Everybody wants to do a better job coordinating care for the frail elderly and younger adults with disabilities who have extensive medical and personal care needs. But just how to do it is becoming increasingly controversial—especially on Capitol Hill.
The current flashpoint is an aggressive new Obama Administration initiative aimed at improving care and cutting costs for those who are very poor and very sick. There are 9 million of these so-called dual eligibles receiving benefits through both Medicare and Medicaid.
Now, some Democrats are worried that states are moving too fast, some independent analysts fear the initiatives are too big, and some insurers fear the program is too narrow. But despite all the concerns, Melanie Bella, the Obama Administration official in charge of these programs, told the Senate Aging Committee today that they will move forward.
Their most surprising critic may be Senator Jay Rockefeller (D-W. Va), who authored the initiative in the 2010 Affordable Care Act. Now, fearing it would result in lower quality care for this vulnerable population, he’s asked the Department of Health and Human Services to shut down the program until it can be redesigned. A major concern: a provision that would allow states to automatically enroll duals into managed care plans
Oddly, the managed care program was backed at today’s aging committee hearing by the panel’s ranking Republican, Senator Bob Corker (R-TN). In a rare example of a Republican saying something nice about the ACA, Corker pronounced himself “pleasantly surprised” by the way Bella is handling the new program for the duals.
The 2010 health reform law made it possible for the Administration to push several key changes in what has, until now, been a poorly designed care system. Currently, Medicare pays for most medical care for this population while Medicaid pays for personal care, or long-term supports and services.
Because the federal government pays for all of Medicare, while states and the feds share the cost of Medicaid, the system discourages the two from cooperating. For instance, if a Medicaid care manager helps keep a patient healthy and out of the hospital, all the savings go to Medicare while the state pays the care manager’s salary.
To address this and other problems, the ACA gave the Centers for Medicare and Medicaid Services the authority to set up a new office to coordinate regulations, improve data, and set up demonstration projects to learn how to better manage the care of the dual eligibles.
States, desperate for cost savings, have scrambled to propose demonstrations. Twenty-six have asked CMS to approve major new managed care programs that would cover as many as 3 milllion–or one-third– of the duals. That would make this the largest Medicare demonstration in history.
My Urban Institute colleague Bob Berenson told the aging panel that these experiments would be far too big, with many aimed at covering all of the duals in a particular state. This, he fears, would make the programs “too big to fail” even if they did not succeed in improving patient care and saving money. His other worry: Medicaid managed care companies have little experience in caring for dual eligibles, many of whom have very complicated medical conditions.
Bella said CMS has not approved any demonstrations yet, would probably limit them to about 2 million beneficiaries, and establish national quality standards against which to measure their success. But one thing is clear: the idea of coordinating care for those who need both medical care and long-term care is on its way to becoming an important trend.
California has proposed a “demonstration” for dual eligibibles that would put almost 350,000 beneficiaries in Los Angeles County into managed care. California lost a law suit that would have abolished one of the effective long term care programs of adult day health care programs. There have been less than useful stakeholders groups that met throughout May and June to look at many of the concerns raised in moving to managed care and the provision of long term care services. I agree with Bob Berenson that the implementation of such programs need to be slow, need to be evaluated and measured for how the programs actually provide more than cost savings.