A troubled Massachusetts managed-care program for low-income people who are dually eligible for Medicaid and Medicare will continue despite one of its leading plans dropping out of the program.
Nearly two years ago, Massachusetts became the first state to enter into an agreement with the CMS to offer dual-eligible beneficiaries coverage plans that combined Medicaid and Medicare benefits into one plan to better coordinate their care. Enrollment in the so-called One Care program began Oct. 1, 2013. Participation is optional, but beneficiaries must explicitly opt out.
The Massachusetts demonstration program and similar ones in other states were authorized by the Affordable Care Act to improve care and reduce costs for the more than 9 million Americans enrolled in both federal programs, many of whom have severe chronic conditions and physical or behavioral disabilities.
Late Wednesday, One Care suffered a major blow when Fallon Community Health Plan announced it would exit the demonstration.
“Ultimately we determined that our continued participation was not economically sustainable,” a spokeswoman for the plan said. The health plan's exit will be effective Sept. 30, which Fallon said should give beneficiaries time to transition to other One Care plans.
Fallon's departure will leave just two plans offering coverage under the initiative: Commonwealth Care Alliance and Network Health. The state plans to continue with the demonstration, a spokeswoman for the Massachusetts Health and Human Services agency said.
One Care was struggling even before it officially launched. Weeks before enrollment began, three of the original six managed-care plans that were supposed to offer One Care plans dropped out because of financing concerns. The narrower choice of plans meant certain parts of the state couldn't participate.
Under One Care, the state receives a capitated payment combining Medicaid and Medicare, minus agreed-upon savings.
One Care has also seen large numbers of residents opt out of the initiative. Just 18% of the roughly 97,000 beneficiaries eligible for the program were enrolled as of May. Fallon, with 5,500 enrollees, was the second-most popular plan within the program.
One Care has additionally struggled to save money. In 2011, Medicare and Medicaid spending on dual-eligibles in Massachusetts totaled $3.85 billion. The CMS expected a 1% spending reduction by the end of 2014, a 1.5% reduction in 2015 and a 4% drop in 2016. The state recently revised those goals to 0.5% in 2015 and 2% in 2016. It's unclear if it met its first-year goal.
Patient advocates were concerned upon hearing about Fallon's exit. “It's unfortunate. It's hard to tell if One Care can survive this, but clearly Massachusetts is committed to finding managed-care alternatives,” said Leo Sarkissian, executive director of the Arc of Massachusetts, an advocacy group for individuals with intellectual and developmental disabilities.
Others viewed the plan's exit as a bump in the road toward improving care for those individuals.
“We knew from the beginning this would be an incredibly challenging undertaking,” said Renee Markus Hodin, program director at Community Catalyst, a consumer advocacy group. “I think it's too early to throw in the towel.”
Hodin said despite the challenges that have plagued One Care, there have been some positive outcomes.
A recent beneficiary survey released by the state found that overall satisfaction with One Care is high and most members intend to stay in the program.