One of the highest priorities in the Affordable Care Act (ACA) is care delivery transformation for Americans enrolled in both Medicare and Medicaid, known as “dual eligible beneficiaries” or sometimes simply “duals.” This priority is embodied in federal-state demonstration programs currently gearing up. It is imperative that we resist calls to delay these initiatives and that we rapidly bring to scale the innovations that have already been shown to improve care for the duals at my own organization, Commonwealth Care Alliance, and elsewhere.
This is not the first time that Congress has sought to address the unmet needs and high costs of these individuals. Nearly 40 years ago, Congress expanded Medicare eligibility to non-elderly individuals with disabilities; legislators simultaneously expanded the scope of Medicaid’s community-based long-term care benefits to make Medicaid our nation’s preeminent disability and long term care insurer. The goal then, as now, was to promote appropriate medical care as an alternative to hospital care and independent living as an alternative to institutional care.
Yet today, less than 1 percent of dual beneficiaries are enrolled in integrated medical and long-term care delivery models designed to meet their needs. As a consequence, far too many individuals with disabilities have their goals of independence and autonomy subverted because of functional decline that is mostly preventable. Far too many frail elders and younger individuals with disabilities are routinely hospitalized because of a failure to effectively intervene to address a predictable and treatable array of complications of their underlying chronic illnesses.
Far too many frail elders are permanently placed in nursing facilities when lower-cost community living options are available and achievable. Far too many individuals with serious mental illness die prematurely — at the average age of 53, mostly due to cardiac and metabolic causes that we know how to treat. And far too many dollars are wasted because of four decades of missed opportunities to intervene on this set of circumstances.
The ACA’s strategy to once and for all end a four decade-policy paralysis is the creation of the Medicare and Medicaid Coordinating Office (MMCO) at the Centers for Medicare and Medicaid Services (CMS). This office has a clear mandate to break down the seemingly impenetrable Medicare and Medicaid financing silos, and to open the doors for insurers and providers throughout the country to test integrated financing and new models of care on an unprecedented scale. Specifically, MMCO has been partnering with the Center for Medicare and Medicaid Innovation on the second phase of state demonstrations testing methods of coordinating care for dual eligible beneficiaries.
Over the past 18 months, MMCO and CMMI have engaged states with unprecedented speed and effectiveness. At last count, 26 states are now in varying states of Memorandum of Understanding (MOU) development with CMS, with goals of launching demonstration programs in 2013 and 2014. These demonstrations will take one of two forms: either health plans will receive a blended Medicare/Medicaid payment rate to provide benefits from both programs to the duals, or states will coordinate Medicare and Medicaid benefits for these individuals on a fee-for-service basis.
However, some members of the medical community are now taking the position that the scope of the planned dual-eligible demonstration is too large and the speed of implementation too fast; they are recommending that implementation should be delayed for at least one year. In a letter to CMS, this past July, American Medical Association Executive Vice President and CEO James Madara argued that many plans are not ready to deal with this vulnerable population or with “managing and being at risk for all Medicare and all Medicaid benefits.”
While there are important cautions in Dr. Madera’s observations that speak to the need for robust safeguards, the decades-long intractability of fragmented, poor care and resulting high costs makes a compelling case to move forward as planned.
Fixing Fragmented Care
As states, insurers and providers move forward with the new integrated financing demonstrations, there are two important questions. First, what does effective care delivery look like for those with the greatest need and highest cost? Second, how can we best protect the most vulnerable subset of dual beneficiaries until effective care delivery transformation achieves sufficient scale?
While there are nine million duals in the United States, the care and cost problems, as well as the greatest opportunity, are concentrated in only 20 percent of dual beneficiaries (1.8 million nationwide) — those with high needs for long term services and supports (LTSS). This subset of dual eligible beneficiaries accounts for about 60 percent of all expenditures and 72 percent of Medicaid expenditures. It includes younger individuals with a variety of severe physical disabilities, developmental disabilities, and serious mental illness, as well as frail or homebound elders who have significant activities of daily living (ADL) dependencies. Many are also clients of state departments of Mental Health or Developmental Services, or the Area Agencies on Aging support networks. All require considerable LTSS in order to live independently and most have exceedingly low thresholds for hospitalizations and then subsequent short-term or long-term nursing facility placement.
The story of Mary J (who combines elements of several actual patients) tells us all that we need to know about what ineffective care looks like.
Mary J. is a 36-year old who has Cerebral Palsy, spastic quadriplegia (paralysis of all four extremities), severe dysarthria (throat muscle spasticity causing significant speech and swallowing problems), mild intellectual impairments, insulin dependent diabetes, and a seizure disorder. She is at significant risk for aspiration pneumonia and requires a feeding tube to her stomach, through her abdominal muscles for nutrition, as well as frequent insulin adjustments to control her blood sugar.
Since leaving a state school at age 22, Mary has lived independently with close family involvement and considerable Medicaid-funded in-home personal care assistance. But the current care delivery system has been a hopeless failure in providing effective care and meeting her life’s goals, despite a rich array of Medicare and Medicaid benefits.
Mary, like most of her counterparts, has never had a primary care relationship because primary care with the skills, intensity, and organization to meet her needs doesn’t exist. Instead Mary, like most of her peers, receives care from an array of specialists — in her case, Neurology, Pulmonary, Orthopedic, Gastrointestinal, and Endocrine specialists in three different non-communicating hospital systems — with no one capable of, or responsible for, providing the totality of her care. Thus Mary’s years of so-called “independent living” have been characterized by multiple recurrent hospitalizations for entirely predictable complications: pneumonia (in one case requiring a 14-month stay in a Medicaid-funded, post-acute respiratory rehabilitation hospital); poorly controlled diabetes; seizure management; and functional GI problems, with overall health, and functional decline.
There are 1.8 million stories like Mary’s out there that create the imperative for the reimagined and redesigned care that is only possible with Medicare and Medicaid integrated financing.
The Commonwealth Care Alliance Model And Experience
Commonwealth Care Alliance is a Massachusetts-based non-profit, fully integrated, dual-eligible prepaid care system. It began as one of the legacy dual demonstrations entities in Massachusetts, Minnesota and Wisconsin that have informed so much of the ACA. Currently Commonwealth Care Alliance cares for about 4,400 low income seniors, 72 percent of whom meet Medicaid’s “nursing home certifiable” criteria, and about 650 younger individuals through legacy prepaid contracts with Massachusetts Medicaid. The care of these beneficiaries is financed by about $225 million dollars of risk-adjusted integrated Medicare and Medicaid premiums on an annualized basis, in return for the delivery of the totality of Medicare and Medicaid benefits.
Commonwealth Care Alliance’s Senior Care Options Program network includes 28 primary care practices in eight hospital systems throughout Massachusetts. Eighty teams of nurse practitioners, nurses and social workers (with very intense caseloads of about 45 patients per full-time equivalent) and supporting management and IT infrastructure are deployed to these practices for the care of home bound elders, for whom the current organization of primary care is increasingly ineffective.
The 650 younger individuals with complex physical, developmental, and mental illness-related disabilities are cared for in a specialized primary care practice that consists of physicians, nurse practitioners, nurses, therapists, durable medical equipment coordinators, and mental health professionals, with even more intimate caseloads than the senior care program given the clinical intensity encountered. For both home-bound seniors and the younger populations with involved disabilities, the essential primary care, and care system redesign elements can be summarized as follows:
- Interdisciplinary clinical teams of physicians/nurse practitioners/nurse and social workers, with the ability to deliver and coordinate care in the home; replaces the ineffective, medically-focused 20-minute physician office visit.
- Individualized care plans that entirely determine resource allocation, developed by the interdisciplinary primary care teams in collaboration with the beneficiary; replaces payer-based utilization criteria widely used for the general population but irrelevant for beneficiaries with high LTSS needs.
- An elastic nurse practitioner home visiting response capability to assess and manage new clinical problems; replaces physician telephone management, the ambulance, and the emergency department.
- For those with physical disabilities, integrated durable medical equipment clinical assessment, management and individualized allocation; replaces distant rule-based prior approval processes and months of delay.
- For those with mental illness and behavioral health needs, behavioral health clinicians integrated into the primary care teams providing individualized care plan development and management; replaces inaccessible, mental health clinics that are structurally siloed from primary care.
- Contracted networks of specialists, agencies and vendors, specific to the needs and choice of the beneficiary; replace “health plan” contracted networks, rendering irrelevant the concept of a “non-contracted network.”
- Clinical care that is available 24-hours a day, seven days a week, in all settings at all times; replaces “going it alone” in an intimidating inaccessible health care system.
- Web-based electronic medical record (EMR) support; replaces inadequate information transfer capabilities.
Commonwealth Care Alliance’s Results
In 2011, Commonwealth Care Alliance, invested $16.9 million dollars above what Medicare fee for service would have reimbursed these 28 primary care practices, to fund the interdisciplinary teams and their supporting data management infrastructure, with the following results:
- According to a Lewin Associates study commissioned by the SNP Alliance, hospital admissions and days were 56 percent of the risk-adjusted Medicare dual-eligible FFS experience (2009 to 2011).
- The NCQA risk-adjusted 30 day hospital readmission rate in 2010 was 4 percent compared with the median Medicare Advantage program rate of 13 percent (99th percentile).
- The permanent nursing home placement rate for nursing home certifiable members between 2009 and 2011 was 34 percent of that seen in a Nursing Home Certifiable frail elder population in FFS care.
- The seven year annual average total medical expense increase is 3.3 percent and 2.8 percent for nursing home certifiable and ambulatory, enrollees respectively, well below the Medicare trend.
- CMS Quality Star Ratings of 4.5 Stars ranked in the 90th percentile of all Medicare Advantage Plans and the 99th percentile of all Medicare Advantage Special Needs Plans in 2010 and 2011.
- Multiple evaluations of the younger disability care program over many years found a high degree of satisfaction, a 60 percent reduction in hospitalizations, and a 50 percent reduction in surgical flap procedures for pressure sores in a spinal cord injured subpopulation.
The transformation principals that have demonstrated such positive care and cost results in the Commonwealth Care Alliance experience are anything but unique to us. Some, most, or all have been developed and deployed in a variety of small-scale, prepaid programs caring for frail elders, children with special health care needs, or other high need populations (FN). These principles are also enshrined in the ACA’s health home provisions for Medicaid or dual beneficiaries with significant mental illness related disabilities.
The fact is, we know what works. The challenge now is to scale what we know works as rapidly as possible with all the necessary safeguards in place. Massachusetts will be the first out of the gate to take on the challenge of demonstrating effective care delivery transformation with effective safeguards.
For the past year, a committed and sophisticated coalition of disability consumers and advocates has come together to positively inform the shape of the Massachusetts procurement. As a consequence, many of care delivery principles for high-LTSS dual beneficiaries that have been demonstrated in the Commonwealth Care Alliance care system will be the procurement standards that all contractors will need to adhere to. In addition, the coalition is in active engagement with CMS authorities to promote the following protections: oversight by consumers and advocates with respect to selection and performance of contractors; the promotion of beneficiary choice at all levels; the promotion of effective LTSS risk-adjustment approaches; and delaying the implementation of auto assignment of beneficiaries with high LTSS needs to contractors that have not demonstrated the necessary clinical and “disability” competence.
Rather than delay a once in a generation opportunity to fundamentally improve care, Massachusetts insurers, providers, consumers and advocates working closely with responsive state and federal authorities are ready to meet the challenge of transformation and protection.