closely with a multidisciplinary team of clinical and nonclinical staff to manage both medical care and social services for beneficiaries. This may be too much for some physicians, said Christopher Palmieri, president of VNSNY Choice Health Plans, one of the plans that will serve duals in New York state's demonstration when enrollment begins Oct. 1.

It's not yet clear whether it's feasible for doctors with dozens of dual-eligible patients to spend that much time on their care, said Dr. Judith Steinberg, deputy chief medical officer of Commonwealth Medicine, a consulting arm of the University of Massachusetts Medical School. Still, after years of treating dual-eligible patients herself, she argues that coordinating these patients' medical and social needs is the best way to keep them stable and out of the hospital and emergency department.

Nursing home operators also are eyeing the demonstrations with caution. They may stay away if the reimbursement isn't adequate, said Scott Hale, executive director at Symmetry Healthcare Management, which owns and operates several nursing homes in Washington state. The managed-care demonstration program there begins enrollment in July. Participating plans have not yet released their nursing home payment rates.

Another major question is how many dual-eligible patients will choose to enroll, since duals can opt not to sign up. Unless they actively decline to join, though, they generally will be automatically enrolled. Already there are indications of problems. In Massachusetts, it's estimated that nearly 94,000 residents are eligible for One Care. But as of Feb. 1, only 9,541 had signed up, while 16,642 had opted out. State and health plan officials say they aren't worried because duals have time to change their minds.

Patient advocates say duals may opt out because their preferred physicians or other providers are not part of the plan network. Others may simply be uncomfortable with the new managed-care system.

Remon Jourdan, 39, a One Care enrollee living in Boston, said he's happy with the care he's received through the Commonwealth Care Alliance, which started working with duals long before One Care. But he said he's talked with other enrollees who have expressed buyer's remorse because they didn't like the care-team approach.

In Illinois, which is a month into enrollment, there are concerns about how many of its 132,000 dual-eligibles will opt out, said Jim Parker, the state's deputy administrator for Medicaid. “Opt-out could be higher in Illinois than in other states because (the state) does not have high managed-care penetration in many markets,” he said. Duals unfamiliar with managed care may stick with the fee-for-service model, despite its many inadequacies, he said.

In California, Nancy Becker-Kennedy, 62, of Los Angeles, said she plans to opt out of the state's Coordinated Care Initiative when enrollment begins April 1. That's because she's heard horror stories about the participating plans, several of which previously were participating in the state's Medi-Cal program. She has heard about problems with coverage denials for needed services and an inadequate appeals process. “The state claimed that switching to managed care would lead to more coordinated care, but it's been a dirty bomb on the quality of care we had,” she said.

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