Executive Summary: Coodinate Care for the Most Vulnerable

No one expects to have a heart attack—but when it happens, most are overwhelmed, scared, and simply hoping to survive. If you’re fortunate enough to survive, you may face another serious challenge dealing with medical bills and rehabilitation coverage. Imagine having a heart attack every year for four years, and having two coverage plans both deny coverage for proper preventative treatment. That’s what happened to M.C. Kim. After four heart attacks over the course of four years, he took the initiative to find a cardiac rehabilitation program that would teach him how to reduce his chances for another heart attack. Instead of receiving coverage, his Medicare office told him to call Medicaid, his Medicaid office told him to call Medicare, and Kim was eventually denied coverage of this program. Kim recalls, “I was like a ping pong ball … nobody wanted to take responsibility.”

Better coordination of care may have prevented some of Kim’s 20 trips to the emergency room over a 6-year period. In order to encourage coordination and coverage of Kim’s program, either Medicare or Medicaid needs to take responsibility for coordinating all the necessary services for those dually eligible for both programs. This coordination would have encouraged coverage of Kim’s cardiac rehabilitation program—and decreased or prevented his future emergency room visits. Coordinating care of dual eligibles can assist patients like M.C. Kim get coverage for necessary treatment programs and can save the federal government $38.9 billion over ten years.

This idea brief is one of a series of Third Way proposals that cuts waste in health care by removing obstacles to quality patient care. This approach directly improves the patient experience—when patients stay healthy, or get better quicker, they need less care. Our proposals come from innovative ideas pioneered by health care professionals and organizations, and show how to scale successful pilots from red and blue states. Together, they make cutting waste a policy agenda instead of a mere slogan.

What is Stopping Patients From Getting Quality Care?

Dual eligibles face many problems due to their health condition and low-incomes. Of the 9 million Americans who are dually eligible for Medicare and Medicaid, more than half are female, suffer from three or more chronic health conditions, and don’t have full mental or cognitive abilities. Forty-four percent cannot live on their own without assistance. Their care is further impeded by an antiquated financing and benefit structure divided between Medicare and Medicaid. Medicare covers most acute care services and some long-term care services, while Medicaid covers most long-term care services, provides some services that Medicare covers only in limited ways (e.g., vision, dental, and transportation), and is responsible for some, or all, Medicare premiums and cost sharing. With this fragmentation, a dually eligible beneficiary can have as many as three entities responsible for their coverage: a state Medicaid program or managed care plan, the Medicare program or Medicare Advantage plan, and a stand-alone Medicare Part D Prescription Drug plan.

The only point of convergence between Medicare and Medicaid historically has been the beneficiaries themselves, who often do not have the ability to navigate and coordinate the various sources of coverage. And the incentives for either Medicare or Medicaid to coordinate care for patients are weak and inconsistent.

Where Are Innovations Happening?

There are a number of innovative efforts happening across the country to help the duals. For example:

• Under contract with the state of Texas, Amerigroup, a private health plan, provides long-term care services to duals with coordinated care and integrated financing. It also has a Medicare Advantage Special Needs plan that enrolls many of the same duals. Together they have reduced hospital costs by 22% and emergency room use by 40%. Compared with the traditional, fee-for-service care, the Texas program has generated savings of 15% for acute outpatient care and 10% for long-term services and support.
• The North Carolina Community Care Network (NC-CCN) provides coordinated care but without the financing integration. NC-CCN is a primary care case management model that was expanded to cover dual eligible beneficiaries under the Medicare Health Care Quality (MHCQ) demonstration program. NC-CCN assigns dual eligible beneficiaries to physician practices that are responsible for coordinating care and measuring outcomes. The state provides these practices with support, including community-based coordination services, and a host of data and analysis tools such as patient-level and provider-level quality reports. In addition, physicians are paid a monthly fee for providing care coordination services. In exchange, the state is eligible for shared savings under the MHCQ program upon achieving quality targets. Not only were hospital inpatient admissions for the elderly, blind, and disabled dual eligible NC-CCN population 15-20% lower than for the un-enrolled population, but from 2007 to 2010, NC-CCN reduced Medicaid spending by about $1 billion (Medicare data is not available yet).
• States are also implementating care coordination models under Centers for Medicare and Medicaid Services’ (CMS) State Demonstration to Integrate Care for Dual Eligible Individuals and the Capitated Financial Alignment Demonstration Initiative in 2013 and 2014. For example, Massachusetts is using the capitated model, where the state, CMS, and health plans will have a three-way contract under which the health plan will coordinate and be accountable for all Medicare and Medicaid services. Called One Care: Mass Health plus Medicare, the state has set contracts with three different plans to integrate Medicaid and Medicare financing and provide person-centered, comprehensive Medicaid and Medicare benefits.

How Can We Bring Solutions to Scale?

Congress should adopt policies to coordinate care and integrate coverage for dual eligible beneficiaries as well as align Medicare and Medicaid financing. Specifically, it should build on the existing demonstration programs to cover all dual eligibles, incorporating care coordination models that have proven successful in other settings and that can be tailored to sub-categories of beneficiaries. One example of such a model is the Better Care Programs (BCPs) envisioned under Senator Ron Wyden’s (D-OR) Better Care, Lower Cost Act. These financially integrated care coordination programs may be expanded by taking the following steps:

• Begin with a voluntary open enrollment period. Once multiple care coordination options are available in a state, beneficiaries who do not enroll in a program after the voluntary open enrollment would be automatically enrolled in the highest quality, lowest cost option appropriate for the beneficiary’s health needs and that demonstrates capacity and competency readiness. The basis for determining the highest value plan would be half from quality rating score and the other from the cost of coverage (cost to the government, not beneficiary, since duals do not pay a portion of the premium).
• Phase-in enrollment over a three to four year period. In order to ensure that private health plans or care management programs have the capacity to serve all beneficiaries who are automatically enrolled in their plans, phase-in enrollment, using geographic area, beneficiary date of birth, or other factors. This phased-in automatic enrollment would begin with beneficiaries who have less complex health care needs.
• Either the state or the federal government takes full responsibility for coordinating care for duals, with financing aligned under the responsible government. Each state would have right of first refusal to establish care coordination programs for its dual eligible beneficiaries and receive payment from the federal government for the Medicare portion of their care. If a state does not elect this option, the federal government would take responsibility for coordinating care for dual eligible beneficiaries in that state through Sen. Wyden’s Better Care Program. Under this option, the state would make a payment to the federal government for the Medicaid portion of their care.

Potential Savings

According to analysis from Avalere and Actuarial Research Company, the federal savings from this proposal would be $38.9 billion over ten years. The savings come from coordinating benefits between Medicare and Medicaid, which would eliminate care that is duplicated between the two programs and also fill gaps in care that can reduce costs across both programs.