CMS Releases Guidance on Payment Model to Improve Care for Dual Eligibles
The issue of improving care for people who are eligible for both Medicaid and Medicare (“dual eligible”) continued to pick up steam with the recent release of a new federal guidance related to payment models. While advocates will not be formally commenting on this new guidance, it is imperative that they keep a close eye on what the guidance says and how this will impact which health plans will be chosen to oversee the care of the dual eligible population.
As readers may recall, the Affordable Care Act created two new offices within CMS to promote long-term systemic improvements for dual eligibles. The Center for Medicare and Medicaid Innovation (Innovation Center) was established to rapidly test, evaluate and replicate innovative models of care. The Medicare- Medicaid Coordination Office (“MMCO”) was created to promote policies and assist states in better integrating care specifically for dual eligibles. As a result, 15 states have planning grants to develop models of care for dual eligibles. In July 2011 MMCO announced a demonstration program to test two new payment models – the “capitated” and “managed fee-for-service” approach – designed to help states improve quality and share in the lower costs that result from better coordination of dual eligibles’ care.
The guidance released last month by the MMCO is directed at health plans or other qualified entities interested in pursuing the capitated financial model. Under this model, CMS, the state, and health plans or qualified entities would enter into a three-way contract, where the participating plans would receive a prospective blended payment to provide comprehensive seamless, coverage to dual eligibles.
Why Focus on the Dually Eligible? The dual eligible populations (approximately 9 million) are a lot more vulnerable and typically have poorer health status and a greater need for more high-cost services such as inpatient and outpatient hospital, emergency room, and skilled nursing care. Navigating the Medicare and Medicaid programs, which have different sets of rules and requirements, is an added burden for beneficiaries and results in care that is often fragmented and uncoordinated.
Given the uncertainty of today’s political environment, state advocates need to be actively engaged in the decision-making process of any duals-related initiative. Advocates need to keep a close eye on decisions made about: enrollment, provider networks, appeals processes, marketing including how beneficiaries receive information, quality measures, financing, and consumer protections. Without an active voice, we are leaving the decisions to insurers and big providers who do not necessarily have consumers’ best interest in mind. It is important that all states be involved – not just the 15 states who received planning grants or those states that have sent in a letter of intent.
What does this new guidance mean for our work? The new guidance on pursuing the capitated approach addresses important issues such as payment principles, standards in programmatic areas, key dates, and network adequacy. For each issue, there is a role consumer advocates can play to ensure that the proposed demonstrations keep consumer interests at the forefront. In a previous blog, we shared with you disability-oriented advocacy principles, to help shape the design of the demonstrations. Advocates should use them as guide as well as this fact sheet that highlights the role consumer advocates should play.
The efforts to improve care for the dual eligible population are commendable. However as CMS and states move forward on their aggressive timetable, advocates must ensure that only proposals that maintain or improve beneficiaries’ access to high-quality, comprehensive services make it to the finish line.
— Leena Sharma, Field Coordinator Integrated Care Advocacy Project