Opening the Leonard Davis Institute of Health Economics’ (LDI) second expert convening of the year on improving care for dually eligible Medicare and Medicaid beneficiaries, Rachel M. Werner, MD, PhD, Executive Director of LDI, set a sobering tone. Despite years of federal efforts under the Financial Alignment Initiative, she noted, “progress on creating integrated and coordinated care for dual eligibles has been slow and disappointing.” The initiative, launched in 2011 by the Centers for Medicare and Medicaid Services (CMS), sought to address the deeply fragmented system. Yet the challenges persist, leaving many patients—whose numbers exceed those of the population of Switzerland—navigating two separate, often contradictory programs with little coordination or clarity.

The latest December 6 virtual event sponsored by Arnold Ventures and the SCAN Foundation brought in four top experts in the field of dually eligible care financing and logistics to discuss potential paths forward to address the conflicts and inconsistencies of the system. The panelists were Melanie Bella, MBA, former Chair of the Medicaid and CHIP Payment and Access Commission (MACPAC); Matthew Behrens, MPA, Integrated Care Policy Supervisor of the Virginia Department of Medical Assistance Services; Toyin Ajayi, MD, MPhil, CEO and Co-Founder of Cityblock Health; and Aisha Adkins, MPA, CNP, a caregiver.

Policy Brief Recommendations

This December 6 session was the followup to a July conference that drew together experts representing beneficiaries, state Medicaid agencies, private insurers, the CMS providers, and others. That July session resulted in a White Paper and Issue Brief that detailed six policy recommendations for integrating Medicare and Medicaid care for dually eligible individuals. Those recommendations were:

1. Create an integrated option for all, authorize funding, and decrease non-integrated options.
2. Create new Accountable Care Organizations (ACOs) that are at risk for both Medicare and Medicaid spending.
3. Implement continuous eligibility by simplifying and improving Medicaid eligibility and enrollment processes.
4. Simplify and improve choice resources and limit brokers, providing easier-to-navigate choices for integrated coverage options.
5. Authorize shared savings building upon the lessons from the CMS Financial Alignment Initiative to develop shared federal/states savings structures.
6. Develop quality measures, establish ombudspersons, and implement joint oversight. Hold programs and plans accountable.

Recommendation Documents

Discussing Recommendation Details

Those six recommendations were the focus of the latest December panel discussion.

Moderator Werner emphasized the daunting challenges faced by both the individuals who are dually eligible for Medicare and Medicaid coverage and the fragmented jumble of federal and 50 state programs currently charged with providing that care.

“There are more than 9 million dually eligible beneficiaries in the United States who receive full benefits from both Medicare and Medicaid. Medicare covers the medical and pharmacy benefits for this group, where Medaid covers copays, premiums, and long-term care,” Werner explained. “Generally, dually eligible beneficiaries make up a particularly vulnerable group. They are people with low incomes, high rates of disability, and other complex health needs. About half are people of color and one-quarter have five or more chronic conditions. A high proportion have serious mental illness. Caring for this group is expensive and costs roughly $500 billion per year.”

Two Separate Systems Out of Sync

Werner pointed out that in their daily reality, these patients must navigate two separate systems and two separate programs, which often have different and, at times, conflicting rules on eligibility and benefits. This lack of coordination can lead to worse outcomes for individuals and higher overall costs at the same time it drives high levels of confusion and frustration for the patients and families trying to access adequate care.

It is widely recognized that the provider incentives of the current system pose serious barriers and problems to efficiently delivered care. Medicaid has no financial incentive to spend money on services that could help individuals avoid Medicare reimbursed care, such as hospitalization. Similarly, Medicare or Medicare Advantage plans have financial incentives to shift the cost to Medicaid when they can. As a result, these out-of-sync programs often leave patients and family members stranded in an administrative maze they can’t navigate.

Bella said part of the problem is that “we have many plans that have figured out how to make money on dually eligible beneficiaries without helping to coordinate their care. CMS has done a great job trying to crack down on that and supporting states in getting rid of non-integrated plan options. And we have seen the growth of integrated products across the states, but the majority of dual eligibles still do not receive Medicare and Medicaid services through the same organization.”

Confusing Plan Information

“Financial integration and having a single entity responsible for Medicare and Medicaid is important but so is the notion of the integrated experience at the beneficiary’s end of the process. That’s about one card, one handbook, one network,” Bella continued. “Right now, when a person’s trying to make a choice about where to get their care, they are bombarded with promotions, a majority of which are very confusing and don’t help the recipient coordinate between the two programs. There is still a lot of cost-shifting going on which, at the end of the day, doesn’t usually end up being in the beneficiary’s favor.”

Behrens explained how the complexity of coordinating CMS and state data makes the process of integration such an “incredibly difficult” challenge for so many states. He pointed to one of the issue brief recommendation that calls for providing seed money or grant funding to states to support the planning and implementation of an integrated program. “It would be hugely beneficial to provide the resources that help a state along that journey,” he said.

“Another area not being addressed is the lack of consumer education about how to understand and select appropriate plans,” said Adkins. “The current enrollment process is incredibly confusing, particularly for those who are not fluent in the technical language of Medicare and Medicaid. Everything from the accessibility and choice architecture of the website to the language used, to the details of so many different separate plans and how they do or do not work together makes the whole process one of trial and error.

“Like On-The-Job Training”

“It’s like on-the-job training when you don’t know what the job is and you don’t have a teacher,” Adkins continued. “It should be the responsibility of these programs to provide some easily accessible education about what is being offered and what the consequences of choosing a particular plan are.”

Behrens concurred and described his own recent hands-on effort to quantify how difficult plan selection can be. “Yesterday, I went into Medicare Plan Finder, pretended I was a dual eligible and the system presented 57 different plans in my zip code,” he said. “And then you have to scroll through a lot of different pages. It took me until the fourth page to find a Dual Eligible Special Needs Plan—so all the plans before that were non-integrated plans.”

“We all may be spending a lot of time creating and providing integrated products but it’s far from the first thing that pops up when a dually eligible individual performs a search. This is a choice architecture issue that affects a lot of people that should be easy to fix,” Behrens said.

Clinicians Lack of Knowledge

According to Ajayi, a less obvious issue in the overall debate around integrating dual eligibles’ care is that of physicians’ general lack of knowledge about their patient’s insurance. “It’s a foundational issue that in medical education and the administration of care delivery, clinicians are not often taught about insurance and don’t know the experience from the patient’s perspective and, so, can’t take into account how coverage issues can impact behavior and outcomes,” she said. “I think there is an opportunity to target specific providers who are caring for dually eligible populations with really nuanced and well-designed education that helps them understand the implications of insurance and coverage type for the people they’re serving.”

Program of All-Inclusive Care for the Elderly (PACE)

Questions from the audience asked why the successful Program of All-Inclusive Care for the Elderly (PACE) was not being used more broadly for dually eligible care.

Established as a permanent part of the Medicare program and an option under the Medicaid program in 1997, PACE was designed to provide a culturally appropriate, community-based alternative to traditional nursing home care for low-income individuals. It focuses on enabling frail older patients with multiple chronic conditions to remain in their homes and receive in-home support and treatment in tandem with in-office care at local provider centers. Currently operating in 33 states, the program serves approximately 79,000 individuals, most of whom are dually eligible.

Noting that evidence has confirmed the effectiveness of the PACE program in both improving integrated care and saving money overall in dually eligible populations, Werner asked the panelists if states should be doing more to expand the PACE model?

Doesn’t Scale Well

“We have a robust PACE program in Virginia, but the challenge is that you can’t just scale it up everywhere because it’s very center-based,” said Behrens. “You have to transport people back and forth from their homes to the treatment centers and that’s just not possible to do in many cases, particularly in rural areas.”

“Another issue,” said Bella, “is that PACE is not a financially integrated program that enables states to understand how Medicaid and Medicare dollars are being used. It’s likely we might see greater state uptake of PACE if we could get a little more transparency on that financial interaction between Medicaid and Medicare and how it impacts the care people are getting, as well as how any savings could be reinvested back into the system.”

Ajayi pointed out the group sense expressed earlier that there should be as many pathways as possible to integrated care for dually eligible beneficiaries and that PACE cannot be the only answer. In fact, it now involves only a tiny percentage of the overall dually eligible population. She agreed that scaling PACE is a daunting challenge in many regions, with many providers who shy away from it because of the program’s capital-intensive demands.

New Presidential Administration

As the session was ending, Werner mentioned that there were a couple bills recently introduced in Congress that focused on improving integration, enrollment, and integrated planning for dually eligible care programs. But in the wake of the recent presidential election, there is now some uncertainty about the prospects for such legislation. She asked each panelist for their thoughts about where the effort to achieve integrated financial and clinical Medicare/Medicaid care for dual eligibles is going.

“The new climate and political landscape create pause because this has been a bipartisan issue requiring collaboration across the aisle and I’m now very concerned that that’s something that may not be easy to achieve now,” said Adkins.

Behrens said, “The problem isn’t that it’s not supported by Republicans or Democrats but rather that it’s so complicated. In the past it has been bipartisan and while I don’t know what this new administration is going to prioritize, I’m still optimistic that we can operate in a bipartisan fashion, at least on this issue.”

“I don’t think anything changes in terms of the needs and opportunities,” said Bella. “We still need to support the states. What does change is making sure people understand that if the Medicaid program is underfunded, it will have an impact on the ability to do integrated care. People should not forget that to make the lives and care of dual eligibles better they should not have to simultaneously navigate through two disparate programs.”

“Change is anxiety provoking and there are a lot of unknowns right now,” said Ajayi. “We are all invested in ensuring these people with the most complex, challenging, and high-cost needs have access to care and services that improve their experience and outcomes and manage their costs in the most effective and appropriate way possible. When we look back over the course of the last decade, we’ve made tremendous progress in understanding the needs of this population and have started to create more pathways and proven models that actually deliver the care and outcomes they need. That gives me hope and a sense of optimism as we look forward.”

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