As health care costs have increased, the challenges of managing complex chronic conditions, compounded by frailty, disability, mental illness, poverty, or limited education, have become more pressing. Correspondingly, individuals, families, and government entities alike are increasingly frustrated with the current health care system. Even people like me – a seasoned health services researcher working in a large integrated delivery system – find it difficult to assemble and coordinate an array of medical and long-term services and supports (LTSS) to meet our family members’ preferences and needs.
Coordinating services for my own mother – an upbeat 94-year old with considerable financial resources but advancing dementia, frailty, blindness, and a variety of health and LTSS needs – requires more of my time and that of other family members. People with similar needs but fewer resources often face far more daunting problems in trying to understand diverse Medicare and Medicaid benefits, access appropriate services, and navigate among multiple health and LTSS providers that rarely communicate with each other.
Below I describe the early work of the PRIDE consortium, a small group of seven high potential health care organizations (CareSource, OH; Commonwealth Care Alliance, MA; iCare, WI; Health Plan of San Mateo, CA; Together4Health, IL; UCare, MN; and VNSNY CHOICE , NY) that aim to provide access to genuinely integrated medical and behavioral health and LTSS for people dually eligible for Medicare and Medicaid. The backdrop for PRIDE (Promoting Integrated Care for Dual Eligibles) is the new federal-state effort to align the Medicare and Medicaid programs and enroll high-needs, high-cost dually eligible beneficiaries in integrated health care entities that will offer better coordinated, more consumer-centric and lower-cost care. At the federal level, the Centers for Medicare & Medicaid Services (CMS) is the chief honcho for efforts to harmonize the workings of Medicare and Medicaid, test innovative payment and service delivery models, and reduce expenditures.
In 2011, CMS awarded contracts of up to $1 million to each of fifteen states to design coordinated care demonstrations involving capitation arrangements or fee for service entities. Additionally, eleven states (plus those that received the $1 million planning awards) submitted proposals to participate in CMS’s “financial alignment initiative,” intended to improve alignment between Medicare and Medicaid policies affecting care for dual eligibles. By September 2013, CMS had signed Memorandums of Understanding (MOU’s) with seven states to pursue coordinated care demonstrations, while others’ MOU’s were in the pipeline.
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