Efforts to integrate care for people enrolled in both Medicare and Medicaid (dual eligibles) took another step forward last month when Massachusetts became the first state to sign a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) regarding the state’s intent to enroll dual eligibles under age 65 in “Integrated Care Organizations.” The agreement is part of an initiative launched by CMS to better coordinate care for dual eligibles and to stabilize the rising costs associated with their health care needs.
The MOU provides state advocates with greater detail about how the demonstration will work in the Commonwealth. For the other 25 states pursuing a demonstration project, it provides some insight into what they can expect in their MOU negotiations and final agreements.
The demonstration project in Massachusetts has numerous positive features, largely attributable to the robust stakeholder involvement process embraced by the state. The final MOU addresses many of the concernsraised during the planning phase. For example the MOU includes:
- • The expectation that the Integrated Care Organizations (ICOs) and providers learn about and use independent living, peer support, individual choice and person-driven approaches
- • The ability of beneficiaries to opt-out of the demonstration at any time or switch plans on a month-to-month basis
- • A requirement that ICOs to contract with providers that comply with the Americans with Disabilities Act (ADA)
- • Inclusion of an Independent Living and Long Term Services and Supports (IL-LTSS) Coordinator as a full member of the care team
- • The addition of important new benefits such as behavioral health and community support services
While the MOU reflects many of the consumer concerns, there are provisions that raise red flags for advocates and beneficiaries.
- • First, it is not clear whether the ICOs will have the necessary levels of capacity and competency to serve this population by the time the project rolls out.
- • The MOU was silent on many critical aspects of consumer engagement. It did not require an independent ombudsman to be established to field beneficiary complaints and questions and it remains unclear on how ongoing consumer engagement will work. Advocates in Massachusetts have urged the state to fund a statewide external oversight entity that will include a strong consumer voice.
- • Other significant concerns revolve around financing. The saving expectations — 1 percent in the first year, 2 percent in the second and 4 percent in the third — may not be realistic and the way in which the savings target was developed is not entirely clear. The analysis conducted by CMS and the state should be transparent in order to understand which factors have been taken into consideration in developing the expectations.
- • In addition, there is concern about the adequacy and incentives of the payment methodology. The demonstration will use risk adjusted payments and risk-mitigating strategies, but, as structured, they may still provide incentives to avoid or underserve the highest-cost dual eligibles.
- • An overarching concern is that many details are being left to the three-way contract between CMS, the state and the ICOs. This is concerning since there are no assurances that the contracting process will be transparent and involve consumers.
What the MA MOU Means for Other States
Widespread concern remains about the CMS initiative. The Massachusetts MOU provides some reassurance, but not enough, not only because of the limitations and blanks in the agreement, but because many states may do less well.
The Massachusetts MOU has incorporated many positive features other states can look to as an example. But Massachusetts sets a high bar that will be tough for many other states to meet. Advocates should push their states to incorporate as many of the good elements from Massachusetts’ MOU as possible in their own projects, while simultaneously working to raise the bar even higher where Massachusetts falls short. A tall order, yes, but the success of these demonstration projects — better care and lower costs — rests on getting these early design steps right.
— Leena Sharma, State Advocacy Manager