This is an unedited transcript.
Good afternoon, everyone. Thank you for joining today’s webinar on Closing the Coverage Coordination Gap for Dual Eligibles. I’m Sarah Dash, president and CEO of the Alliance for Health Policy, and for those who are not familiar with the Alliance, Welcome. We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues. The Alliance gratefully acknowledge as Arnold Ventures for supporting today’s webinar. And I am pleased, without further ado, to introduce Arielle Mir, Vice President of Health Care who is overseeing Complex Care at Arnold Ventures. To make some brief opening remarks. Arielle, welcome.
Thank you, Sarah. Welcome, everyone. My name is Arielle Mir, and I lead the Complex Care program at Arnold Ventures.
Thanks to you all for showing up to this conversation today.
It’s one of the most important issues that most folks are not talking about, and that’s what happens to the 12 million people whose care is delivered at the intersection of Medicare and Medicaid.
Next slide, please.
You might think that having two sources of insurance coverage would be better than having just one.
But that’s not always true for the low-income seniors and people with disabilities who get their coverage this way.
Because Medicare and Medicaid were not designed to work together, The people who have both, people who we call in, in policy circles, dual eligible, often receive fragmented, uncoordinated care, that leads to poor outcomes, for individuals and high costs for the program.
We at Arnall Ventures see an opportunity to change that trajectory by promoting models that integrate Medicare and Medicaid into single, unified, coordinated programs.
Next slide, please.
There is a lot more to say about what these models are and what they could be and what it will take for all people with Medicare and Medicaid to have access to enrolling in these models.
I wasn’t gonna spend a moment to get beyond the policy jargon to emphasize what we are talking about when we talk about dual eligibles.
We are talking about people who are very low income because access to social supports puts their health at risk.
We are talking about folks will have trouble with activities of daily living, of triple eating, dressing, moving from place to place, many of them living in nursing homes, which as we know, and higher hospitalizations and deaths from COVID-19.
And we are talking about a glaring health equity issue.
A greater share of this population are people who are Black and Latino than in the Medicare only population.
I’ll stop there and turn it over to our panel for today. We’ll tell you more about why this population and these programs need your attention. What programs have potential for change and what the Congress and States can do to make an impact here.
Thanks again for coming.
Great. Thank you so much, Arielle, for this, for that contacts and his opening remarks.
And I want to go over some very quick housekeeping items, and then I’ll introduce our panelists. First. Let me remind everyone that you can join today’s conversation on Twitter, using the hashtag #AllHealthLive. Join our community at all health policy as well on Facebook. And LinkedIn, please get your questions ready. You should see a dashboard on the right side of your web browser with a speech bubble icon. Go ahead and use that to submit questions at any time, We’ll get to as many as we can during the broadcast, as well as, if you have any technical issues, you can go ahead and chat them there as well. And finally, check out our website, all health policy dot org, where you can find background materials, including a resource list and an expert list, and later today, a recording of today’s webinar.
As Arielle mentioned, this is a topic that has enormous implications for some of the most vulnerable Americans, including low-income seniors and people with disabilities. And if you’re new to the dual eligible conversation, as I was, as a new Hill Staffer many years ago, the number one thing I want you to remember is that this is a diverse population with many different health, social, and financial needs. And that means that there are no simplistic solutions.
And perhaps even more important, it’s important to remember that, as as Ari mentioned, dual eligible is a wonky health policy term that we have applied to real people as a result of the policies we have created around them.
Each of them, more than 12 million individuals we’re talking about today, has a unique life story and set of needs. And so here with me today to help us unpack the policy issues that can support or hinder their improved care is an esteemed group of experts. So I’m pleased to be joined today by Denny Chan, who is directing Attorney for Equity, Advocacy at Justice and Aging. In this role, Danny is responsible for developing and leading Justice in Aging Strategic Initiative on advancing equity with a primary focus on racial equity for older adults of color. And he co-ordinates the organization’s equity team, the son of working class Chinese immigrant parents.
Danny has worked significantly on non discrimination language access, and healthcare delivery reform issues for low-income older adults. And he brings all of those experiences to his advocacy, He previously served as a rotating law clerk for the US District Court in Los Angeles. And participated in the Fulbright English Teaching Program as a Fellow in Macau, China.
So super excited to have Denny with us today. And next up, pleased to introduce Allison Rizer. She’s a principal at HAI Advisory. Allison brings nearly 20 years of health related experience to ATI advisory, including more than a decade, focused on insurance and government programs. Prior to joining HEI, Allison served as vice president of health policy and strategy with United Healthcare, where she led the organization’s national policy efforts specific to individuals’, duly eligible for Medicare and Medicaid.
And she served as a Medicaid Policy Director, working with individual states and Medicaid health plans to provide strategic guidance on emerging policy and program trends, in addition to prior years of service with the lewin group. And it’s great to have Alison with, as part of what we’re going to talk about today, is the co-ordination or sometimes lack thereof between the Federal Medicare Program and the Joint State Federal Medicaid program. And, finally, last but not least, we’re joined today by Sarah Barth, who is Principal at Health Management Associates. Sarah’s policy experience includes extensive work, partnering with states, federal commissions, health plans, and philanthropic foundations to lead efforts around state and federal policy requirements, program trends, and market strategy for integrated Medicare and Medicaid managed care models. And Medicaid managed LTSS our long term services and supports programs.
She also has deep operational expertise, including state and federal program oversight care co-ordination, communication plans, and facilitating engagement with Medicare and Medicaid. And she was previously Director of integrated care and LTSS at the Center for Health Care Strategies. So we’re gonna launch today’s discussion by hearing from Denny Chan because as REL said, this is an, this is a topic with huge implications for health equity and so it is only fitting that we start the discussion there today, Denny. Thanks for joining us.
Great, thank you so much, Sarah. I’m excited to join all of you today, and I say good morning from California, where I’m based, but recognize that many of you are in other time zones. So, wherever you, I hope you’re doing well, I’m really happy to be part of today’s conversation.
one quick thing, before I kinda dive into the meat of my presentation, you know, the introduction was wonderful.
And one highlight I would sort of offer is that, um, before I took on this new role as directing attribute, the advocacy of justice and aging, I served for about seven years as a health care attorney and justice in Aging, working primarily on issues of Medicare and Medicaid dual eligible integration, specifically here in California. So a lot of what I’ll be commenting on offering in terms of remarks is based on that experience. Next slide, please.
All right. So if you haven’t heard of us before, Justice Nation, we are a national legal advocacy organization.
And our mission is to use the power of law to fight senior poverty. So all of our programmatic staff are attorneys. And we’re constantly doing advocacy, whether that’s in the courts, policy, advocacy at the state or federal level, to ensure that the needs of low-income older adults are being met.
Several primary programmatic areas. one around health care, which is where I was working before I took the position, another run economic security, including housing, and then a growing amount of work around elder justice and elder rights. And we are celebrating our 50th birthday next year. So happy birthday justice management and happy early birthday to us. And in those 50 years, or 49 years, plus, we have spent our efforts to really focus on those older adults who have faced historical discrimination and continue to face current day discrimination, such as women, people of color, LGBT older adults, and older adults with limited English proficiency. All of which is why we started our strategic initiative to advance equity for older adults earlier this year, in March. And if you want more information, you can visit our website at justice nature dot org.
We offer free trainings, resources, for advocates, and other individuals who work with older adults. Next slide.
In order to really fulfill our mission to end senior poverty, we really have to acknowledge the ways in which poverty in this country is racialized.
That there is both a complicated relationship between the two, that they are not synonymous in terms of race. And poverty.
Our work also has to to address the enduring negative effects of that racism and differential treatment, which compound over an individual’s life cycle as they age.
And so we will you make it our focus to promote access and equity in economic security, health care, and the courts for our nation’s low-income older adults. And that really starts with the recruitment and retention and support of a diverse staff internally, as well as a diverse or set of board of directors, among many different types of diversity.
All right, so some of these numbers will look familiar, because they were part of the earlier introduction, but I really wanted to unpack.
Cool, we’re talking about here because that is such an important piece to why this conversation is important. And you’re gonna hear a lot of different policy wonky kind of things in the next hour or so. And I think it’s really important for us to focus on who we’re talking about, justice and aging. You know, we say dual eligible, we’re trying to say people who are dually eligible with Medicare and Medicaid to emphasize the humanity of these individuals, so, they don’t get lost behind the term, but it’s a much longer term. So, if I slip and say, Duals, you understand what we’re talking about, a set of twelve point two million individuals who are enrolled in both Medicare and Medicaid, and this is both a professional interests, as well as a personal interest of mine, my grandmother, or just visit this past weekend is dually eligible. So, it’s also, a personal interest of mine to make sure that she gets the care she needs, 41% of those tools have at least one mental health diagnosis.
And almost 50% of the last slides, and 49% receive long-term services and supports to help them get the care they need with activities of daily living. And 60%, well over half, have multiple chronic conditions.
So, this is a population that needs more help, And they are stuck in two systems that were not meant to work together, because there are a lot of unique issues that happen, at the intersection of Medicare and Medicaid.
There is an important distinction I want to point out between someone who is fully dually eligible and sometimes a partial dual eligible most dual eligibles. Well, over half almost 75% are full dual eligibles need to have both Medicare and full scope Medicaid.
But there are some people who are Medicare, Medicare, and also receive just assistance through Medicaid through a Medicare savings program. They have no other Medicaid benefit. and because of that, we call them partial duals, and there’s a little over a quarter of duals who are partially dually eligible.
That’s an important distinction, because for those people who are fully dually eligible, they really have a lot of issues coordinating between Medicare and Medicaid oftentimes. And then for partial duals they.
so, you know that’s still an important distinction because oftentimes only full benefit dual eligibles are allowed to enroll in certain types of plans.
And so, we’ll probably hear more about is all the different types of options that dual eligibles have in considering how they want to get their care. Some more integrated and some less integrated.
It’s also important to highlight that a growing number of individuals who are dually eligible are enrolled in Medicare Managed Care, meaning, they have a Medicare Advantage plan, whether that’s a D snap or just a regular old Medicare Advantage plan. It was 37% in 20 18, and it was even lower than that earlier year. So, it’s a trend that’s only going up. And then also really important to note that we’re talking really about a group who is much more racially diverse than the Medicare only population.
As you can imagine, because of the impacts of poverty, that 1% of tools are black, 17.8%. Almost 20% are Latino, 6.4% Asian, Pacific Islander, and almost 1% American Indian Alaskan native, which is all significantly higher than the general Medicare only population. Next slide.
I want to talk a little bit about the impacts of co-ordinating team on dually eligible individuals. You know, the highlight here is that dual eligibles are more likely to be infected with Coburn 19 compared to Medicare only individuals, as well as more likely to be hospitalized. So what you’re seeing here on your screen is the case infection data to CDC releases on a regular.
I’m sorry, that CMS releases on a semi-regular basis of this is, I believe, as of earlier this year, is what captures really the bulk of infections that occurred over the winter when we were all fighting the fatigue.
But you can see that the blue bars represent Medicare only individuals.
And the yellow bars represent people who are dually eligible Medicare and Medicaid across the board.
No matter how you cut it. Whether it’s looking at people who are aged on Medicare, or people who are disabled on Medicare, whether you look at different races, whether you look at different age groups, gender, no matter how you slice it, the infection rate among people who are dually eligible is consistently higher than people who are Medicare only. And that’s a really important piece to show both how high risk this group is, and continues to be at risk because of the ongoing changes with the variants. And also to show you that really the impacts of being dually eligible. There’s something about that intersection of Medicare, Medicaid, poverty, race, all those different things that make this population much more susceptible. And that’s true, both of Covid-19, but also other health disparities, which we can talk about later. But it’s, I think it’s just really important to highlight.
And then, so I wanted, before I pass it to other panelists for their kind of opening remarks, I wanted to offer some key considerations to think about what care looks like. What choice looks like.
You know, I think regardless of the vehicle, whether it’s a D SNP or some other type of plan, or whether it’s in fee for service Medicare, Original Medicare, or whatever it is, it’s so important that this population, these groups of, in this group of individuals have care co-ordination from a trusted source.
And that can be, one care coordinator can get a team of care coordinators, But it’s so important that at that intersection will be no, people need more help navigating a complicated system that there actually is someone walking them through that system.
I think it’s also important to highlight the role of states, to monitor integrated delivery options. So much of this is different on a state by state basis, as you’ll hear about later. And so there is an increasing, you know, I think importance, and the role of states to actively monitor what those integrated options look like.
The feds can only monitor so much from a high level, but a lot of it’s in the details and state policy.
I think it’s also important to think about, what does choice really mean?
I see this with many older adults in my own life, that, you know, especially around the annual election period.
They get a ton of mailing and a ton of communication about all the different choices they have, and it’s great to have choice when there’s so much choice. And it is so hard to tell what differences actually exist between swipe from choice to choice. It can actually feel like there isn’t a lot of choice that you actually need someone to help you choose. When we don’t wanna sit, We set up a situation where that’s the case.
As we said before, the population of dually eligible individuals is very diverse.
There are a lot of people who need that extra level of care management or care co-ordination, and would maybe be better off in Managed Care or some other integrated plan.
There are others who have cobbled together, whether it’s over time and trial and error, their own network of providers, some of whom may be with certain plans, others who may not be contracted with these plans. But there’s just a works, and of stuff that system were, to change that system, really, can offer a lot of risks, and potentially not. A lot of the images. If that individual is getting the care that they need, and their network of providers, their existing system already works.
It’s also important to make sure that, regardless of how integrated these services are, the services themselves, are actually accurate, or actually adequate, excuse me.
And at that intersection, in particular, we know there are specific types of benefits or duals. people who are dually eligible.
Often struggle, whether that’s durable, medical equipment, transportation, dental benefits, other areas where Medicaid sometimes is primary as opposed to Medicare generally being primary. We see that dual eligibles face a lot of problems. And then you add on the managed care layer that can introduce prior authorizations and all sorts of things can be it can be done really hard to get the care they need.
So I think all those are kind of initial key considerations I would offer us, as we think about, you know, what care really means. What integrated care should look like. And ultimately, what care makes the most difference and helps the most this group of very diverse individuals.
Alright. And with that, I’m going to pass things back to Sarah.
But look forward, Here’s my e-mail. In case you want to reach me afterwards, feel free to e-mail me. and I look forward to the Q&A as well. Thank you. Great.
Thank you so much, Jenny. It was a really fantastic overview. And now I’m pleased to turn things over to Allison Riser.
Allison, take it away.
Thank you, Sarah. Thanks for the opportunity to you and to Arnold, for the opportunity to, to talk about this important topic today, Allison Riser with a UTI Advisory. Just a little bit of background. We are an advisory services and research consulting firm focused on frail older adults and I lead our business area focused on dual eligibles and long-term services and supports. And I am just going to jump right in if you could go to the next slide.
So, this is our famous spaghetti graphic and I’ve included it here not to talk about all of these acronyms but rather to show the overwhelming breadth of coverage options that exist for dual eligibles today because the Medicare and Medicaid programs were not designed to work together.
And so we find ourselves I’m in the middle of at least 43 unique program and coverage combinations.
Really that policymakers have to sift through as, you know, as we seek policy solutions. And the actual choices within each of these coverage combinations can be in the dozens. So, we just released an analysis and a blog with Arnold Ventures yesterday on this very topic actually, and found that, on average, a dual eligible has access to 26 Medicare Advantage plans in, in her or his county. And so there’s a lot of benefit design within each of these coverage combinations. So Danny touched on it, is too much choice bad, is it really, choice at all, when there’s so much to choose from?
So, what this looks like in practice actually varies considerably by state. And importantly, before you even start to think about integration between Medicaid and Medicare, you really first have to recognize that Medicaid by itself can be really fragmented, you conceivably could have a program where a dual eligible has their physical health benefit administered by one organization in one program. Their behavioral health benefit administered by another program, their long term services and supports and a third program. You know who knows what’s happening with dental. If they’re central coverage, transportation, pharmacy. So you get the picture that even in the Medicaid only space. There is a lot of fragmentation that has to be addressed before you even start to think about Medicare integration.
And then you layer on the Medicare benefit. And so there’s really two kind of broader approaches to this. There are Medicare only options. They’re not formally connected to Medicaid And then there are options that are in some way, formerly connected between Medicare and Medicaid.
So first, those that are not formerly connected, the one I’m going to call out here is the acronym that you see at the bottom that says, I SNP Eisner. This is an institutional special needs plan. And I’m calling this out, in part, because I think it’s an untapped opportunity to think about dual eligibles and pre dual eligibles, and a more sophisticated manner. I SNPs are institutional special needs plans that are limited to Medicare beneficiaries who have a long term care level of need, so long term services and supports. It is Medicare only.
There’s no formal Medicaid relationship, currently, at least.
And it’s not a dual specific product, but by its very nature of targeting individuals with long term care needs, it does tend to enroll a high portion of dual eligibles, again, as well as these pre dual eligibles who are kind of along the path of spending down into full dual status.
So, Slack again, I think this is one of our untapped opportunities to talk about.
Then as we shift over to these, sort of like turquoise sea, Teale, combinations, these are the formerly Connected programs.
So the most ubiquitous is the de snap a column in the middle. This program is in nearly every state so dual eligible special needs plan. It offers the most flexibility to states.
However, at its Core a D snip is still a medical care product.
It does have an underlying state contract. It is the only Medicare Advantage product that has an underlying state contract called a … agreement, or a smack, a state Medicaid agency contract. And this contract offers states a ton of latitude to really lean into this Medicare Advantage product and shape integration in a way that is meaningful to that state’s residents. This is another untapped opportunity in my opinion, because of that amount of latitude that states have. Some have lean into it and then it has not.
Depending on the State a D snip organization may have a companion Medicaid plan. They may have other arrangements to cover Medicaid services, or they may not be at risk for Medicaid services at all. And generally, as you look down this list, these acronyms that you’re probably hearing kind of floating around right now, do snap, Heidi, Snip, and fighting snap.
Generally as you move down that list, the programs become more integrated. It’s not always the case because of the latitude have that smack on a contract, a state can actually have a really aligned Heidi snippet, that’s sort of the spirit of integration as you move down that list.
Then, another point I want to make on this slide.
I’m not gonna call out everything, but I do have a reference at the end for you, if you’re interested in diving deeper in each of these acronyms, but another point I want to make is the financial alignment initiative column that you see here.
So you may be familiar with the MMT program, the Medicaid Medicare plan program. This is the duals demo. I believe it’s currently in 8 or 9 states still, and it sits within the authority of the duals office at CMS or MCO.
Um, this is essentially a singular contract that includes both Medicaid and Medicare services, which is a key distinction between MMT, AMD snap recalled the steps of Medicare program, and it may include Medicaid. The MMT always includes Medicaid and Medicare.
However, the MMP, while a very significant and important program, is not the entirety of the dual office financial alignment initiative.
Some calling this out because it’s another untapped opportunity. In my perspective, an MCO the duals office has this broader pilot authority in the duals space to test out. for example, lessons learned from the MP in other platforms and chassis.
So, just briefly, all of this choice, all of these program designs, and yet, we still find ourselves in an environment where a large portion of the 12 million dual eligibles in our country are in fee for service programs.
So about 70% of dual eligibles have at least some Medicaid benefits in Medicaid fee for service.
Creating a comprehensive managed care program for dual eligibles in Medicaid can be very politically challenging at the state level. one of the reasons why we do tend to see a higher rate of fee for service in the duals population in Medicaid.
However, we also see more than 50% of dual eligibles in Medicare fee for service. And so it’s really hard to create a co-ordinated and integrated environment when you have so many individuals still sitting in these fee for service programs.
But also, to call your attention to the last set of data points on this slide, because in the policy world, I think we tend to focus very narrowly. I’ve heard some buzzwords, and some people calling out that these are buzzwords.
You know, we think about this only in the context of integration, for example, and that’s really important, but the duals population has medical, Social, Functional Complexity, regardless of whether the individual, as Danny was saying, is a full dual eligible or a partial dual eligible, or again, a pre dual eligible.
So I include these statistics to challenge all of us to think about this population as a population that has these complex needs. And we should be solving for these complex needs, one of which happens to be integration.
But this isn’t just about integration, and so we need to treat it that way, because we end up excluding some individuals from programs when we say, OK, only for those can come in, for example. And then when we leave them with really no good plan options and kind of this eligibility clipped, where they’re left in a desert, with, again, not really any good plan options.
So unfortunately, there is not a single program that emerges as the winner and there are programs I haven’t talked about as well that are making their way around Congress.
But the reality is the value of a program depends on what you are looking for.
And no single program hits all of these boxes. So, this is our approach at kind of assessing across some of the key attributes of these programs, like how strong or what the challenges are for each of these programs. And, I often say publicly, that DCF comes the closest.
If the state is really leveraging that, and if a contract. And particularly if the state wants to have a conversation about how to maybe use that financial alignment authority on top of the DCP.
And I say this, because the de stamp is easier to implement than the other programs. Typically, it’s easier to scale. It’s easy to enroll in, and it has the ability to capture the broadest population.
That said, the other programs have some really wonderful, wonderful attributes that we should be thinking about.
But these attributes don’t necessarily matter if a state can’t afford to implement a program. States have pretty significant budget restrictions. And so if they can’t afford several million or several tens of millions to stand up a program, and the program is not going to ever come into that state, program also has to be attractive to dual eligibles. They have to be willing to enroll in it. The providers have to want to participate health plans. If it’s a managed care program, health plans want to participate.
So I say all this, because, again, I feel like decent coupled with the best aspects of some of these other programs really has the ability to appease the needs of a variety of stakeholders, the state, a health plan, provider, and most importantly, the beneficiary.
But, again, it depends on where a state is in its own infrastructure.
Different programs can be more or less meaningful. And also, this assessment is a point in time. This is where we are today. These are the strengths and weaknesses. Currently, I do think that there is a lot of opportunity to fill in some of these Circle bubbles in advance.
A program or a couple of programs in a way, that can be much more meaningful across the dual population and across integration, generally.
So, one last, very quick slide before I turn it back to Sarah.
And, next slide.
And this is a list of resources.
I just threw a lot of information at you all, a lot of statistics and acronyms, and this is just a list of some of the resources that we’ve published over the past few months that provide additional detail into many of the points I was making today. Including the blog post and the detailed analysis. That I mentioned that we pushed, pushed out yesterday, so with that, Sarah, I will turn it back to you.
Fantastic. Thank you so much Alison, and I have to say like for myself as as somewhat of the Queen of over complicating things. You know, I’m compelled to quote my mom who had sort of encouraged me to keep it simple, Sarah, and perhaps here today to tell us how we are trying to simplify things for people who are dual dual eligible’s Sarah Barth from …. And Sarah and I had the opportunity to work together on a project sometime ago. And I’ll just I’ll just highlight that the highlight of that project for me was when somebody said, you know, it’s not the people who are complex. It’s the system that’s complex. So, Sarah, take it away.
Thank you. Thank you, Sarah, Dash. Thank you, the Alliance, and thank you to Arnold for the commitment to simplifying and improving care for individuals with complex needs, including individuals who are dually eligible for Medicare and Medicaid. Next slide, please.
Kind of obligatory my program Health Management Associates would not likely to reference it that way, but I’d been at each and I am a principal there for the past five years. We are an independent, national healthcare research and consulting firm. We work nationwide. We work on publicly financed healthcare systems with providers, health plan, the work that I do, it with Foundation Advisory Committee with the Congress. And we are devoted to improving the quality and cost effectiveness of our publicly financed health care system. Next slide, please.
I just want to say thank you to Arnold Ventures for funding what we just currently wrapped up, a two year, Medicare and Medicaid integration project. I just wanted to highlight, we have three brief, I’m going to be focusing on the third phase of the research, but the first phase focused on enrollment rate in current integrated care program.
Many of the model that, Alex, and highlighted, we defined for our research just to help contact here, ITP, as financing and care delivery, organizing entities, or programs, co-ordinate and integrate Medicare and Medicaid coverage services and supports for dually eligible individual to the Dual Demonstrations. Some of those aligned health plans across Medicare and Medicaid.
I’m not going to go down a rabbit hole of detail, but research showed that and other research that currently about one in ten of people, fully eligible for Medicare and Medicaid, are enrolled. So, that led to a question. Why are they not enrolling, or are they not staying enrolled?
Second issue briefs, and part of the research was what are integrated care programs? Would have been the barriers? What have been the successes? What are some of the unanswered questions, and what led us to identify essential, but really necessary program elements for these integrated care programs that people want to enroll in? They enrolled in because they meet their needs and preferences and are tailored to the diverse needs of the dually eligible population.
Next slide, please.
So some of this has been covered.
That contact was laid out by Sarah, Arielle, Danny and Alex. And so I’m just going to go over a couple of these that you know, we do have that.
Duly eligible individuals more often than not are navigating separate programs not designed to work together. There have been promising model that the state and federal government have worked on together and as I said, but currently only one in ten individual dually eligible individuals are enrolled. And we just, from our research and interviews with stakeholders, and for state to really increase enrollment, policy, makers need to continue, They have, but continue to partner with consumers, to design programs that meet.
They’re diverse needs and preferences, and as Danny underscored, really address health equity.
As Alison highlighted, states really, and input we received really need federal support.
This is important, complex, hard work.
They have limited budget, you know, competing priorities, and they have a significant role in implementing and overseeing these programs. Next slide, please.
So, from interviews with these, with stakeholders, or states from a highly integrated, from states, with a highly integrated program to states that do not have any integration activity currently, or low.
And they would be, the spectrum would be Michigan, with a dual demo, Pennsylvania, with a Medicaid managed long-term services and supports and aligned dual eligible special needs plan model. And then, to date with, to a lesser degree level of integration in their programs, Oklahoma and Louisiana. I’m not going to go over the categories, because they are on the next slide, Which is my final slide. I know we want to get to the discussion, and Q&A.
Um, so from discussions with stakeholders that included consumers, community based organizations, state Medicaid administration officials.
Many of all right.
Fully integrated dual eligible special needs plan, a behavioral health managed care plan. We heard and I would say 81, but what bubbled up to the top worthy or just what we heard repeatedly.
These 10 areas that Sara Dash noted at the beginning, we’ve been working on these and highlighting many of these and working on them for over a decade as we try to integrate care in the state, federal government partner. So I just going to go through these quickly and hand it back over for Q&A.
We also identified some policy recommendations for each of these elements that, hopefully, we can talk about during the Q and A So, the first area was, when we talk to people in a particularly consumers, the confusion starts or enrollment. It starts with eligibility and eligibility for the program. And particularly Medicaid, at the point of turning 65, And you have to be determined using different eligibility criteria in the brief complicated.
But what came out, why we need a simplified Medicare and Medicare Medicaid eligibility process, the paperwork that is understandable.
Now, individual need expert advice to help them navigate their options and the information as to the benefit, to determine which program, which health plan is optimal for them to enroll in and want to enroll in.
Then the next category, the delivery of care and support.
What was underscored, and what Danny really highlighted is the burst dually eligible population.
We need to engage a divert the diverse consumers to inform and tailored delivery systems and the integrated programs to their needs and preferences.
There needs to be a robust data infrastructure, both at the population and individual level.
So, you know, all their characteristics, not just their medical needs, their social situations, their social challenges.
And really have that information can drive health, equity, then coordinated effort to address their social means, housing, food insecurity, transportation, a single process for assessment and plan of care and one care team for each consumer.
And I would note that the dual demo that capitated financial alignment and the program pace program, program of all inclusive care for the elderly requires with, but as we move forward, really need that in other models that that emerge.
There’s a lot of work around quality measurement and not to have add to quality burden.
But really, interviewees highlighted the importance of key quality indicators for consumers that are important to them as my provider.
And the plan that this program, are people enrolling? I should ask the question, why? How many people are supported with really high needs? May be nursing facility level of need in the community over institutions.
So the need to really put together just some key indicators to help people choose between plans and between program and payment models to incentivize really quality of life improvements, commuting, community engagement, and things that individuals receiving services and supports, want and need.
And then what really emerged were two areas related to access.
The first one, an adequate, engaged and diverse workforce to support individual and to support them where they want to receive services, how they want to receive services. And what was really highlighted with the adequacy of the direct care workforce for those individuals. And at REL noted, really high number of or most duly eligible individuals need assistance with activities of daily living. And we need an adequate direct care workforce that can support people in their homes and community, and then, also, access to needed services in rural areas.
In Oklahoma, they noted as you move out to more rural areas, yes, smaller population, but higher prevalence, proportion of people, are dually eligible individual. And I also have to say, having been the Bureau Chief for Long Term Services and supports at New Mexico, Medicaid, and standing up a program that this is an area near and dear to my heart to really increase access in rural areas.
So, I ran through that quickly, but I wanted to hand it back over. Next slide, actually. And just wanted to highlight that the brief is out there.
But we also have a fact sheet that is easier to read. So, you have the links right there, and thank you very much.
Thank you so much, Sarah. And why don’t you stay on camera? I’m going to invite everyone else to come on camera while they’re doing that. Um, thank you all for calling out the great resources, and I want to call out just one, more. The Alliance for Health Policy recently published a health policy handbook. It has a chapter on dual eligible beneficiaries and it was also supported by Arnold Ventures. I’m going to ask folks to put that in the chat for my team. And it is a great resource. It’s written by a phenomenal bipartisan team of health policy veterans. Rodney Whitlock, improper awhile. It’s in partnership with Health affairs. So check that out for some more information.
So thank you all for the really terrific overviews. And I just want to start off, you know, a lot of you use this word integration, and, and we’ve already had some terrific audience questions come in, and so I’m going to try to combine them a little bit. But, you know, Sarah, especially in your last slide, it seemed like those were some of the, perhaps, characteristics of what an integrated care system would look like.
But is there a common no definition or understanding of what that looks like? And how does that differ from the perspective of the policy and practice community? And then the perspective of the consumer. So maybe let me start there, and and see what your responses are.
Directed at me, Or I want to just jump in you just for me, OK, Yeah.
I think, yeah, I just want to, in answering this question, reference an interview that we had with a consumer.
The word integration doesn’t mean a lot to them.
They want to know that they can get care, services, support from the people they have relationships with.
And then the communities in which they live, And from a person and providers who understand their living situation and all of their needs.
So, I would say integration is really addressing the whole person, I maybe, you know, sidestepping your question, but, really, this, this word, there isn’t a uniform definition of integration anyway. And, it is.
I just think what I just said that people have access to services and care that will work together, and that they don’t have to put together themselves that it is a seamless system that addresses their whole person.
Great. Yeah. Yeah. You’re not it. Go ahead.
I would just add I think the word integration appeals to us because we know that the silos exist dual eligibles people who are dually eligible.
Are so confused by all the systems that the word integration to Sarah’s point doesn’t mean anything I think ultimately the the ultimate test is whether they get what they need in a timely way and in a way that is person centered.
You know, we and another way that I think about it, too is is the plan actually is the option. Whatever. the option, it’s right.
Is the current system, actually, one that someone could navigate without someone else’s help?
And whether that means that you have someone who, you know, is doing a more of a care coordinator role, or someone who’s helping manage inside, is that, is there actually, are there barriers to getting the care that they need?
I see this regularly with my own grandmother, who I said, at the very beginning, is dually eligible.
Just getting her to the doctor’s office is like, it takes a team of her people in her Medicare plan, plus all the caregivers, plus my family. I mean, it is such a feat just to go for a regular office visit. That, if you said to her, you know, always your plan, integrated enough for you, She would have no idea what that means. She just knows.
It’s a big hassle for her to get to the doctor’s office to get what you need, and I think that’s how it shows up For consumers. So really, you know, I think someone, we’ve said before multiple times, it’s about simplicity. And I think we need to make sure that the system is simple enough, but also flexible enough to meet the needs of the people who are.
That’s great, and I wanna, I wanna, I wanna ask you a follow up and then take a slightly different tack with for Alison, but also related to this integration question. And we had a question from the audience, about, you know, do you have a recommendation, or what is your best recommendation for providers to assist their dual eligible clients? You know, this particular one comes from a small home care agency, but like who do people call is that the plan is at the state, like, is it the county, is it you like? Who do they call?
I should have clarified in our introduction that we don’t offer direct services, So we’re not the people to call. I think part of why the word integration is so appealing is because there isn’t oftentimes one answer to that question of who to call.
I remember when we were working on the California MMP, the Medicare and Medicaid Plan Financial Alignment Initiative.
The catchphrase that the state really hooked onto was one phone number, right? And that was great because it was a integrated plan that was offering Medicare and Medicaid services. So that phone number, oftentimes, we do the trick.
But I’ll even say that even when there was one plan that was offering Medicare and Medicaid services, that oftentimes with carve outs and other sort of very wonky things that we don’t have enough time to get into.
That was actually slightly deceptive.
There was a phone number to call, but then there might be someone else to call it. That might be too warm handoffs or something else. So, I think part of it is, you know, can we create a system, regardless of whether how integrated does on the backend, it’s at least integrated for the consumer rights that they do have only one phone number, regardless of whatever.
Then we, as, you know, the walks, everyone else behind the scenes can work out the systems behind that. But I think it is really important for consumers to have one touch point.
And unfortunately, I don’t think we have a very simple answer to that question right now.
Yeah. And for those who are kind of newer to the conversation, you know, carve out is not a fun barbecue term. It is like, What it means is, like, maybe your behavioral health benefits might be coming from a different plan. And, as we saw from you, know, from your slides earlier with, you know, I think was almost half of folks in this, you know, population, having mental health condition, you know those. Those are, those are some real considerations.
So, Allison, I want to turn to you because, you know, we’ve had a couple of questions around policy levers, right, regulatory, Congressional, legislative, and, like, What are some of the things that can either move the needle on integration, or, you know, make it, like, make a big difference. And, you know, You mentioned that, the Medicare Medicaid co-ordination Office. And it just think it’s, it’s important to call out that, that is, that Office is about 10 years old, right? That was created during the ACA.
So, can you talk about, like, what, you know, what have we learned?
You know, these were some of the same things we were talking about before, the creation of that office that office has, has created some the financial alignment demos to show. like, really try to grapple with these problems.
But, like, what have we learned, and how do we move the needle in the next 10 years or hopefully less, or hopefully do even more than move the needle? All right, like make care and co-ordination a lot better for folks. Allison, you want to take a stab at that really easy question.
Million, other questions? I think, what we have learned, that whatever the solution is, it has to work for all stakeholders. Like, we can’t just designed something that is ideal on paper, because then we probably won’t be able to execute against it unless we completely rewrite Medicare and Medicaid, right. Because we have choice in medicare wide open choice that has a policy conversation to have. But we have wide open choice. We’ve got state design Medicaid programs that really are 56 different programs with carve outs and all of these other wonky terms. And so it has to work in, the Medicare space, has to work in the Medicaid space. But guess what? If we want to do this in a risk based way, it’s gotta work for health plans. It’s like we’ve gotta figure out a way how to bring the health plans along, and how to bring the providers. So I guess my point is not necessarily about like this one thing that does this really great job at coordinating or improving.
We have to figure out the solution that is sustainable, that brings in the most number of dual eligibles, and that works for all stakeholders. Which is, is one of the reasons why I tend to go back to decent it because it has been the most popular among dual eligibles. You’re able to sell. Now, that’s a separate policy conversation. Should you be allowed to sell it off. And you’re able to sell so we can maximize enrollment in those programs. There’s a lot of latitude for a state to design those in ways like, wherever their readiness is, because we’re not just going to flip the switch, and everyone’s not just going to be Massachusetts overnight.
So we have to let states stair step into this, right? So, I think, that’s maybe not a satisfying answer But I think that is, again, kind of one of the big things from my vantage point, that has been a really important lesson learned where we see look alikes popping up. That’s another term that we’re not going to dive into probably today. But we see all of these whack a mole solutions that pop up in response to the ideal policy environment. And that’s just not sustainable. Millimeter, hmm, Yeah, and one follow up for you and I want to talk a little bit more about this. No state, Federal Diamond Amec because it’s, again, it’s a problem of, you know, there’s a lot of cooks in the kitchen, right?
And when when we think about no, one of the things in particular that I think has come up in the policy conversation, although not yet in this conversation, is this idea of, like if you make something work, that, let’s say keeps someone who’s in a nursing home, and therefore receiving, you know, medic Medicaid benefits if you keep them out of the hospital.
Right, that’s like a Medicare savings. So, how, so this, this question of, you know, and again, and wonky policy community, we like to call it the wrong pocket problem. Although, I like to say, it’s all taxpayer money in the end, and consumer, money, and time, and energy. But like, you know, have we come any further in dealing with this issue that you know, that the money is coming from different buckets? And therefore, perhaps there is sometimes some reluctance to like implement a solution that might work for people.
But you know, is is is sort of not not a budgetary solution, if you will.
Yeah. I think there’s, there’s kind of two answers to that. The first is, like the state perspective, and the second is the plan perspective.
And, you know, from the state perspective, that is still absolutely, I think, the typical sort of sentiment, that why invest all of this money in an integrated program, if the savings are going to accrue to decreased emergency department utilization and hospitalization, that’s Medicare savings. That is, I think, a space where the MMP, you know, really got it conceptually right, was figuring out how to share those savings back to the state.
That’s where I would love to see the financial alignment, authority applied, you know, potentially, outside of D snip to scale, the ability of, of States who don’t have MLPs to scale their ability to share some of those savings. You know, there’s also the long term care of, we are also slowing or preventing institutionalization, which then becomes a Medicaid covered benefit. The challenge with that is that the tenure of a Medicaid directors is, is less than two years. It’s way less now that time, right?
So it’s hard for them, as they think through, like, this annual budget cycle. And I’ve got two years to do everything I want. And it’s really politically hard to do it. It’s hard to think about the long term payout.
But there is an increasing amount of evidence to say that, yes, in fact, this can help save dollars long term.
I think from the plan perspective, too, this is where, like, this is where I think pace gets it, really, right? Which is, you’ve got your, your bucket of money.
It doesn’t matter if it’s a Medicare service or Medicaid service, or even sometimes a social service. You’ve got your bucket of money, use it as you need to for this individual.
And I do think we’re starting to inch closer to that. CMS had released guidance maybe a month or two ago on how you supplemental benefits in Medicare, in ways that states can set their rates in a way that starts to blend those dollars. But at the end of the day, you do still have, like, it’s a plan. You’ve got your Medicare dollars, your Medicaid dollars. You’ve got to encounter against each of those. So, we do still have some of those barriers.
Yeah, Thanks. And I will note we have about five minutes left. I think we need clearly we need like a two, a one and a 3 oh 1 on this on this really important topic to just because it’s there’s layers and layers.
one of the things I do want to mention are asked about you know, in terms of you know, and I’ll direct this to Sarah Barth and then to Danny in terms of policy supports. You know you mentioned kind of broader supports for long-term services and supports. There’s a, there’s obviously big proposal out of the Administration on home, and community based service says, what impact?
If any would know that the, the idea of increased availability of HCBS have, you know, for the duals population? What is the crossover?
So, I just want to sort of unpack your question. You said, what are the incentives needed?
And then sort of the importance of HCBS see that population?
OK, so the incentive, I mean, I’m going to jump to something. We’ve really heard.
They need support and they call it up.
They really need federal support, four for the financial kept kind of financial alignment initiative from the state received, you know, grant money.
They also need support to, I don’t know if I’m answering your question, but really to hire expert back.
I mean, they have limited budget to hire staff, you know, just for the Medicaid program, but people who are expert in Medicare and Medicare and Medicaid integration and really support on information technology, Data sharing and the importance of HCBS for this population as they all need. A majority need assistance with activities of daily living. I don’t know if I really navigated those two parts to the question well.
Well, let me yeah. Let me ask you, in terms of, like, I mean, we’re sort of, talking about this. And we’ve been talking a lot about the financing as though, like, the resources are out there in the community. Right.
And so, talk about what? What is that capacity?
You know, and, Sarah, I don’t know if you want to start, and then we’ll go back. Yeah. well. And that gets to really the adequacy of the Direct Care Workforce really making it.
Some states have partnering where maybe community colleges and universities really making it a career. And it’s something that is recognized as important. They, they direct care workers provide really essential services to people. They have close relationships with them, They can identify when there’s a change in circumstance, and that could be very important to the helpline, or anyone, you know, to, to put an intervention in there. Or support to avoid a trip to the emergency Department.
And I just think that there need to be more incentive for people to want to enter this profession, including, sorry, if I’m like, I’m gonna cry here, but wage, or they pay the living wage for what they do, or, are they recognized as important, and incorporated into the integrated care team having a voice. They know the individual.
And I don’t want to take all the airtime here, but there are ways they can partner with universities and other entities to really try to raise the profile of the importance of this profession. And Danny, I’m gonna let you jump in. My, I’ll just say two things really quickly because I know we’re coming up on time.
The first is that, you know, obviously, we support the proposal. We think even that the amount of money that’s been proposed, the various amounts, none of it is actually adequate.
It’s all just sort of it’s all really, it’ll be really helpful, but it’s not going actually it’s, like Meet all the HCBS needs of dual eligible dual eligible individuals.
The second thing I’d add is this is a race equity issue, not just because of the people who we’re talking about.
But because if you think about how, how we compensate based on who is doing the work and our notions about what’s that intrinsic value of the work that’s being done, caregiving, and that kind of related type of work, is both suppers from sexism and racism based on who’s doing that type of work.
On the flip side, on the consumer side, we also know that communities of color, dual eligibles and of color are going into nursing facilities at higher rates than white adults.
And that partly that is because HCBS is not being made available in the same ways.
And so, if we’re putting in money towards HCBS system, there’s both race equity implications for people who are getting those services as well as people who are receiving the services.
Thank you. That’s, that’s such a great point, that, you know, it’s, it’s as always right, like, none of these policies are monolithic And we have to think about equity considerations throughout each. And every step, Danny, I want to take moderator’s prerogative and ask and give you the final word. But really, I want to give your grandmother the final word right?
Like as 1 of 12 million, of these, you know, individuals, what, what do you think she would say, you know, what do you think she would ask for of her of her policymakers?
So, I don’t want to speak for her, but I can just see her this weekend. I will try and channel, sort of, her spirit to the best of my ability.
And, you know, she’s both so thankful for what she has as an immigrant, 88 year old immigrant woman.
But also, I think her key message to policymakers would be, make a system that works for me.
Let me get the care that I know I need. I know what my cares. I know what my needs are.
Don’t put the burden on me to figure it all out.
But create a system that actually is responsive to who I am.
Thank you so much. And so with that aspiration in mind, I want to thank you Danny for joining us and Sarah Barth and Allison Riser. It’s been a pleasure to speak with you today and certainly hope to have you back sometime to delve into some of the deeper issues that we raised today. Thank you, Arielle mirror and Arnold Centers in the Complex Care Team for making this event possible. And please, again, check out all health policy dot org and the handbook for more information. And feel free to reach out to us anytime with suggestions for future programming. With that, we’ll end today’s webinar, but certainly not the work.
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