Bad contact and demographic information for people dually eligible for Medicare and Medicaid is complicating demonstration programs intended to coordinate and improve the quality of their care, according to insurers participating in the program.
The CMS Innovation Center is administering a program called the Financial Alignment Initiative that allows states to launch three-year demonstration projects in which health plans are hired to manage care for the so-called dual-eligibles, who are among the most expensive patients in the U.S. healthcare system.
The programs employ a passive enrollment model. States participating in the initiative enroll dual-eligible residents in a plan unless the person proactively chooses a plan or opts out of the program.
The health plans, however, say they're having trouble tracking down these auto-assigned enrollees. “Finding members is one of the largest challenges,” Michael Monson, a vice president at Centene Corp., said at a recent summit on the dual-eligible population organized by World Congress. Centene is part of the demonstrations in Illinois and Ohio.
Jeffrey King, vice president of healthcare services for Molina Healthcare of Florida, said plans should consider sending employees to places that dual-eligible people hang out so they can collect up-to-date contact information. “It's almost like being private investigators,” King said. “We go to pharmacies, the liquor store and the grocery store and ask: 'Have you seen our members? If you do, can you have them give us a call?'”
In Illinois, the state's Medicaid agency is planning to give Medicaid beneficiaries SafeLink cellphones starting Jan.1. The plans in the dual-eligible demonstration there are in talks with the state to get the their enrollees' cell numbers and also have plans' contact information programmed into the phones, according to Sonia Robins, director of community engagement at Molina Healthcare Illinois.
The CMS and state agencies offer little help, the companies say.
“We get name, bad number, bad address and race unknown,” said Lisa Price-Stevens, medical director of Fallon Total Care, a managed-care plan participating in the duals demonstration in Massachusetts.
The inability to reach beneficiaries is frustrating the plans' attempts to manage their care as envisioned under the experiment.
“We have requirements to do health-risk assessments and we're reaching only about a quarter of our individuals,” said Diane Sargent, senior director of dual eligible product management and program implementation at Health Net.
CMS officials acknowledge that getting accurate information for dual-eligibles can be difficult and said the agency is striving to improve the data. “We are learning new ways to find and engage beneficiaries,” a spokeswoman told Modern Healthcare. “We are collaborating with our state and plan partners to share best practices and steadily improve in order to reach our ultimate goal of a person-centered system in which beneficiaries are actively directing their own services.”
Demonstrations are underway in Massachusetts, California, Illinois, Ohio and Virginia and are slated to begin in the coming months in Michigan, New York, South Carolina, Texas and Washington.
Duals are low-income people, some under 65, often with physical, cognitive or behavioral disabilities. In the past, they generally have been exempt from mandatory Medicaid managed-care programs because of their specialized needs and vulnerable status. Even though they number just over 9 million, they account for 40% of all Medicaid spending and 27% of all Medicare spending, with their care costs totaling about $350 billion a year.
Earlier this month, the CMS said some providers are obstructing the care-coordination initiative by encouraging beneficiaries to opt out. Lower-than-expected participation could make it difficult for policymakers to evaluate whether the efforts are reducing costs and improving quality.
Follow Virgil Dickson on Twitter: @MHvdickson
