Rush to Judgment?
Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) is assisting states in integrating care for people who are eligible for both Medicare and Medicaid – primarily low-income people over age 65 and working-age adults with disabilities. In 2011 CMS invited states to submit proposals to operate three-year demonstration projects that would better integrate care for their dually eligible beneficiaries by aligning the financing of Medicare and Medicaid. Massachusetts was the first state to launch its demonstration in 2013, and as of mid-2015, twelve states have begun implementing demonstrations. This population, which is by definition low-income and also disproportionately from racial and ethnic minority communities, has historically received very poor health care, and the status quo is not working for them. The hope for these demonstration projects is that they will be able to provide better coordinated care at lower costs, including integrated higher-quality primary care, behavioral health care and long-term services and supports. Are the projects achieving those goals?
Over the last few months, both the trade and mainstream press coverage has painted a dire picture for the projects. Modern Healthcare, for example, ran a story in April with a headline suggesting that the future of the demonstrations was in question. In July, the industry publication Crain’s New York Business ran an article headlined “Problems Plague Program for Dual Eligibles” (subscription required to view). In early August the Boston Globe reported on the financial losses sustained by health plans participating in the Massachusetts demonstration, One Care.
Each of these articles has identified some real difficulties that exist in the demonstrations. State advocate partners in our Voices for Better Health project also report a myriad of concerns such as lower than anticipated enrollment numbers, poor communication with primary care providers about the demonstrations, cases of disrupted care for enrollees, inadequate readiness review, inadequate financing and risk adjustment provisions, and financial losses for plans. Consumer advocates are working energetically together with beneficiaries, to identify and implement solutions in collaboration with plans, states and CMS.
What’s largely been missing in the press coverage, however, is the impact of the demonstrations on the people they are aiming to help. Responses to the Boston Globe article from an enrollee, a provider and a plan attempt to balance out the picture with real stories of people with complex conditions getting measurably improved care. This is not to say that such successes are yet as widespread as we would like across the demonstrations. But any balanced evaluation of the projects must acknowledge successes, and also be measured against the failings and unsustainability of the current health care system. The existing system is expensive, uncoordinated and inadequate. Too many of these enrollees have been falling through the cracks for decades, and the problems with the demonstrations can only be fairly viewed through that lens.
Most importantly, we must take the long view and give these demonstrations time to work. This is hard. It is far too soon to pronounce either failure or success. Coordinated care can provide better care at lower costs, but reaching this goal will take time. While mid-course corrections are needed, that in no way means we should give up on the project, since we know that the status quo doesn’t work. The kinds of things the demonstrations are trying to do – and in some cases are already doing – are the right things. There is a proven track record in Massachusetts, for example, of improved care for low-income older adults in the Senior Care Options program. The same is true of PACE (Program of All-inclusive Care for the Elderly) sites around the country. These and other working models show that well-integrated coordinated care results in higher-quality care that can reduce preventable hospitalizations and unnecessary nursing home admissions. Given ample time to work, robust state and federal oversight and meaningful consumer input, the dual eligible demonstrations can be just as successful as these models.
Changing how we care for the dual eligibles is not like altering course in a speedboat. It’s more like turning a tanker. It won’t always be smooth sailing, but commitment to the long-term goals of the demonstrations and to fixing problems as they arise, will help us stay the course.