Recently, the Medicare-Medicaid Coordination Office (MMCO) released three new evaluation briefs on the Financial Alignment Initiative (FAI), demonstrations designed to test models of care with states that align Medicare and Medicaid financing and services – medical, social, behavioral and long-term services and supports (LTSS) – for the dual eligible population. Currently there are a total of 13 states participating in the FAI. This initiative came into being thanks to the establishment of the MMCO through provisions of the Affordable Care Act (ACA). As these three briefs outline, these innovations are now starting to show promising preliminary results. A summary of all three briefs is available here.

With every sign from the current administration and leadership in Congress pointing to continued efforts to either roll back or undercut progress on so many fronts made possible by the ACA, it is important to monitor and evaluate ACA-established innovations that are demonstrating benefit to health care consumers, especially some of our most vulnerable populations. In addition to highlighting progress, these evaluations are also important in order for stakeholders and advocates to learn from the challenges outlined, as we work to create a system that is responsive to the needs of consumers.

The evaluation briefs discuss beneficiary experience in the FAI overall, early findings on care coordination (which is the foundation of the FAI) and special populations enrolled in two of the early demonstrations. The latter brief evaluates the experience of three sub-groups of enrollees in the demonstrations in Massachusetts and Washington state: those who are using LTSS, both at home and in institutions; enrollees with behavioral health needs, including those with serious and persistent mental illness; and people from linguistic, ethnic and racial minority groups.

The methods used for evaluation were a mix of beneficiary focus groups, including a few Black-only and Hispanic-only focus groups to identify any unique experiences of racial, ethnic and linguistic minorities enrolled in the demonstrations; interviews with key stakeholders such as state officials, federal officials, health plans and consumer advocates; data from the CAHPS survey and from the required reporting by states and health plans.

As we celebrate National Minority Health Month in April, it is also worth noting the elevation of health equity in the evaluations. A high proportion of dually eligible consumers who are served by these Medicare-Medicaid demonstrations are from communities of color. The evaluation findings suggest that while interpreter services were available for care coordination services when needed, it is more helpful when care coordinators are bilingual. Similarly, the evaluation also reports that Limited-English-proficient (LEP)enrollees valued having providers who spoke their language, which influenced their selection of and satisfaction with their demonstration health care provider network. In addition, many focus group participants spoke of cultural preferences and the need for their care coordinator to receive training to be sensitive to these preferences. For example, two participants in the Washington demonstration said some Hispanics are averse to discussing certain medical procedures and end-of life planning.

Beyond health equity, other key findings from the three evaluations included:

Beneficiary Experience findings:

  • Overall, enrollees have greater access to a broader and more flexible range of services, including home care and home modification services
  • A majority of beneficiaries report improved quality of life and a more coordinated and patient-centered approach to their care
  • Beneficiaries continue to experience issues regarding limited access to providers (including behavioral health providers), particularly regarding the size and scope of provider networks

Care Coordination findings:

  • Plans contracted to be part of the FAI reported investing heavily in hiring linguistically and culturally competent staff and in providing training to care coordinators on the needs of special populations, such as enrollees with Alzheimer’s disease and other dementias
  • In the early implementation phase of the FAI, beneficiaries lacked understanding and awareness of the care coordination benefit, but this has begun to improve
  • Care coordination workforce experienced significant turnover, and there was a need for additional training given the large volume of passively enrolled beneficiaries in the FAI
  • Many beneficiaries who understood their care coordinator’s role reported satisfaction with the relationship

Special Populations – MA and WA:

  • Findings show that demonstration services have helped at least some beneficiaries achieve a wide range of improvements in their lives, from managing chronic conditions to increasing community engagement
  • Focus groups reveal that care coordination was generally helpful; but many beneficiaries had difficulty differentiating between their care coordinator and other services or were unaware of a wide range of supports available
  • Patient-centered care and patient engagement is important to focus group participants, but some indicated they had difficulty finding providers with whom they felt comfortable

Regardless of where the efforts to protect and improve health care take us in the coming months and years, the evidence is beginning to show that innovative models of care hold promise and need to continue. We encourage CMS to continue to evaluate the consumer experience in the FAI, including how consumers are involved in their health care as well as understanding the impact of their role in health plan consumer advisory councils, which were required under the demonstrations.  

The findings from these evaluations start to weave a story together of what an effective model of care can look like for vulnerable populations and emphasize the importance of investing in those good models of care. Let’s amplify the consumer voice and most importantly engage consumers in their care and in the health care system.