Back in 2013, Massachusetts became the first state to use a full managed care approach under the CMS-sponsored Financial Alignment Demonstration. This demonstration, known as One Care, serves people with disabilities ages 21-64 who have both Medicare and Medicaid and seeks to provide better care at lower cost. Since the launch, advocates from the disability community have regularly voiced the need for the public reporting of outcome data. And, nearly three years later, that day has arrived! Results from One Care’s first year (October 2013-December 2014) are now available! 

While the evaluation did not reveal any big surprises, and findings are only from the first demonstration year, having the data to back up claims of successes and challenges is critical as our health care system shifts more and more toward integrated models of care for people with complex needs, utilizing various innovative payment mechanisms. A few key takeaways of note from the evaluation:

  • One Care enrollees had a lower 30-day readmission rate compared to non-enrollees.
  • There are opportunities to further improve beneficiary education and engagement. For example, focus groups convened to obtain participant feedback suggest that many beneficiaries were not aware of the formal complaint and appeals processes or available resources to assist them with problems.
  • It’s important to ensure stable financing structures and adequate payments. The evaluation reports that One Care plans experienced losses during the first year, noting that Medicare and Medicaid capitation rates were inadequate to cover new costs associated with care coordination, additional benefits offered, and administrative start-up costs of the demonstration.
  • With the large number of beneficiaries being enrolled during passive enrollment phases, One Care plans reported their greatest difficulty was reaching enrollees, including many who are homeless or without a stable address.
  • The Long-Term Services and Supports (LTS) coordinator role, while widely supported and very much needed, was difficult to implement due to ill-defined roles and responsibilities, which led to inconsistencies and confusion in implementation. The plans and community-based organizations found it difficult to strike the right balance between flexibility and structure for the LTS coordinator role.
  • Participants reported unmet needs for oral/dental care and substance use disorder services.

Though many of these early challenges have been largely addressed, there is still additional work to do both in Massachusetts, which extended the demonstration for another two years, and elsewhere. It will be important to take these early findings and use them to continue to improve One Care. Other states with ongoing demonstrations may also find much of interest within this report, as they work to refine their projects to provide maximum benefit to participants.

And, to continue the virtuous cycle of quality improvement, we eagerly await further demonstration evaluations out of CMS!