Reports of low enrollment are not dampening CMS officials' optimism over moves aimed at improving coordination of care for millions of low-income and disabled Americans who are dually eligible for Medicaid and Medicare.
The agency acknowledged high opt-out rates in the voluntary initiative, but said it's not the red flag some have made it out to be.
The Affordable Care Act authorized demonstrations to improve care and reduce costs for the more than 9 million dually eligible beneficiaries, many of whom have severe chronic conditions and physical or behavioral disabilities.
Out of the 1.7 million people eligible to participate in the 11 states with demonstrations, 26%, or 450,844, have signed up as of May 1, according to Community Catalyst, a consumer advocacy group based in Massachusetts.
“The trade press have framed this as a disappointment, I don't know if it is; I think we're learning as we go,” Tim Engelhardt, acting director of the CMS' Medicare-Medicaid Coordination Office, said at the Medicaid and CHIP Payment and Access Commission (MACPAC) meeting on May 14.
Under the three-year Financial Alignment Initiative, led by the CMS' Medicare-Medicaid Coordination Office, participating states are responsible for coordinating Medicare and Medicaid benefits and spending for the dual-eligible beneficiaries through contracts with private managed-care plans.
The states receive a capitated payment combining Medicaid and Medicare, minus agreed-upon savings. The plans, which are paid a risk-adjusted capitated rate, generally are responsible for providing the full range of care, including long-term care, though each state's program is somewhat different.
The impetus for the demonstration is that even though dual-eligible beneficiaries make up only 13% of the population enrolled in both programs, they account for 40% of total Medicaid spending and 27% of total Medicare spending. Experts say the lack of coordination results in poor quality care and unnecessarily high costs and that addressing this is one of the biggest opportunities for Medicaid and Medicare savings.
MacPac Commissioners wondered if the CMS is worried about the demonstration saving enough money, given the high opt-out rate.
“I hate to talk about the money … at the end the day it's about people and how we serve them,” Engelhardt said.
He noted that this is the highest amount of duals ever receiving truly coordinated care. Before the demonstration, a mere 20,000 were part of a little-known initiative called Program of All-Inclusive Care for the Elderly (PACE), which was designed for nursing-home eligible beneficiaries.
“If we end up spending what we're spending now, but improve quality of care, I don't know if that's a failure,” Engelhardt told Modern Healthcare after the meeting.
Advocates and plans have said once a dual-eligible is enrolled in the demonstrations, he or she is happy with the care. However, some dual-eligible beneficiaries face challenges in the early days of being enrolled, according to focus groups performed for MACPAC. Researchers spoke with 55 dual-eligibles in California, Massachusetts and Ohio.
Those interviewed reported lapses and delays in care once they joined the demonstrations in their states, including not getting prescriptions filled, mistakenly being charged copays, and some lost personal-care attendants as they were not receiving payments from plans.
However, Michael Perry, a partner at Perry Undem Research/Communication, which conducted the research, said many of these difficulties subsided after a few weeks. He also reported numerous positive outcomes such as keeping their doctor, getting access to new services such as expanded dental benefits, non-medical transportation and behavioral health services.
The CMS plans to release the results of evaluations of demonstrations in Massachusetts and Washington state in the first half of 2016.
