The CMS official in charge of coordinating care for Americans covered by both Medicare and Medicaid says some healthcare providers are illegitimately trying to dissuade dual-eligible beneficiaries from participating in a managed-care initiative designed to test ways to reduce costs and improve quality. She said her agency has increased its surveillance of these providers, though she did not identify any by name.
“We are unfortunately seeing lots of bad behavior in most of the states,” said Melanie Bella, director of the Medicare-Medicaid Coordination Office at the CMS, during the National Association of Medicaid Directors (NAMD) on November 4. “Providers and other plans are telling beneficiaries they are going to lose benefits or lose prescription drug coverage.”
Bella did not provide specific examples but said providers are obstructing the care-coordination demonstration by scaring the beneficiaries and leading them to opt out of participating. The information the providers are giving beneficiaries is often inaccurate or misleading, she said. Beneficiary participation in the demonstrations is voluntary.
Virginia officials informed the Virginia Health Care Association, the state's nursing home trade group, that some of its members were inappropriately advising patients and families about the state's dual-eligible initiative, said Steve Morrisette, the association's president. But he said his members had no malicious intent. After receiving guidance from the CMS, his member facilities now have a better understanding of how they are allowed to communicate with patients about the program.
There currently are coordinated-care demonstrations operating in five states—California, Illinois, Massachusetts, Ohio, and Virginia. Demonstrations also are slated to begin in the coming months in Michigan, New York, South Carolina, Texas, and Washington.
The CMS Innovation Center in 2011 established the Financial Alignment Initiative, which gave states the option to launch three-year demonstration projects under which dual eligibles' benefits and care is overseen by health plans receiving a capitated rate per enrollee. The goal is to coordinate care for dual eligible beneficiaries, who are among the most expensive patients in the U.S. healthcare system.
These beneficiaries are low-income people, some under 65, often with physical, cognitive, or behavioral disabilities. In the past, they generally have been exempted from mandatory Medicaid managed care programs because of their specialized needs and vulnerable status. Under the various state demonstrations, beneficiaries generally can choose whether to opt in to the program.
The reason the Financial Alignment Initiative was launched was that dual eligibles often face a difficult time navigating the separate Medicare and Medicaid programs and their multiple doctors and other providers. That drives up the cost of their care and leads to poorer outcomes. The average cost of care for dual-eligible beneficiaries is significantly higher than the cost for the general Medicare and Medicaid populations. Even though there are just over 9 million dual-eligibles, they account for 40% of all Medicaid spending and 27% of all Medicare spending, with their care costs totaling about $350 billion a year.
Some hospitals, physicians, and nursing homes likely are resisting the demonstrations because the CMS is moving away from the lucrative, unmanaged, fee-for-service payment model they were used to, a CMS spokeswoman said following Bella's remarks.
The CMS and state Medicaid agencies are concerned about providers trying to discourage beneficiary participation because if the demonstrations don't get enough participants, it will be hard to evaluate whether the care coordination programs are reducing costs and improving quality. Many experts say better coordinating care for expensive dual-eligible patients is one of the most important ways to control Medicare and Medicaid costs.
But patient advocates warn that dual-eligible patients have complex needs and question how many managed care plans and providers are prepared at this point to adequately serve them.
Some of the resistance providers are putting up to the dual eligible demonstrations potentially could have been avoided if the CMS had worked more closely with providers ahead of the demonstration launches, Bella said. “If we had to do it all over again, we probably would have started early trying to communicate directly with provider groups,” Bella said. “We focused a lot on beneficiary engagement and how to work with advocates on the state and federal level. But we underestimated when we should have started to talk to providers.”
In Virginia, the state Medicaid agency has found evidence of resistance from a wide range of providers, including health systems, hospitals, and nursing homes, said Cindi Jones, Virginia's Medicaid director. She pointed to one instance in which a nursing home called state officials and said it and its patients would not participate. At times lawyers have contacted the providers to get them to stop engaging in such actions.
A spokesman for Jones' agency later clarified that no formal legal action was taken. “We are speaking to the identified providers and explaining which actions and activities are not allowed in the identified dis-enrollment efforts,” the spokesman said.
“We communicated with our membership that the basic rule was that they could only be factual in their discussion of [the demonstration],” said Morrisette of the Virginia Health Care Association. “The decision to opt in or out of the program is entirely a beneficiary's choice.”
California's Medicaid agency has faced similar problems with its care-coordination demonstration. But officials of the state's Department of Health Care Services declined to discuss details. “As a department, we have worked quickly to address issues and any misinformation that may have been shared by providers so we can ensure that dual eligibles are able to make informed choices,” said Anthony Cava, an agency spokesman. To aid its outreach efforts, the state has launched a site to provide information to physicians about the program.
Some providers in states with dual-eligible demonstration programs say they have simply told their patients the truth about the programs. They say some providers are choosing not to participate because of concerns about payment.
Under the demonstrations, dual-eligible beneficiaries receive a full range of care, including long-term care, in capitated managed-care programs rather than in the Medicare and Medicaid fee-for-service programs. The managed-care plans have contracts with the states and the federal Medicare program that build in cost savings for the public programs, which means lower payment rates for providers that serve these managed-care patients.
“We do feel that it is important that physicians be able to talk with their patients about their access to care if it would be impacted – but in a factual way that outlines what changes they may see in their healthcare, not using any sort of scare tactics,” said Molly Weedn, associate vice president of public affairs at the California Medical Association.
“For the program to achieve its goals, beneficiaries must be able to readily access all levels of medically necessary care,” said Jan Emerson-Shea, vice president, external affairs at the California Hospital Association. “To this end, the program must ensure that plans have adequate networks for all specialties and provider types, reimbursement levels are sufficient to maintain networks and continuity of care, and care authorization and reconsideration/appeals processes are well defined and effective.”
Even with the lower payment rates, there are providers who are willing to participate in the demonstrations. But some are worried about how the demonstration roll-outs are going. “There are concerns among physicians regarding eligibility, payment and other challenges as the implementation phase has started, said Reginald Fields, communications director for the Ohio State Medical Association. “It is not always clear what providers will be paid for their services.”
In the Massachusetts demonstration, the state Medicaid agency recently had to increase the amount it pays health plans to manage dual-eligible patients' care, and to share more of the plans' losses for the next two years because of the unexpected challenges the plans have encountered, the Boston Globe reported.
In California, physicians filed suit this past summer in an unsuccessful effort to stop that state's duals eligible demonstration.
They said they sought the injunction because the state had not honored its commitment to issue enrollment forms geared to consumers who read at or below a sixth-grade level. Since many duals have cognitive disabilities, it was claimed they might not realize that by enrolling they were potentially agreeing to sever ties with their current providers.
Follow Virgil Dickson on Twitter: @MHvdickson
