So-called dual-eligibles often have a difficult time navigating the policies of both programs to get the services they need. Caring for them is also significantly more expensive than for other beneficiaries in the programs, costing the state and federal programs about $350 billion a year. The 9 million dual-eligibles make up just 13% of the population enrolled in both programs but account for 40% of all Medicaid spending and 27% of all Medicare spending.
Reform Update: Many dual-eligibles opt out of care coordination
Under a provision of the Patient Protection and Affordable Care Act, the CMS Innovation Center invited states to launch three-year demonstration projects that would align care for dual-eligibles. Eleven states volunteered to participate and have launched or are about to launch programs that give health plans capitated payments to align care. But the programs are also voluntary for beneficiaries, and most of them are saying no.
In California, for example, only about 40,000 of the estimated 450,000 dual-eligibles had opted into the state's Cal MediConnect program as of July 1 and nearly 40,000 have opted out. The program began enrollment April 1. Massachusetts started enrolling residents in its One Care demonstration in October last year. Out of 94,000 people who qualify, just 13,000 had signed up and 21,000 had opted out as of May 1.
The numbers are similar elsewhere. If the lack of participation persists, it could be hard to determine how to evaluate the approach.
“If this model is deemed not successful, it's not going to reach duals that are beyond this initial demonstration,” said MaryBeth Musumeci, associate director of the Kaiser Commission on Medicaid and the Uninsured.
Only Massachusetts so far has formally studied why so many beneficiaries are declining to participate. According to a February focus group, patients feared losing relationships with trusted providers and worried they'd face new restrictions on services.
“Given the fact that the demonstration introduces a significant change to the delivery system, it makes sense that continued access to one's provider is a primary concern for beneficiaries,” said Fay Gordon, a staff attorney at National Senior Citizens Law Center. “Dual-eligible individuals are low-income beneficiaries, and their needs were not a priority in previous transitions to private managed-care systems.”
Massachusetts officials did not return a request for comment for this story but previously have said they are not concerned because beneficiaries who opt out can change their minds.
As of July 2014, beneficiaries in five states—California, Illinois, Massachusetts, Ohio and Virginia—are participating in capitated demonstrations, to be followed by five more states—Michigan, New York, South Carolina, Texas and Washington—in the coming months.
Using these rates in other states as extrapolation points, consulting firm Health Management Associates estimated that Illinois and Virginia had 25% opt out rates as of June. Neither state has publicly released figures.
In California, at least one plan blames opt-outs on confusing forms being sent to duals by the state.
“The biggest problem we found our members encountered was thinking that they were required to opt-out, since the opt-out forms were included in the notification letters,” said Russell Hoyle, marketing director at Health Plan of San Mateo in San Francisco.
In Ohio, only about 9,000 of an estimated 114,000 qualifying Ohioans have agreed to allow the state's demonstration program to coordinate their Medicare and Medicaid benefits.
State officials from Ohio and Virginia said they were not concerned about the opt-out rates. Requests for comment from California and Illinois were not returned by deadline.
Some patient advocates, meanwhile, are concerned that some of the programs are not honoring dual-eligibles' right to choose the way they receive care. Most of the offerings have passive enrollment, which means that if an individual takes no action in a certain time frame to either pick a plan or decline participation, they are randomly assigned to one.
In California, a hearing is scheduled Aug. 1 in superior court to determine whether or not to issue an injunction to stop the state's duals demonstration.
The Los Angeles County Medical Association and several independent living centers are suing the state, alleging the program failed to meet a requirement to draft enrollment forms at or below a sixth-grade reading level. The lawsuit alleges that beneficiaries, many of whom have cognitive disabilities, may not realize they could be severing ties with their current providers when they join the program.
“We just want our patients to be told what's good for them and let them choose,” said Rocky Delgadillo, CEO of LACMA.
The lawsuit has surprised participating insurers. The state took extensive steps to get feedback from both providers and patient advocates before enrollment notices were released, said Lisa Rubino, Molina Healthcare's senior vice president of duals strategy, adding that the plan believes coordinating care for the dual-eligible population is an important initiative. “Medicare and Medicaid were two programs that were designed to never work together, and dual-eligibles were falling through the cracks of the two programs.”
Florida has banned health insurance companies from marketing their plans directly to Medicaid recipients as the state continues to transfer program beneficiaries from the current fee for service model to a managed care model.
Private companies that have contracted with the state to provide care for Medicaid patients are allowed to market to consumers with prior state approval via items like billboards and radio ads but are banned from conducting marketing events like health fairs, or other scenarios where companies have direct access to enrollees.
Follow Virgil Dickson on Twitter: @MHvdickson
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