[NYAPRS Enews] NYSHF Reports on Dual Eligibles Urges Health Homes, Managed Care Strategies, Benefit Education & Enrollment

[Harvey Rosenthal]

NYAPRS Note: The newly released report on dual eligibles (those who
receive Medicaid and Medicare) commissioned by the NYS Health Foundation
underscores the following: 

*         There are 700,000 dual eligibles in NY, 2/3 of which are over
65 and 40% of which have 'significant behavioral health or cognitive'
issues especially for those in the 1/3 that's under 65.

*         They represent 15% of NYS Medicaid beneficiaries but use 45%
of those dollars; New York's per-person Medicaid expenditures for dual
eligibles are twice the national average and the highest in the nation.

*         Prominent in the report's recommendations include:

o   constructing the state's health homes and capitated managed care
initiatives to serve dual eligibles and 

o   emphasizing that beneficiary education and enrollment processes that
incorporate the input of beneficiaries and their representatives will be
crucial to the success of such an effort, a prominent NYAPRS member
advocacy priority 

 

Integrating Care for Dual Eligibles in New York: Issues and Options

James M. Verdier, Jenna Libersky, Jessica Gillooly

Mathematica Policy Research  for NYS Health Foundation February 2012

Executive Summary

http://www.nyshealthfoundation.org/userfiles/file/DualEligibles_2012.pdf

 

More than 700,000 people in New York are simultaneously enrolled in both
Medicare and Medicaid. These "dual eligibles" and their families, health
care providers, and those who operate the two programs are continually
challenged by an intricate maze of overlapping and conflicting programs
and services, and by the inefficiency, fragmentation, and duplication of
services that drives up overall costs for both programs. 

Dual eligibles get almost all of their physician, hospital, prescription
drug, and other short-term acute care services from Medicare, while most
of their long-term care services in nursing facilities and in the
community are provided through Medicaid. 

Some services, like home health, nursing facility, hospice, and durable
medical equipment, such as wheelchairs, are covered by both programs,
but the coverage rules in each program are different.

These divisions of payment responsibility between Medicare and Medicaid
thwart efforts to reduce preventable hospital, emergency room, and
nursing facility use because the costs of prevention are often borne by
one program while the financial savings accrue to the other. Divided
payment responsibility also fosters wasteful efforts by providers and
payers to shift costs from one program to the other. 

Better coordination and integration of care for dual eligibles could
save State and Federal dollars and substantially improve the quality of
care for this diverse and vulnerable population.

 

Dual eligible characteristics, care needs, and costs. Almost two-thirds
of dual eligibles are over age 65, and more than one-third are under age
65 and have serious disabilities and chronic illnesses. All have low or
no incomes, more than half do not have a high school degree, and more
than 40% have significant behavioral health or cognitive problems, with
behavioral health problems more prevalent among those under age 65, and
Alzheimer's and dementia more common among those over age 65. Twenty
percent are living in an institution, and another 27% are living alone.

Not surprisingly, health care costs for dual eligibles are very high.
Nationally, while dual eligibles represent only 15% of Medicaid
enrollees and 18% of Medicare beneficiaries, they account for 39% of
total Medicaid expenditures and 31% of Medicare expenditures. In New
York, these cost patterns are magnified-dual eligibles represent 15% of
Medicaid enrollees, but account for 45% of total Medicaid expenditures.
Significantly, New York's per-person Medicaid expenditures for dual
eligibles are twice the national average and the highest in the nation.

 

New York and national initiatives. Major initiatives are underway both
in New York and nationally to improve the coordination and integration
of care dual eligibles receive through Medicare and Medicaid. In January
2011, New York Governor Andrew Cuomo appointed the Medicaid Redesign
Team (MRT). The MRT recommended-and the Legislature subsequently
passed-a number of initiatives aimed at improving the management and
coordination of care for dual eligibles and other high-need, high-cost
beneficiaries. The major State initiative related to dual eligibles is
mandatory enrollment of Medicaid beneficiaries in need of long-term care
services in managed long-term care (MLTC) health plans. 

At the national level, the Medicare-Medicaid Coordination Office (MMCO)
and the Center for Medicare and Medicaid Innovation within the Federal
Centers for Medicare & Medicaid Services (CMS) joined together in April
2011 to award $1 million contracts to New York and 14 other states to
design demonstration programs to better integrate care for dual
eligibles. Approved demonstration proposals will receive additional CMS
funding for implementation.1

 

Recommendations

Use the Federal dual eligible demonstration to support and enhance State
initiatives for dual eligibles. The Federal demonstration can test ways
to provide more fully integrated Medicare and Medicaid services on a
smaller or more geographically limited scale than is planned in the
State MRT process. MLTC plans that currently cover Medicaid long-term
supports and services (LTSS) in the community and in nursing facilities
could, for example, add linkages to primary, acute, behavioral health,
and Medicare services for dual eligibles in the New York City area,
where the building blocks needed to add these capacities already exist
among a variety of health plans. Those aspects of the Federal
demonstration that prove successful could be incorporated into the
broader State initiatives as they are implemented over time.

 

Require greater integration of all Medicaid and Medicare services in
capitated managed care programs. As part of the demonstration, the State
could require managed care organizations or other care coordination
entities participating in the demonstration to cover all Medicare and
Medicaid primary, acute, behavioral health, and long-term supports and
services for dual eligibles, or to have close contractual relationships
with entities that do.

 

Use the CMS Financial Alignment Models to Help Finance More Integrated
Benefits for Dual Eligibles. The financial alignment models that CMS is
making available in the demonstration provide a way for states and
health plans to share in the savings that can result from better
coordination and integration of Medicare and Medicaid benefits for dual
eligibles, including Medicare inpatient hospital, emergency room,
prescription drug, and skilled nursing facility benefits, and Medicaid
LTSS and behavioral health benefits.

 

Use three-way capitated contracts to broaden and integrate the benefit
package for dual eligibles. The CMS capitated financial alignment model
permits states, CMS, and health plans to enter into three-way contracts
that cover all Medicare and Medicaid services for dual eligibles,
including benefits that are now provided separately through Medicare and
Medicaid health plans, or through fee-for-service (FFS) arrangements.

While few managed care programs in New York fully integrate both acute
and long-term care and Medicaid and Medicare benefits, there are health
plans that operate plans in several of the Medicaid and Medicare managed
care programs in the State that partially integrate these benefits. They
include the different types of MLTC plans, Medicare Advantage Special
Needs Plans (SNPs), and Mainstream Medicaid Managed Care plans, in
addition to the small but fully integrated PACE plans. These plans could
serve as building blocks for more fully integrated managed care options
for duals. The kinds of partnerships and collaborations among health
plans and other entities needed to accomplish this greater degree of
integration have already begun in the New York City area, and the dual
eligible demonstration could provide further support and encouragement.
The biggest challenge in upstate New York will be bringing LTSS into a
managed care framework, because few health plans and providers operating
in those

areas have that experience.

 

Use State's health home initiative to increase integration of behavioral
health services for dual eligibles. Another important State initiative
related to dual eligibles is establishing "health homes" for Medicaid
beneficiaries with complex and costly physical and behavioral health
care needs. Nearly 1 million Medicaid beneficiaries in the state have
complex physical and behavioral health conditions and could benefit from
the greater coordination health homes could provide, and nearly
one-third are dual eligibles. Health homes can be used in either managed
care or FFS settings, so they could be used as a way of more fully
integrating behavioral health into capitated plans, both in the dual
eligible demonstration and as part of the MRT process.

 

Use health homes funding to cover initial Medicaid care coordination
costs. The Federal Affordable Care Act of 2010 authorizes 90% Federal
funding for specified care coordination activities for the first two
years of health homes initiatives. Health homes can be a source of
upfront funding for the care coordination support systems needed by dual
eligibles, with particular focus on the behavioral health care needs
that are widely prevalent among dual eligibles under age 65.

 

Use passive enrollment to increase enrollment in the dual eligible
demonstration. In order to support the enhanced care coordination
activities needed to make the Federal demonstration successful, and to
increase the likelihood of Federal Medicare savings that would benefit
the State, the demonstration must achieve a significant volume of dual
eligible enrollment. CMS has authority to permit states to "passively
enroll" dual eligibles in capitated managed care plans for their
Medicare services for purposes of the demonstration, as long as those
who are passively enrolled have the ability to opt out easily.
Beneficiaries must be fully informed about their care options, including
their ability to return to the Medicare FFS program at any time.

 

Continue and expand stakeholder engagement and consultation. Extensive
stakeholder engagement is one of the major CMS requirements for dual
eligible demonstrations. New York has considerable experience with this
approach, since it has been a hallmark of the MRT process. Stakeholder
engagement will be especially important for generating support for
expanding enrollment in the Federal demonstrations through passive
enrollment. Beneficiary education and enrollment processes that
incorporate the input of beneficiaries and their representatives will be
crucial to the success of such an effort.

 

Next steps. The NYSDOH proposal for the design of the dual eligible
Federal demonstration proposal is due to CMS in April 2012. The time
between now and April can be used to design a demonstration proposal
that builds on the strengths of the MRT initiatives by testing
approaches that can move New York as quickly and effectively as possible
toward programs for dual eligibles that fully integrate and coordinate
all of their care.

 

1 Both the State MRT initiatives related to dual eligibles and the CMS
dual eligible demonstrations share the goal of developing
person-centered approaches to coordinating care for dual eligibles
across primary, acute, behavioral health, and long-term supports and
services, but the time line for implementation of the State MRT
initiatives is somewhat longer and the State initiatives are focused
more broadly on all Medicaid beneficiaries and the services they
receive, not just dual eligibles.

 

http://www.nyshealthfoundation.org/userfiles/file/DualEligibles_2012.pdf

 

 

 

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