Navigating Complex Systems: Care and Policies for Dual-Eligible Beneficiaries
December 12, 2023
1:00 pm-
2:30 pm
Virtual Event
Event Description
This webinar provided an overview of dually eligible populations and discussed key programs and coverage arrangements that coordinate care for beneficiaries. Panelists also identified policy considerations for managing the cost and quality of care for dual eligibles.
Learning Goals
- Comprehend what it is like to navigate as a dually eligible individual, including what works and what doesn’t from a first-person perspective.
- Describe the heterogeneity of dually eligible populations and how people become dually eligible: including definitions, demographics, and paths to eligibility.
- Understand how dual-eligible programs are financed, administered, and delivered.
- Understand commonly-held policy goals and a brief introduction to policy efforts on dual eligibility.
This webinar was sponsored by The SCAN Foundation, the Association for Community Affiliated Plans, Santa Clara Family Health Plan, and Health Plan of San Mateo.
Speakers
Allison Hamblin, MSPH
President and CEO, Center for Health Care Strategies
Allison Hamblin, MSPH, is president and CEO at the Center for Health Care Strategies (CHCS), a nationally recognized nonprofit policy resource center devoted to improving outcomes for people enrolled in Medicaid. In this role, she is responsible for the overall strategy and management of the organization, which is supported by the nation’s leading health care philanthropies, corporate community benefit programs, states, and the federal government. She oversees CHCS’ national portfolio, including Medicaid leadership and capacity building activities; delivery system and payment reform efforts to promote accountable care and improve population health; and projects focused on advancing effective care models for people with complex medical, behavioral health and social needs.
Prior to her appointment as CEO in 2019, Allison served as senior vice president responsible for program development and organizational oversight. Over 15 years at CHCS, Allison has worked directly with state Medicaid, federal, health plan, and provider stakeholders across the nation to develop and test new solutions for enhancing care delivery for populations with complex health and social needs. In particular, she has substantial expertise in the areas of physical and behavioral health integration; alternative payment and delivery models for people with complex needs; innovative financing strategies to support social service investments; and return on investment.
Before joining CHCS in 2006, Allison worked at Apax Partners, Inc. and Goldman, Sachs & Co., where she provided venture capital and investment banking services to companies in the health care and technology industries. She holds a master’s degree in public health from the University of North Carolina at Chapel Hill and a bachelor’s degree in biology from Duke University.
Tim Engelhardt, MHS
Director, Federal Coordinated Health Care Office
Tim Engelhardt directs the CMS Medicare-Medicaid Coordination Office. The office was created in the Affordable Care Act to improve services for individuals dually eligible for Medicaid and Medicare. Prior to joining CMS in 2010, Tim was a consultant with The Lewin Group, and he previously served as the Deputy Director for Long Term Care Financing at the Maryland Department of Health and Mental Hygiene. Tim received a BA in Sociology from the University of Notre Dame and an MHS from the Johns Hopkins School of Public Health.
Thomas Betlach, MPA
Partner, Speire Healthcare Strategies
Tom Betlach served as the Arizona Medicaid Director for almost 10 years where he reported directly to the Governor. In 2019, Tom completed 27 years of state service in Arizona, working for five different Governors in three different cabinet positions. He is a nationally recognized thought leader on Medicaid and healthcare policy, known for his expertise in serving complex populations, delivery system transformation, value-based purchasing, managed care and cost containment. Tom joined Speire Healthcare Strategies in 2019 as a partner to advise government and private sector clients on health policy and strategic initiatives.
Tom served as both Vice President and President of the National Association of Medicaid Directors and on the NRI and NASMHPD Boards. Tom currently serves as a Board member for NCQA, Circle the City, Mutual Insurance Company of Arizona and Oakwood Creative Care.
Dennis Heaphy, D.Min., M.Div., M.Ed., MPH
Policy Analyst/Researcher, Disability Policy Consortium
Dennis, a person with a disability is a qualitative researcher and policy analyst at the Massachusetts Disability Policy Consortium (DPC). DPC is a Massachusetts-based disability rights advocacy organization committed to the civil and social rights of persons with disabilities. Dennis, a member of One Care, was actively engaged in the managed care program’s development and works closely with MassHealth and other advocates on the new Disability Special Needs Plans development. (D-SNP) transition. Much of his work focuses on pressing for increased accountability of health insurance companies to advancing health equity through the operationalization of independent living philosophy and recovery model in care plan development and coordination.
His previous work experience includes the Americans with Disabilities Act Project Coordinator for the Massachusetts Department of Public Health. Dennis serves on several state-level health policy committees and community nonprofit boards. Dennis is a Commissioner on the Medicaid and CHIP Payment and Access Commission (MACPAC). He holds a DMin, MDiv, MEd, and MPH.
Presentation: Speaker Slides
Event Resources
Key Resources
Additional Resources
Transcript
0:01
Health policy, the root of the nation’s health care issues, and the tradeoffs posed by various proposals for change.
0:08
We are so thrilled today to be presenting our webinar, Navigating Complex Systems: Care and Policies are Dual Eligible Beneficiaries.
0:17
The Alliance has served as a trusted educational resource for the health policy community for more than 30 years, and today’s discussion will focus on policies that impact the nearly twelve point five million, duly eligible people who are enrolled in Medicaid and Medicare.
0:31
This work is critically important because this is a diverse population. That includes seniors are people with disabilities who face significant challenges accessing high quality health care and navigating the intricacies of the Medicaid and Medicare systems.
0:44
We are excited to showcase different viewpoints and considerations today that will hopefully help you in your work and help to inform solutions for improving our health care system.
0:54
Before we get started, I want to thank our generous sponsors.
0:57
Today’s webinar is supported by the Scan Foundation, the Association of Community Affiliated Health Plans, Santa Clara Family Health Plan, and the Health Plan of San Mateo.
1:08
Thank you so much for your support of this program and for joining us today.
1:12
I also want to share a few quick logistical notes.
1:15
You can follow the Alliance for Health Policy on LinkedIn to stay informed about upcoming events like this one, and you can also find us on Facebook or YouTube.
1:23
Today has a Q and A section at the end, and we encourage all of you to be active participants. So, please share your questions at any time.
1:31
You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.
1:37
You can use that speech bubble icon to submit questions that you have for the panelists at any time, and we will collect and address these during the Q&A.
1:45
Throughout the webinar, you can also chat about any technical issues you may be experiencing, and our team can assist you.
1:51
After the discussion today, I encourage you to visit additional resources we have available on the event page on our website, and, of course, if we don’t get to your question during that Q&A, please don’t hesitate to reach out to us at info at all health policy dot org, and we’ll do our best to connect you with additional information.
2:08
With that, I am so pleased to introduce our moderator for today’s webinar Alison Hamelin, Allison hamlin’s President and CEO at The Center for Health Care Strategies, a nationally recognized non-profit policy resource center devoted to improving outcomes for people enrolled in Medicaid.
2:24
She is responsible for the overall strategy and management of the organization and oversees the national portfolio, including Medicaid leadership and capacity building activities, delivery system, and payment reform efforts to promote accountable care and improve population health, and projects focused on advancing effective care models for people with complex, medical, behavioral, and social needs.
2:45
You can read more about her illustrious background and the bios of our other panelists on the Alliance website today. And now I’ll turn it over to Allison to introduce our speakers and get us started.
2:57
Thank you so much. It’s a delight to be with you today to discuss this important topic.
3:02
In a few moments, I’m going to provide a high level overview of duly eligible individuals, including how they become duly eligible, their characteristics, some of the challenges that they face, And introduce a conversation between an amazing group of panelists that we have with us today.
3:21
And right now, it’s my pleasure to introduce them. I’ll say that I, and my colleagues, at the Center for Health Care Strategies, have the great fortune to collaborate with each of these individuals, on efforts to improve integration of care for dually eligible individuals.
3:35
And so, first, it’s my pleasure to introduce Dennis Heaping, a person with a disability, who is a Qualitative Researcher and Policy Analyst at the Massachusetts Disability Policy Consortium, a massachusetts based Disability Rights advocacy organization, that is committed to the Civil and Social Rights of Persons with Disabilities.
3:53
Much, dennis’s work focuses on pressing for increased accountability among health insurance companies for advancing health equity, grounded in independent living philosophy and the recovery model of care.
4:06
Next is Tim Engelhard Timm directs the CMS Medicare and Medicaid co-ordination Office.
4:12
This office was created through the Affordable Care Act to improve services for individuals duly eligible for Medicaid and Medicare.
4:19
Prior to joining CMS in 2010, Tim was a consultant with the … Group, and he previously served as the Deputy Director for long term care financing at the Maryland Department of Health and Mental Hygiene.
4:30
And finally, we’ll hear from Tom that lack.
4:32
Time served as the Arizona Medicaid Director for almost 10 years, where he reported directly to the Governor, is a nationally recognized thought leader on Medicaid and health care policy, known for his expertise in serving complex populations, delivery system transformation, value based purchasing, managed care, and cost containment.
4:50
Tom join Inspire healthcare Strategies in 20 19, as a partner, to advise government and private sector clients on health policy and strategic initiatives. Welcome Denis 10 and time and look forward to having you join me on Screen in just a bit. But for now we can go to the next slide.
5:10
Great And one more.
5:14
Excellent. Thank you. Alright. Let’s talk a little bit about the dually eligible population.
5:20
To get us started and focusing on that green, overlapping segment between the Medicare and Medicaid circles before you, note that there are currently over 12 million people in the US were eligible for both programs.
5:31
Because of their significant needs, their high cost of care, and the complexity they encounter navigating these programs, policymakers at both the federal and state levels are actively seeking ways to improve how their care is delivered.
5:44
Next slide.
5:48
So, how does one become dually eligible?
5:50
To do so, an individual must qualify for both Medicare and Medicaid.
5:55
There are three ways to qualify for Medicare.
5:58
An individual can be age 65 or older, or they can be under age 65 with a permanent disability, including an intellectual or developmental disability, a physical disability, or a disability based on behavioral health conditions.
6:12
Or they can be at any of any age if they are diagnosed with end stage renal disease or certain other conditions.
6:20
In terms of Medicaid eligibility, the requirements vary by state and are related to an individual’s income level and assets. And whether they fall into certain eligible groups, such as older adults, people with disabilities, and people who are pregnant.
6:34
People with slightly higher incomes also can qualify for Medicaid, if they have a significant disability, or if they have high medical or long-term care expenses relative to their income.
6:44
Among the dually eligible population, about half the Medicare eligible due to their age and about half due to their disability. Similarly, on the Medicaid side, about half a full benefit dual eligible individuals also qualify.
6:59
Her disability pathway is so it just referred to full benefit dual eligibles. So let me explain that a bit further.
7:07
Dual eligibility can be partial.
7:09
First of all, partial benefit dual eligible individuals have full Medicare benefits that do not meet the categorical, an income, and asset limits, to qualify for full Medicaid benefits.
7:20
However, if their income and assets are low enough, they can qualify for partial Medicaid benefits where Medicaid helps with some or all of the out of pocket Medicare costs that they would otherwise be responsible, it’s OK.
7:33
Bottom line, the key takeaway here is that these different pathways to dual eligibility, whether my age, disability, or by a particular condition, result in different subpopulations that have varying, but typically complex care needs, particularly those who are eligible for full Medicaid benefits.
7:51
Next slide.
7:58
As I just noted, duly eligible individuals are a diverse population and Allison mentioned this in her opening remarks as well.
8:05
And importantly, they are generally quite different from people who are covered by Medicare only.
8:11
People that qualify for Medicare and Medicaid are more likely to be female from a racial or ethnic minority group and to live alone.
8:19
They’re also likely to have fewer years of formal education.
8:22
Overall, duly eligible individuals have more limitations and functional status and more often report themselves as being in poor health, insignificant number seven mental health condition, or use long term services and supports.
8:35
In terms of their diversity, I’ll note that the clinical and services profile of dually eligible individuals under and over age 65 are quite different.
8:44
Specifically, those under age 65 are more likely to have a disability.
8:49
They’re also much more likely to have behavioral health conditions such as anxiety disorders, bipolar disorder, depression, schizophrenia, and other psychotic disorders.
8:58
Meanwhile, Juliet’s will individuals age 65 and older have higher rates of physical health conditions such as diabetes, heart failure, hypertension, and heart disease.
9:08
And they’re much more likely to have Alzheimer’s or a related dementia.
9:12
They are also more likely to use long term services and supports.
9:16
Next slide, please.
9:20
These high clinical and support needs mean that this complex population, accounts for a disproportionate amount of spending in both the Medicare and Medicaid programs.
9:30
In Medicare, duly eligible individuals comprise 19% of enrollees that 34% of program costs, similarly in Medicaid or just 14% of enrollees, but account for 30% of costs.
9:43
Next slide.
9:48
So, for somebody who is eligible for both programs, which program pays for what?
9:52
Medicare covers hospitalizations and emergency Department visits, short-term skilled nursing facility stays, position and ancillary services, prescription drugs, and limited home health care services.
10:04
Medicaid, on the other hand, pays for Medicare cost sharing, long stay, nursing facility care, home and community based services, and most behavioral health services.
10:14
Next slide.
10:18
Despite some complementarity in terms of these benefits, there are many misalignments between Medicare and Medicaid that cause difficulties for both dually eligible individuals and their providers, Coverage and payment policies for this population are really complicated, which affects how beneficiaries receive their care.
10:36
The previous slide showed, which program pays for what services, and you may have noted that several services overlap, including nursing facility stays, home health services, durable medical equipment, often referred to as DME.
10:48
Let me give you an example of how this plays out in the case of DME because Medicare is generally the primary payer for dually eligible, individuals, DME provider must first fill Medicare Medicare determines if it will pay for the equipment or not.
11:03
If Medicare denies the claim, the provider must then submit the bill to Medicaid.
11:09
This can lead to confusion and delays in the receipt of necessary supports for enrollees.
11:14
Medicare and Medicaid also have very different administrative processes that impact beneficiaries, providers, and payers.
11:21
There are separate beneficiary communication materials and notices, separate identification cards, separate processes for enrollment, assessments, and care planning.
11:31
There are also separate appeals and grievances pathways that people with Medicare and Medicaid must navigate when coverage requests are denied.
11:39
Finally, I’ll note that differences between the two programs and financing and payment rates create incentives for cost shifting, and a bias for providing care in institutional settings.
11:49
Next slide.
11:55
This lack of integration between Medicare and Medicaid results in gap’s, duplication, and fragmentation of care.
12:02
Our panelists are going to talk more about these challenges, and importantly, efforts that federal and state partners are making to address them.
12:08
Well, let me just say that our current separate uncoordinated systems make it incredibly difficult for dually eligible individuals to access needed Care, and for providers, to deliver and co-ordinate what’s needed.
12:20
The result is often disparities in access to care.
12:23
Dually eligible individuals are less likely to have a regular source of primary care, or access to specialists.
12:29
They’re also less likely to receive home and community based services, or hospice care.
12:34
Ultimately, this leads to disparities and outcomes.
12:37
Julie eligible individuals are more likely than people with Medicare only to be hospitalized or re-admitted to the hospital within 30 days of discharge.
12:45
They’re also more likely to be discharged from the hospital to lower quality nursing facilities, and to become long stay residents of those facilities.
12:54
With that background, I’m now going to give each of our panelists a chance to provide some opening remarks on the challenges as they see them, as well as what’s happening to address these challenges. And, Dennis, I would love to welcome you first, to share your perspective. So please join me on screen.
13:20
Thank you very much, And I’m doing this differently than I usually do it, so I don’t really get invited back. That’s fine. I understand why. Let me first say the reason why I’m dressed up. Like, I’m in winter.
13:35
It’s because my PCA leaves in the morning I’d suggest for the day and, And so that means I may have my gloves my jacket on, and so I can take my dog my service dog and training out after this after this webinar.
13:51
You can see behind me.
13:52
I hate these webinars where you can put your background, and so I’ve gotten, they’ve been in the background, which is, which is a medical that, and a few other medical devices in the background. So I am one of the medically complex folks who’s also dual eligible.
14:07
Go to the next slide.
14:10
Oh, yes, thanks.
14:12
So, I guess I’m doing this, definitely, ’cause I’m usually caught in the weeds and getting very wonky.
14:17
So, this a little bit higher level.
14:24
Solutions don’t work unless people with disabilities are not only at the table with a with a philosophy of, of, uh, everyone, with a display and having a seat at the table. We really want to, If it’s about should we want it to be bias.
14:39
We want to help design that. Hey! We want to be able to design the solutions not to be brought in after the fact.
14:45
Wanted to just be one stakeholder out of many. We want to really be part of and then designing that solution, whether it’s folks with disabilities of folks who are older, like the whole dual eligible population.
14:57
Next slide.
15:02
OK, there is no such thing as a single issue struggle because we do not live in a single. We do not live single issue lives.
15:10
That’s Audre Lorde, who is a, who is a black lesbian civil rights leader, mom, and poet, And she also had disabilities and the dual eligible population the state is very complex. And there is no one size fits all solution.
15:31
And so when insurance companies attempt to fit dual eligibles L two eligibles into a traditional commercial model of care system, it just does not work.
15:46
People with disabilities are not going to get their needs met. Elders are not going to get their needs met and the costs are just going to increase.
15:53
Next slide.
15:55
I would also say, with that, with that, no single issues is that it’s also about health equity.
16:01
And then, in order to achieve health equity, we really have to make sure we’re not looking at things in a silo, and the people with disabilities may be African American in that, and that, that identity as a person, who’s African American compounds, the impact of disability and ableism.
16:20
This one rights guaranteed under the Americans with Disability Act are only as meaningful as an individual opportunity to access those rates. For better or for worse.
16:29
People like myself, other folks with disabilities, with complex care needs.
16:34
The only way we can really engage in the community is, if we have our basic needs met, bye, Bye, our health plans by health care providers. And that’s especially true.
16:45
But when we need long term services and supports and home and community based services.
16:51
And so, if I don’t have the the community based services, I need the LTSS services. I need the ADA means nothing because I can’t get out of my house.
17:02
I can’t engage in the community.
17:04
So in order for us to, actually live, full lives, has the opportunity to live lives that have had meaning.
17:11
We need plants to provide us with these basic services, So we can, actually, we can, actually understand and, and, and receive services that are rights under the ADA.
17:22
Next.
17:26
OK, what I personally, actually needs is not attention enlists the state, but rather than striving and struggling for some goal worthy of her.
17:35
And and I love big fan of Viktor Frankl.
17:39
It’s challenging for people too.
17:42
Finding meaning and lives of meaning.
17:45
If they’re struggling with day-to-day, the lowest level needs on Maslow’s hierarchy of needs.
17:52
And if someone doesn’t have a wheelchair.
17:53
So that if someone does not have basic access to care providers, they need, then they’re not till they’re not dealing with goals or struggles worthy of them.
18:03
They’re just struggling with day-to-day, getting, getting by, wondering what’s going to happen from moment to moment.
18:09
And health plans have the ability and the opportunity to actually reduce some of those tensions, and support the ability of people to move beyond depression movie on isolation to actually engage in activities that support a state of tension that’s actually meaningful.
18:29
Next slide.
18:33
I don’t trust words. I trust actions.
18:36
There’s a tremendous amount of distrust among folks among dual eligibles, whether it’s younger or older people because the health care system often says what it’s going to do with it actually doesn’t carry out what it says it’s going to do.
18:52
I was on a close in a meeting this morning, very painful meeting, and people were talking about lack of communication access, bye, bye the health plans and how those health plans are meeting their communication needs.
19:04
one woman talked about how, uh, the health plan required her to use a specific portal.
19:11
And she’s blind, and the oral could not meet her needs.
19:15
And she was told, she had to use that portal, and the woman described it as being tortuous, not being able to access the communication. The way that she needed it. And so, there is distrust.
19:28
They, we don’t, we try. We thought we thought we’d distrust plans.
19:31
Because plans say they’re going to provide services but then those services get reduced, especially community based services.
19:38
We see the promise of increased access to a personal care attendant services and get over time those personal care aides and services.
19:47
Get whittled down or access to DME Then, over time the DME service, the existence of DME that’s needed is is reduced.
19:55
And so we don’t we we need we need to build trust in the system. And it can’t just be we’re just gotta reactions.
20:02
Next slide.
20:06
OK. We’re people, not patients.
20:09
I love the term patient because much of what people, much … needs are not medical needs.
20:17
They really are our needs to lead differently beyond just medical.
20:22
This is socioeconomic education, housing, social support networks, health literacy, behavioral health, culture, and social identity needs, individual goals and aspirations. And these are all from from CMS.
20:37
And these are all identified as drivers of health and these drivers of health really needs to be addressed by health plan in order to support the needs of folks of dual eligibles. Next slide.
20:51
It’s less than, OK, Meaning of person centered care.
20:56
Value comes from consumer leadership and governance, and oversight of all levels. That’s at CMS State and Plan levels.
21:03
The civil or civil rights model of care, that’s Integrating Independent Living and Recovery Model of Care. I can say more about that later.
21:10
Conflict, free, trust based care, plan development and implementation.
21:15
Um, then, also, we balancing services, billing systems that focus on addressing non medical service drivers of health and individual, non medical life goals, and needs.
21:26
I’d also add to this transparency, so we need a transparent system that said, that includes oversight by states that have the capacity and competency to provide an oversight.
21:38
So, thank you.
21:49
Thank you.
21:50
But, you know, you’ve finished at it.
21:55
So, we need, We need, stylish, measurable goals, matter, evidenced based measures of consumer engagement, impact on the state and federal policies.
22:06
We can set benchmarks, and this is more about, the service, themselves, reduction of disparities between disability populations, the general population reduction in disparage between byproduct, build populations with disabilities in white person, with disabilities.
22:24
When I say people with disabilities, and I don’t just mean folks, under 64, I’m going across the lifespan.
22:29
Increased investment in holdings based services, increased investment in the medical services, than just social Joseph Vault and individual goals.
22:36
They realized that redundant, But I appreciate you give me all the time to present this and now I turn it over to Tim.
22:45
Dennis! Thank you. Let’s take.
22:48
Everything is just talked about it, and connect it to government policy. Right. Because oversimplification does paint the picture. Right of all the complexities of individualized and, and, and disparities and challenges, and everything else. But I can boil it down into like, to really broad policy goals related to dual eligibility. That happens to be pretty widely shared across the health policy community.
23:20
The first, on the next slide is improving access to the Medicare savings programs. Now, using the MSPs, I’ll call them despite their name.
23:31
The MSPs are really Medicaid eligibility groups through which state Medicaid agencies cover Medicare premiums. And in many cases, they cover Medicare Parts A and B cost sharing to What means For many people, they can go to the doctor for free rather than paying a 20% co-payment that most other people would pay with their Medicare coverage. MSP make Medicare affordable for about 10 million people who have low income near below, or near the poverty level. So the industry is really improved access to Medicare covered services.
24:08
They’re also essential for economic well-being when the MSP cover someone’s Part B premium.
24:17
That means hundred and $74 a month that are no longer being deducted from someone’s Social Security Check, that’s 174 more dollars a month someone can use or housing for transportation to put food in the fridge. So, before, MSPs cover any Medicare, cost sharing for, for actual receipt of services is incredibly important.
24:40
Almost anti poverty, programs to, so, incredibly important, despite that importance, the MSPs are undersubscribed, there’s an advisory body for Congress called Backpack.
24:53
In fact, Dennis is one of the commissioners on Backpack and in 20 17, Backpack Commission to study in which they concluded that only about half of the eligible people are actually enrolled in the MSP. So that means millions of people. People at or below the poverty level pain, what amounts to more than 10% of their income every month just for Part B premiums alone. She, she’s incredibly important that we get more people who are eligible for these programs into them. Now, one reason to that under subscription, because it’s a very complex application and verification process, and the MSP eligibility process is really run by the state, which means there’s some variation across the country, and it also means that they don’t always align really deeply with other forms of means tested subsidy programs.
25:43
We’ve got a long way to go on this, but there’s actually been some meaningful progress through some recent legislation. And administrative actions to a big legislative milestone was something called the Medicare Improvements for Patients and Providers Act.
25:57
of the middle passed in 2008 and included several new requirements, potentially to improve access to the Medicare savings programs, including by creating some better connections to the similar Part D subsidy program that we often call low-income subsidy or extra help.
26:15
Now, despite the intent of …, as I noted, millions of people who are likely eligible for MSPs, but not enrolled, including, over a million people who are on that Part D subsidy program, but not on the analogous Parts A and B subsidy the MSP.
26:31
Fast forward to this fall, September of 2023, when we CMS, published a rule that codify some of the provisions and builds upon it. I won’t get into the details here, but it’s a set of rules that will dramatically simplify.
26:48
The application of verification process or the MSP is in fact, we estimated that, will save older adults and people with disabilities, about 19 million hours of paperwork every year. And it’ll reduce administrative burden for our State Medicaid partners by about two million hours a year. So a huge reduction in red tape estimator will get about 960,000 older adults and people with disabilities to benefit from enrollment in the MSPs progress.
27:17
There’s a lot more work to be done on this front.
27:21
The next broadly shared policy goal, so called advancing integrated care, and integrated care, means different things in different contexts.
27:32
Alison touched on a little bit, I’ll say integrated care, to me, means achieving some level of seamlessness across Medicare and Medicaid, and also mitigating or eliminating some cost shifting incentives across the two programs. But really, it’s about creating systems that are more about the person, than about the two programs, in which they’re enrolled.
27:56
Now, the most natural way that we actually integrated care for this population is by having dually eligible individuals receive all of their Medicare and Medicaid services.
28:07
From one organization, we usually finance that approach through various capitated rate setting, methodologies, you think of examples, like paste the programs of all inclusive care for the elderly, plus a range of other broader Managed care options.
28:25
More meaningful, integrated care has been something that backpack and its sister agency medpac have written to over the years.
28:37
A broadly shared, long term aim of having all, or at least many more dually eligible individuals being enrolled in some form of integrated care. Now, in fact, enrollments in integrated care options has increased substantially over time.
28:51
Back in 20 11, they’re only about 200,000 people in any form of what we would call an integrated care. Now, we’re pushing two million people.
28:59
That means over 20% of those full benefit, dual eligible individuals in some form of integrated care, less, Medicare and Medicaid remain separate programs with separate eligibility criteria, separate, covered benefits, separate payment methodologies.
29:15
And most duly eligible individuals are the remaining what we call misaligned enrollment, which means they’re getting their Medicare through one entity under Medicaid through it completely separate one. And almost no one thinks that’s a smart way for us to organize our health care system.
29:34
10 years ago, our work focused on creating new forms of integrated care. A big part of that was something called a Financial Alignment Initiative, through which we and partnering states created new demonstrations, we create a new types of health plans called Medicare Medicaid plans or an NP and in those arrangements, we had a three-way contract between the government payers and the organization. That organization is fully capitated and provided a fully integrated benefit package to individuals with gold.
30:05
But those plans meant accountability was clear, they were care co-ordination requirements, and we gave those plans, really, an unprecedented level of benefit flexibility. We also integrated a lot of administrative functions, some of which Allison referenced earlier, like Appeals and grievances processes are materials that included all of Medicare and Medicaid information together, not in separate forms of documentation.
30:30
Now, over the past decade, we’ve learned a ton from those demonstrations and the partnerships with States and others that we’ve built during the process, and in fact, our experience of those demos is very significantly in the form, some more recent rulemaking and policy development.
30:46
In the meantime, Congress passed legislation related to: organization got dual eligible, special needs plans are decent. Either Medicare Advantage plans that exclusively enroll people who are on both Medicare and Medicaid. … existed for a while, but they’ve always been temporarily authorized. in the Bipartisan Budget Act of 2018. Congress gave those decent permanent authorization.
31:09
The law also required us to establish new minimum standards for how those … co-ordinate with Medicaid.
31:16
It also directed us to unify the appeals and grievance process uses across Medicare and Medicaid, much like we had done in those financial line and demonstrations.
31:28
And the biba also expanded the types of supplemental benefits that MA plans, including …, can provide, Really allowing plans to offer types of, like, non traditional services that previously could only be offered, either through Medicaid or through of our demonstrations.
31:45
More recently, decade after the FBI demonstrations, that half a decade after, The Bipartisan Budget Act of 2018, We’re in a different world. We’re in a world in which an enrollment in these snips and other forms of Medicare Advantage has exploded.
32:02
It’s a world in which choices are numerous, maybe even in some places, overwhelming. And so we continue to work with states to bring integrated care options where there are none today.
32:15
We’re also increasingly focused on simplifying a market that has in some cases become unbelievably complex.
32:24
We’ve done some of that through recent rulemaking.
32:26
As part of that, we are graduating those financial alignment initiative demonstration plans and empties into being forms of SNPs to lots of special needs plans. That will simplify the market in some places.
32:40
Meaningfully will also tightening up this alphabet soup of different types of managed care plans and other organizations to help make options a little bit clearer across the market. And now in some rulemaking, It’s out for public comment.
32:55
Right now, we’re proposing to limit the number of …
33:00
in certain circumstances, to re-orient Medicare special election periods, to focus more on promoting integrated care options, thinking a lot more about the choice infrastructure, to try to ensure that people can make informed decisions, and not be overwhelmed by the number of options that dually eligible individuals have.
33:22
So, there’s been a lot of progress on these two big goals. We have more people in meaningfully integrated care. We have new ways to simplify enrollment in a way that makes care affordable, and helps people be more financially independent.
33:37
But, we have an incredibly long way to go in this stuff.
33:41
Hard work. It’s exciting and important work, but it’s hard work.
33:45
On the data with the Federal Government, a lot of that is with our partners in, in the state, and so we have to acknowledge that those states have their hands full, already running incredibly important Medicaid programs. An important part of our work is on the federal side is try to provide some technical assistance and capacity for those states.
34:07
We do a lot of that through something we call the Integrated Care Resource Center, but again, here we have so much more to do as well, and Tom will take that in a second. So, much more to do. And we know it’s urgent, because we’re also doing a better job of listening to the people that we serve.
34:25
Perfect job!
34:26
But a better job, and doing that help to eliminate the fact that we’ve got a lot more to do, still, to build a health care, and long-term care system, that’s truly person centered, and that genuinely ensures access to the services to which people are entitled, found out like Ticket from You.
34:53
Thanks so much, Alison Denis, 10, very difficult acts to follow in terms of just incredible presentations that you’ve provided, The overview, the depth, the stories, and thinking about, not only the challenges of the dual eligible population but also in terms of really some of the advancements and progress that has occurred over the last many years.
35:18
And so I apologize, I don’t have a presentation with fancy slides or wonderful quotes to go over.
35:25
But I wanted to spend just a few minutes offering up, sort of the state’s perspective as it relates to how to be thinking about advancing strategies to better serve the dual eligible population.
35:40
I think Kevin touched on it in terms of the different ways that states need to be thinking about the changes that have occurred in this space.
35:50
This is such an exciting, important policy topic area, and there are so many more tools available today to states, when you think about comparing that to maybe 10 or 15 years ago, and how states need to be thinking about leveraging those tools.
36:07
So, Tim talked about the dual eligible Special Needs plans, and now, states, with their contract with those plans, through the state Medicaid agency contract, have so much more ability to really think about the policies they want to achieve, the goals they want to achieve.
36:25
And working with the stakeholders as Dennis identified it in terms of being able to advance change in the system.
36:32
There’s more resources available today than ever before.
36:36
Tim mentioned to the ICRC in terms of resources that states can reach out to and really have and adapt complex conversations, not only to better understand the different tools that are available as it relates to dual eligible strategies.
36:52
But also to be thinking about, you know, ways to advance their goals and what they want to achieve, and how to think about that incrementally, then finally, as much more models that are available for states to really look towards and learn from. We know that states come out this, each state comes at it from a different place with a different system design.
37:13
But it’s important to be able to learn from the lessons that have occurred over the last 15 years of states.
37:20
Have worked with stakeholders and they have pursued different models, in terms of being able to advance, care for the dual eligible population and reduce that fragmentation.
37:30
But Allison started this conversation.
37:34
I love data.
37:35
I love to be able to look at data to help level conversations, Allison highlighted some information that’s out there from the Map pack dataset.
37:44
And I would strongly encourage you, if you’re interested in this policy area, and you haven’t perused those documents, to go ahead and take a few minutes to do that.
37:52
There’s so much information that’s available. A couple of data elements that I would share beyond what Allison slides is, when you look at what the delivery system looks like as it relates to how the dual eligible populations being served today.
38:08
So the first is from the Medicare lands.
38:11
When we look at the dual eligible population, 55% of the population are non traditional, fee for service Program, 37%, and Managed Care. And of those and Managed Care to mention this, the growth of the dual special needs plans.
38:25
Path, R N D, Snell.
38:28
When you look at it through the Medicaid lines, you’ve got 42% of the population and fee for service, 20% that sit in some combination, a fee for service and managed care.
38:38
So that might be waiver services being delivered through a fee for service structure, and some of the acute or behavioral health services, or wraparound services being delivered through our Managed Care organization.
38:52
And then finally, 37% of the population comprehensive Managed Care on the Medicaid side.
38:57
So, in thinking about the dual population and looking at the data, you have to not only look at, in terms of the separate lands on Medicare and Medicaid, but then also be thinking about, well, what does that mean for the dual eligible population and where they may be sitting, either aligned or aren’t aligned, as it relates to the overall delivery system.
39:16
So, there’s some great data out there that didn’t exist before, in terms of having to be able to level, set, better understand the dual eligible population.
39:26
Alison did a very nice job of providing an overview in terms of the role of Medicare and Medicaid and who covers what services.
39:34
And, and of course Dennis talked about the importance of stakeholder engagement as it relates to some of the different subpopulations that are being served within the dual eligible population.
39:45
I’m Kevin, talked about the tools at the federal level and our goals that, that people are driving towards. I’m going to now focus on sort of, the state perspective.
39:56
and so when you think about states and you think about some of the subpopulation, Allison touched on fragmentation.
40:03
Fragmentation can be expanded even more within a state, because you might have aging services, and a separate division or agency agency, from Medicaid.
40:14
You might have services for individuals with developmental disabilities, also sitting outside the Medicaid agency.
40:20
And behavioral services also may sit outside the Medicaid agency.
40:24
And so, the fragmentation that occurs between Medicare and Medicaid is oftentimes further enhanced. Just in terms of how state structures exist and how those services have historically been delivered. So, we sit and look at this, and we know that system design matters.
40:42
But we also have, you know, often times, some of the most complex individuals and some of the most complex fragmented systems.
40:50
And so, I think back to, when I first started as the Medicaid Director of the State of Arizona for the individuals with Serious Mental Illness.
40:58
45% at the State of Arizona are dual eligible members, And they sat, oftentimes, in a fragmented system of a separate behavioral health managed care organization, a separate physical health managed care organization for Medicaid. And Medicare side, they might be a traditional Medicare Part D plan.
41:15
So four separate systems, just to deliver health care coverage, are very fragmented, very poorly co-ordinated.
41:22
And so, thinking about the system design and how to advance goals at the state level to improve the integration that Tim talked about is so important.
41:32
But then to do that through a thoughtful process in which, as Dennis identified, making sure that that is done with stakeholders.
41:40
And in a very collaborative fashion, in terms of being able to build strategies, to advance integration alignment, and better improve service delivery models.
41:53
So the first area I would emphasize, in terms of thinking about this through the state lines, is having dedicated staff that work on dual eligible issues.
42:04
Oftentimes, State Medicaid agencies are strapped in administratively.
42:08
They think about the different areas that they’re having to manage for just the Medicaid population.
42:14
And oftentimes, there’s not a focus in terms of how to think about dual eligible populations holistically and the types of resources that are needed to meaningfully engage in terms of all the different aspects of dual eligible policies.
42:31
So, states would want to consider, potentially, identifying a specific resource that can work on dual eligible issues.
42:38
They can work on the state Medicaid agency contracts that, I mentioned earlier, which really give the states a lot of opportunity and leverage to duck significant policy through those smart contracts.
42:52
So, for example, a state may be able to limit the number of D steps in a market to those organizations that have Medicaid contracts, If you have managed Care serving the Medicaid population.
43:05
There’s also other quality expectations. Health equity, reporting on supplemental benefits.
43:11
We see states really now starting to push and increase their use of the …, to be able to drive policy within the state, to look at ways to better integrate services.
43:24
Tim talked about the proposed regulations.
43:27
It helps to have a staff person within the Medicaid agency, within state government, to really be looking at those proposed regulations and thinking about how they impact the states, initiatives, and dual eligible population to be able to engage stakeholders.
43:43
Get meaningful impact back from those stakeholders. And really be able to incorporate that.
43:49
Do a thoughtful state response.
43:52
The resources that a state could also help drive the different strategies and goals the state wants to achieve around your population.
44:01
Obviously, through meaningful stakeholder engagement, and being able to think about that as it relates to the different populations being served.
44:10
I strongly encourage States to be thinking about a comprehensive data strategy.
44:16
Oftentimes, States don’t necessarily think about the disparate data streams that exist and how to connect them to get better insight.
44:26
They’re the dual eligible populations that they’re serving.
44:29
So States need to be thinking about, well, from the federal government, I received the MMA file. That tells me information on What does an individual become eligible for Medicare? If they’re currently enrolled in Medicare, who are the plans that are serving?
44:46
And being able to take that information in.
44:48
and really be able to analyze it in conjunction with the Medicaid side of the house, and, of course, on the Medicaid side of the house, you see information on what waiver services an individual may be enrolled in.
45:01
And so being able to have a crosscut time in terms of that section, and even be able to think about, how do I share that information with other organizations that would benefit from the dissemination of that information?
45:17
So for example, the D snippy plans would benefit from understanding what waiver services an individual may be receiving.
45:25
On the Medicaid side, a managed care organization on the Medicaid space may benefit from seeing some of the additional information that comes through and the MMA file.
45:35
So, being able to have a data strategy that thinks about all the information that’s coming in, how do you disseminate that information to improve care co-ordination?
45:45
And then also, in terms of how do you analyze that information to have a better understanding of your population.
45:53
Today, what percent of the population that you serve, that’s aging, is dual eligible?
46:00
What percent of the population on the IDD for individuals with developmental disability are dual eligible? What percent of population for individuals with serious mental illness are dual eligible?
46:11
All these different types of analysis, really providing more insight, I think, will be more meaningful in terms of being able to go out and have robust stakeholder engagement, thinking about strategies and goals, and objectives of where the state wants to drive towards in terms of improving and reducing fragmentation for dual algebraic numbers.
46:37
The third piece is, really that stakeholder engagement piece.
46:41
I can’t add a whole lot more beyond what Dennis already described, other than the fact that, you know, states need to be committed to this. They need to engage in this on a regular basis.
46:52
They need to have different strategies as it relates to some of that subpopulations but Dennis identified.
46:58
And it really needs to be done at the front end to help shape and inform.
47:03
Then, of course, throughout the process, So states are working to drive, change and improve their overall delivery system.
47:13
Finally, I would encourage states and individuals who aren’t states and looking to engage their Medicaid program on how to operationalize better systems of care for our dual eligible members.
47:25
To really come up with a thoughtful strategic plan that identifies really your goals and objectives of how you wanna advance care for the dual eligible population.
47:36
Tim did such a great job of talking about the true goals at the federal level in terms of improving overall enrollment and the MSP and really to create more integration to reduce the fragmentation for dually eligible members.
47:51
But States should also be able to identify what are your goals and objectives, and strategies that you’re identifying, in terms of being able to improve care for the dual eligible population.
48:04
We all know the challenges. I think the panelists before me did such a great job of being able to describe the challenges that dual eligible members face.
48:13
But the exciting part is, there are so many more tools, resources, and models that states can look to in terms of how to improve care.
48:24
And there’s also resources out there available to achieve all of those.
48:27
So, with that, Allison, I’m going to turn it back to you to be able to have more of a discussion and some partial answer.
48:36
So much, and thank you to Dennis and 10 for your presentations.
48:41
I feel like I laid out all the like doom and gloom of all the challenges.
48:45
And then you brought us some opportunity and optimism, thankfully, in terms of all that’s happened, all the progress that’s to me, the need, and, um, the tools that are available to do the significant and important work ahead.
49:00
So, thank you so much for, and getting us to this point in the conversation, where we can have more of a discussion. And I’m going to start fielding some questions. And thank you to folks in the audience who have been submitting questions.
49:14
We are tracking those, and the good news is, we have about 40 minutes for Q&A here, which, which is wonderful. So I’m gonna jump right in, and Dennis. I’m gonna turn to you first.
49:26
And Tim and Tom talked a lot about the advancements in Integrated Care Programs for Dually Eligible individuals. Particularly, post ACA through the financial alignment demonstrations, through through … platform, etcetera.
49:47
And you are a person who has been actively engaged in Massachusetts in the rollout and design and ongoing implementation of integrated care programs through Massachusetts. And I’d love for you to tell us a bit about your experience.
50:06
What difference has it made for you to be in an integrated program in terms of navigating the supports and services that that you need, both in terms of the positives and where gaps remain?
50:22
Sure. Thank you.
50:25
I am someone who firmly believes in integrated care.
50:31
Whether it’s through PPO, a A pace program, the snip or some other, an ACO, whatever.
50:42
Whatever it may be.
50:43
that they’re there, they’re, it’d be different models, um, because then, just, personally, I can say that my mom had really complex medical needs to an autoimmune disease that, resulting in kidney failure, but there was no one co-ordinating our care at all.
50:57
And so, as a result, my mom died from lack of having really care care co-ordination, which is the option of my story, which I care co-ordination from.
51:10
for the last 30 years.
51:12
I actually ended up in the hospital one day and, this predates all the, the innovations that are taking place, but, and started by doctor Bob Masthead, Community Medical Association. The CUNY Medical Association.
51:29
And I’ve had co-ordinated care for all these years, and so I don’t I wouldn’t know what to do with our co-ordinated care.
51:37
And when I say co-ordinated care, I mean, at least back, then, things have changed since then, where the locus of co-ordination took place in my home.
51:46
Whether it’s a nurse practitioner or a or a prime or a PA.
51:51
A physician assistant, who’s in my home, who knew me and knew my family or my personal care attendant or saw firsthand the service are required and really help co-ordinate access to the different services.
52:04
Whether it be medical LTSS or whatever, whatever the services might be, um, and as it’s changed over time.
52:14
Now I have a telephonic care co-ordinator, who is somewhat primary care team, are not part of my care team, and and the Telephonic person helps you with things like access to transportation, which is which is phenomenal.
52:27
Because when I have to go to a medical appointment, if that transportation does not show up, the care co-ordinator will assist in ensuring that that transportation actually gets their oral follow up, and make sure that it doesn’t happen again.
52:42
For other people, the care co-ordinator can, it can help facilitate access to.
52:48
I’m gonna stick with very simple things like access to medical supplies, ensuring that people have the medical supplies that they need, and do things just as things like, like like urinary tract infections or so simple issues, issues like that.
53:05
And so I think the other huge benefit from integrated care is the integration of behavioral health and medical services where they wish you got a good care team that’s integrated. You’ve got folks who are looking at the whole person.
53:19
Then a whole person’s needs are being met.
53:21
We’ve got the medical providers and the behavioral health providers working together, and I would add into that, in Massachusetts, at least. Well, there’s also integration of certified peer specialists and recovery coaches.
53:36
So you’ve got folks got tears and re engaged in in the teams with people working on the person working with the person to meet their meet their goal.
53:46
So so I think in that sense, my experience has been it’s ever changing program.
53:55
What can we do?
53:55
have concerns about the shift from the Medicare, Medicaid plan to the DCP with it with the with the difference with the?
54:04
Now we’ve got the three-way contract, we’re going to have separate tracks to clean Medicare and Medicaid, and what that will do, how that might impact seamless integration of services, and all sorts of things.
54:20
But I would say, in general, we’re very, very pleased, I think, I should say, that the model of care, Then, we have the inclusion of peers at different levels, Inclusion of long-term service and support co-ordinator.
54:37
Will do all these innovations that the Massachusetts Advocates worked with the state to include, And these are not just things, too, improve the quality of life for four, for members. But they really, they can reduce costs.
54:51
They can include they can lead to savings for four plans.
54:56
And I’d say, I think, did I answer your question?
55:01
We could listen to you for hours, but, yes, you absolutely. Feel free to say more, but you absolutely answered the question.
55:08
Um, I guess, uh, I’d say the challenges that we’re facing right now or are some of the challenges as good, Glad to Tom, I would appreciate social with Tom said.
55:21
And that is, we need, we need a third title. We’ve got Medicare titled Medicaid Title.
55:27
I really think we need a tools title one that’s going to ensure that there’s that the resources for states are there.
55:34
So you don’t have the inequities in access to services that we have today between folks in the Oklahoma versus Massachusetts or or Mississippi versus Minnesota.
55:44
Um, but then, there needs to be some some way of ensuring also, this is the baton’s it is the states don’t bear the burden, the financial burden rebalancing spending.
55:58
Because right now, when when stace invest in, uh, LTSS another Medicaid services. Keep folks out of hospitals, Medicare benefits.
56:09
And so, we need to make sure that the Medicaid States benefit from those savings, that there’s incentive for those savings.
56:17
I also think they need to build value based purchasing.
56:20
Uh, innovations put in place, so that we define what value is, that we’re ensuring that, that the plans and other agencies aren’t just using fee for service payment models.
56:31
But they’re actually using models of payment that lead to to better outcomes for members in terms of measurement.
56:39
Because, Tom mentioned that, mentioned that, is that, Are you looking measuring, like reduced hospitalization rates reduced, nursing home rates, that we also look at increased increased integration in the community, reduced isolation, and loneliness, we do is real or look at mentoring, there are an increased reliance on on anti-depressants or anti-anxiety medication, but if people are actually, you know, engaging the community and we want to see those measures as well.
57:12
And I’ll stop there for now for now. Thank you, thank you, Dennis. So, so much in there.
57:19
You’ve given me so many jumping off points to bring the other panelists into the discussion.
57:25
one of them, that Dennis just mentioned, is the question about state level incentives to invest in integrated care programs.
57:35
And, as, um, as Dennis alluded to, we often hear that, um, a barrier to states pursuing Medicare Medicaid integration is that the investments they make on the Medicaid side would likely result to savings to Medicare through reduced hospitalizations and emergency department visits.
57:55
I’m curious for your thoughts on that. And particularly, as you think about the move from the demonstration to, um, and, you know, increase, focus on the decent platform. Do you see opportunities for states to realize Medicaid savings from integrated care programs in this landscape?
58:14
Yeah.
58:14
It’s been an article of faith for a long time, that that state investment equals Medicare savings. And I think we can easily think of good examples. If I had better access to in home support for better access to certain forms of community based behavioral health treatment. I’m less likely to end up in the emergency room. Those examples are real.
58:37
We haven’t solve this completely, but I think we’ve found some ways to mitigate it really significantly.
58:44
So, first written about published in the Federal Register last year, ways that states in the context of capitated managed care, could use some of the rules around actuarial soundness and capture rate setting.
58:57
To better recognize some of the dynamism between Medicare and Medicaid, where people are in certain types of integrated care programs to ensure, not necessarily, states can completely capture all forms of that savings. But, there are lots of tools that they can use, some of whom have already used it, to better balance the investment side of that equation. So, that’s number one. Number two.
59:25
I guess, as what we have some of the things we’ve learned from the financial alignment initiative demonstrations is that what happens from an integrated care product isn’t as completely linear, is that narrative, always leads us to. So, for example, in multiple states, in which there have been statistically significant reductions in long stay nursing facility placement, where we integrate where it implemented integrated care options.
59:51
So, I think it’s just, there’s not that it’s untrue, it’s just that the narrative’s a little bit more complicated than like state investment equals Medicare day beings. I think that the, the reality is more complex than that.
1:00:04
What I would also note, I mean, it’s really I do it, too, and it’s really tempting to always focused on like a very crass economic kind of financing here.
1:00:14
And there’s an important reason for that, which is that the State Medicaid agencies operate in a balanced budget world, and that forces them to almost always be a lot more thoughtful about investments than frankly, we often have to be at the federal level.
1:00:30
That being said, there are state leaders from coast to coast who also have goals here and to reduce disparities to improve outcomes That I wouldn’t say completely obviate the need to balance the budget but also I mean that there are lot of state leaders who have invested in these things. Not simply because they want to save money in the Medicaid budget, but because they have no other objectives, and that’s often to reduce disparities.
1:01:00
Appreciate that.
1:01:01
And it’s a, it’s a great segue, I turn to you, and we’d love to hear your thoughts on this question of sort of the case making at the state level.
1:01:11
You’ve sat in that in that chair, and you work with states across the country and would welcome your thoughts on, you know, how much the states need to be sold on, whether this is, you know, this should be a policy priority, how much it’s top of mind.
1:01:27
And I can add questions from there, but we’d love your reaction.
1:01:33
So, Allison, I’m going to completely ignore that question for like NaN. And then, I. said something that was so important.
1:01:40
And I just wanted to touch on it for folks that are out there, and just sort of thinking about the big picture of the dual eligible Program.
1:01:48
And that is 60 years ago, almost 60 years ago, when Congress created Medicaid and Medicare, I doubt they were thinking of a population like the dual eligibles, that would grow to be over 12 million individuals and represent some of the most complex cases in our country and the different fragmentation points. That would result not only between Medicare and Medicaid, but also, like, just within the delivery system itself.
1:02:14
So, no Dennis mentioned like this new title, notion and how to really, you know, completely step back and rethink about dual eligible members.
1:02:24
And, you know, a lot of my peers, former peers in the Medicaid space, are doing a lot of great work to try and improve delivery systems for dual eligible members.
1:02:32
But I also think it’s a legitimate conversation to be had a federal level And engaging states. And, of course, you know, stakeholders and different populations need to be around the table.
1:02:42
But I do think it’s an incredibly important policy point that demonstrates, and I just wanted to circle back to it for one minute. Sort of come back and answer your question.
1:02:51
I think clearly when you look at the opportunity to move the needle on improved outcomes and reduced spann, that spanned from a broad public perspective coming up with strategies around dual eligible populations, is critical for our Medicaid program.
1:03:12
one of the major kind of strains that are Medicaid directors, 10 years, less than two years, that most states don’t have the type of staffing that I mentioned earlier in my presentation, where you have individuals that are focused on advancing dual eligible strategy.
1:03:30
And thus, as a result, this topic oftentimes gets placed down on the priority list.
1:03:39
There are other areas that rise to the top based upon either what’s happening at the federal level, at the state level with regards to budget and other things like that.
1:03:50
And unless, you can actually get leaders that have some continuity that can look at. I’m going, I mean, because we all know that doing this work, although, very important, takes a lot of time. I mean, 10 laid out, things that were accomplished over the course of 13 to 15 years, right?
1:04:08
And so, if you have people that are turning over every two years, it’s really difficult to continue to keep the dual eligible topic at the top of the list and to move it forward.
1:04:19
And that’s why I think, you know, I think, one, when Congress and others, think about how to continue to engage States on this topic. Having something like, you have to have a State dual eligible plan. And we’re going to provide some resources to help you support That.
1:04:37
Is an important policy discussion to have, because something needs to keep the dual eligible population near the top of the list for medical Directors. Because just the natural turnover and kind of junction, with other priorities, oftentimes results in it, not be a priority.
1:04:58
I appreciate that time, and you’re forgiven for ignoring my question first and starting answering another question. So, it was, it was, it was a worthy pause there.
1:05:11
And Dennis, I’d love to hear you react to what, what Tom just suggested in terms of, um, the notion of a mandate to states.
1:05:21
You mentioned in your earlier comments and the equity issue, across states, if you’re a duly eligible individual living in one state versus another, what might you have access to or not have access to based on what level of prioritization these policies have, have garnered in one place versus another.
1:05:42
So, I’m curious, in your advocacy work and in your discussions with advocates and policymakers across the country, do you think that mandate is as what we need? Do you think that we can make enough progress across states given just the increase in the in the sort of voluntary tools and incentives that are available to support this work?
1:06:11
Yeah. Thanks.
1:06:12
But I’m going to start with equity, even. in.
1:06:15
and access to decision making and CMS, the rule change that went through.
1:06:20
I want to thank Tim and his team for for ensuring that there’s the width with the mac, and the and the bag heat attack, and, but the mac and the bag ensuring that there’s actually engagement with folks across the country in, in policy development.
1:06:37
That’s a huge advancement, and that that’s, that’s, that’s a way of advancing equity, by bringing different populations around the table and having them impact policies at the state level.
1:06:48
And so, we called us of what’s available in that state, that what resources are available, that those resources are being used in a manner that reflects the priorities of the folks who, who, whose, whose lives are affected by those policy. So, there’s a new role that’s coming out, that, that, we’re going to be, that we’re going to be, will be.
1:07:12
Responding to, again, you know, advancing, advancing the voices, and integration of services for folks, and so, like that. That’s a form of equity. That doesn’t require a lot of resources, but it’s really about doing things differently.
1:07:27
And so, so it’s not, I don’t think it’s just about creating a new act. The reason why.
1:07:32
I do think that that’s something that needs to be discussed, is that, is that, I don’t think there’s going to be equity request states, because the research is different.
1:07:43
But ensuring that the input, ensuring that there’s equity, in terms of how resources are used, or how you use these, but, ensuring that states are incentivized to use to use their resources to reduce hospitalization rates and to invest in community based services. That states have a greater competency capacity. You said, the time. two years That, That’s that’s absurd level of turnover? And even in Massachusetts, where we are, We do have a lot of resources.
1:08:16
We don’t have a Medicare expert in State, who can actually can actually shape a smack state Medicaid, state Medicaid contract, for the D slip in a way that is really for the foreign from the Medicare perspective. And so, so, by having a third act, it might make the might reduce some of the the burden of states.
1:08:43
Administratively. So they actually are all working for the same from the same perspective. So it’s not just that it’s not just about finances. The financial piece is far more complicated, complex. Let’s get into today. But, but I think there were some administrative pieces of this that can be looked at as a starting place. And then get into then get into what are the finances look like in terms of what would, in terms of the third title.
1:09:10
But I do think we need to move in that direction.
1:09:12
We should move in that direction, because the population is so complex, it varies by population, by age, and, and, and we states.
1:09:20
Population is different, And so, so each state how it’s going to invest, those resources may vary, because depending on the population, depending on whether it’s urban or rural, So, And that’s, that’s good, it’s beyond the scope of this conversation, but to say, moving that direction and more conversations that way, I think, is really is really important.
1:09:40
And Alice?
1:09:43
Stats are wired to do quality improvement plans that they submit to CMS. The required to do health information technology plans.
1:09:50
What’s wrong with having a dual eligible plan that identifies the strategies for the state, wants to advance an exchange for some additional administrative resources.
1:09:59
I think, you know, everything dennis’ laid out, in terms of broader equity across states is a really important discussion, too.
1:10:06
But, I’m a firm believer in incremental things change incrementally over time.
1:10:11
So, you know, in order to do that, just sort of level setting up the playing field, as it relates to the capacity of the State Medicaid Program, and sometimes having a tool to try and keep dual eligible issues front and center. And I think that’s something Congress should be interested.
1:10:27
Really appreciate that time, actually, in the context of turnover in state leadership and that complication of building Medicare capacity and some of the data infrastructure and so forth, that you talked about in your remarks earlier, and recognizing that, you know, some, some requirements alongside resources to support that work and to act upon the information put forth in a plan, is a really important no compliment to two hour requirement itself, and we can talk more about that.
1:11:04
Tim, I want to turn to you. We’ve been sort of pie in the sky a little bit here, about, you know, what a perfect solution might be, or what what might come through future legislation, or what have you. But, as you mentioned, in your remarks, we found a lot of tools today. And there are a lot of opportunities that are not yet fully tapped in terms of increasing enrollment in integrated programs, as well as increasing what’s available to beneficiaries within this integrated programs. And so, I’m curious from your perspective.
1:11:40
In terms of what we know today and what we have today, what, what policies, or which, which of those tools, do you expect to generate the biggest gains in integrated care over the next five years? What gives you the most optimism at this point in time?
1:11:55
Oh, yeah, the biggest asset that we have, all the States, is the expertise of the people we serve and how we tap into that meaningfully can vary in different ways. And sometimes it’s easy, and sometimes it’s hard, we’ve, we ourselves, have learned a lot from various human centered design projects, including on some of the eligibility related stuff I talked about. Dennis just alluded to a proposed rule that would require every state Medicaid agency to have a beneficiary advisory group associated with its statewide. Medicaid advisory councils are generally called, we ourselves finalized the rule requiring every decent to have an enrollee Advisory Committee. So.
1:12:51
Learning doesn’t get so long so far to go, and lots of those things proved to be a little bit of lip service, and not always, like the genuine thing they are meant to be.
1:13:04
But I think, as a community, among the states, seem like meaningful recognition, that when we talk to the people who are trying to serve, we do better at serving them, is like a real thing.
1:13:19
And so, to me, that’s like, asset number one, As opposed to, like, that cuts through differences and the resources to, like, any stage should be talking to you and learning from the people that that are enrolled in that state. So that, to me, that’s like asset. I don’t want to call it a tool that gives the wrong way.
1:13:38
I said number one, in a more bureaucratic sense.
1:13:43
Half the people we serve now are in Medicare managed care.
1:13:46
And in many of the most populous states, virtually all of the dually eligible individuals are in Medicaid Managed Care. And Tom alluded to something called the State Medicaid agency Contract is also came out of Federal statute, as I mentioned earlier, in which Congress said, these dual eligible special needs plans can operate in any State.
1:14:08
Contingent on having an agreement with the State Medicaid agency to operate there. And in establishing that requirement, Congress didn’t put many bounds on what the State could require in those contracts.
1:14:16
And Tom alluded to the fact that you could say, we’re only going to contract with a D snip and this data from fat.
1:14:23
They participate in Medicaid if they achieve certain performance improvement. Objectives: Like, whatever we can, we can work in there. That is a tool that is given to the States.
1:14:34
We at CMS review those contracts to ensure they meet minimum requirements, but states have increasingly used that in thoughtful, constructive ways.
1:14:46
And so, to me, like the very crass bureaucratic sense. Those are the most powerful tools we have right now to to effectuate change in a world in which space it on an old the majority of people now are in capitated managed care.
1:15:02
I’m going to stay with you for a second.
1:15:03
And I’m going to turn this question to Dennis some time here in a minute, But we’ve got a question from the audience, and that points to some of the discussion earlier around the explosion of choice in the market, and how there are, in some cases, there’s, there’s more sense making to do for beneficiaries than might be necessary or useful. And a specific question we got is about any changes that would be helpful to the Medicare plan finder, for example, to improve beneficiary education on their choices And to welcome you to comment on that question. And more broadly on this issue. And then, Tom.
1:15:45
And then, as I’m really curious for your perspectives on this question, as well, the broader question, then, how do we simplify choice for folks?
1:15:55
I tell you, first, I need a place to begin.
1:16:01
one starting place is to is to acquire, Is to do away with lookalike plans.
1:16:08
That that, if, if, if it’s an insurer, has a dual eligible plan in the state, that, though, that’s the contracting through the state, did they not be permitted?
1:16:20
The other Medicare Advantage plans that look like they’re contracted plans in the state, but don’t provide the same level of services that are available for the dual beneficiary.
1:16:35
Because it’s dualism, parted by advertisements, promising them this, this service or that service that don’t necessarily come through.
1:16:46
And there is a plan out there for them that is contracted through the state that’s partnering with the state, then ensures that the minimum number of service, so they can get.
1:16:57
So I think for me a place of winnowing serve, the more the choices, to real choices, is to, is to is, to start there, is to get rid of the false choices, and focus on, and focus on the ones that are, that, are, actually, actually, going to meet folks, needs, rather, is a basic minimum standard.
1:17:21
Dennis is alluding to something called the Snip look alikes, which are medical management.
1:17:25
Largely are almost exclusively, or people who are dually eligible, but don’t meet the requirements of being a dual eligible special needs plans, like having an evidence based model of care and conducting annual health risk assessments and contracting with the state Medicaid agency. And that’s an issue on which we have an open rulemaking proposal right now. Similarly, that same proposal we’re soliciting comments on the choice infrastructure, big piece of that being Medicare Plan Finder, which is this incredibly powerful tool that helps people identify plans that that fit best for them.
1:17:58
Currently, that’s the tool that doesn’t have business intelligence kind of like connected to the Medicaid program.
1:18:03
So, we’re not necessarily showing you that among the literally 100 options that you may have in Cuyahoga County, Ohio. Not really leveraging it, too.
1:18:16
But at the top of that list, like here’s the Medicaid plan currently enrolled in, and we want people to have a lot of choices, and if they’re not satisfy that plan, currently in when the newly eligible for Medicare, we want them to be able to make good choices.
1:18:28
But we also want to excessively difficult to find something that is designed to blend together your Medicare and Medicaid services.
1:18:35
So there’s a lot more we can do on that front building on, incredibly talks to a dentist also noted the proliferation marketing activity, other things that we’ve got some proposed rulemaking on that make it just an incredibly dynamic.
1:18:49
Hmm, market for people right now.
1:18:56
Allison, I really don’t have much to add.
1:18:57
You know, I would just come back to my example I gave earlier in terms of, know, there’s a state out there, and established an LTSS program Medicaid managed Care for long-term services and supports.
1:19:09
And it basically indicated to the market that anybody didn’t get that contract, would need to exit, and that one resulted in, you know, Margaret going from tech plans to three plans.
1:19:19
And so, know, that’s a conscientious decision state made leveraged authority through the the state Medicaid agency contract and was able to, I think, more aligned, the choice in the marketplace with those plans. And actually, so, I know it’s a repeat. I wanted to give just a specific example, where it’s been a great example. Yeah. Thank you for that time. It’s a great example.
1:19:41
An example, as, in some cases, states, in increasing their awareness of their ability to do things like that. And limit decent contracting and the constraints on what choices are available to their beneficiaries, So thank you. Thank you for reinforcing that.
1:20:00
Like, to say, I also think that, in some states, there aren’t a lot of choices. There may be choice plans, but they’re all the same plan.
1:20:09
And so, it’s, it’s, it’s, it’s, it’s a dis managed care, as opposed to a PPO, or, or some other, or an ACO, or maybe like, like, I like PPS. But just just, that, there’ll be, some, so that’s other options.
1:20:25
That, that people have, other than just a managed care plan, and so when we say choices, if they’re all, um, someone.
1:20:37
But from the same cloth, the same model in some ways, that’s not necessarily offering choice.
1:20:44
It may just be nuanced, to, I suppose, to real choice. So I think we really have to define what we mean by choice.
1:20:52
Dennis?
1:20:53
You mentioned a moment ago, and the term model of care, and that came up in one of our audience questions, as well. And from your perspective, can you help our audience understand what’s, what’s the role of the model of care in this next? And what’s the opportunity with the model of care, specifically, as it relates to improving integration of care for the dually eligible population?
1:21:15
Every special needs plan has to have, what was lost as an evidence based model of care, gets submitted to NCQA, who reviews and approves those models of care for some period of time.
1:21:30
Done, right? It’s a blueprint for how?
1:21:35
the Managed Care organization is going to serve a special population in a way that’s different from their, like, kind of commercial, traditional business.
1:21:44
So, that’s an opportunity, should lay out, like, here, is how we’re going to develop a health risk assessment, and implemented in a way that’s cognizant of the fact that people may be receiving Medicaid, home and community based services as well.
1:21:59
Or here’s how we sold peer supports into our approach to serving people with 20 behavioral health services, right?
1:22:08
So, this is the opportunity to kinda like customize the approach is different from like, I guess what we call kind of cookie cutter, Mike, commercial style, Managed care.
1:22:20
Now, we have seen variable, kind of like, development of the models of care in and how well they integrate the Medicaid piece of the equation, and, in fact, have recently worked with states to intro, to, kind of like, add Medicaid elements, to the models of care themselves. So, in states, like, Minnesota in Massachusetts, and California, and elsewhere, are our state partners. So that that process, kind of, like, baked in, is like you’ve gotta address in that model of care, how you’re achieving certain policy objectives related, In the case of California, related to dementia care services, and others. So, we tried to, like with many things, we tried to, like, better co-ordinate both the federal and state into a document.
1:23:03
That’s largely wasn’t meant to be the Blueprint, now, Not just some aspirational thing.
1:23:10
We have teams of people here at CMS who go out and audit of plans, and when they audit a special needs plan, they audit with that model of care, to ensure that your organization delivered services in a way that they laid out in the approved model of care.
1:23:25
So, it’s a real thing that drives both the approach to co-ordination of care, but also like our approach to compliance related to that.
1:23:35
Just build on that, Allison.
1:23:37
Yeah, you come at it through the state lands. And there’s so many opportunities that the model of care. I mean, it’s 200 pages plus.
1:23:45
Usually up, a lot of detail in terms of what the plan needs to be doing and how they’re thinking about care management, care, co-ordination.
1:23:54
Remember engagement and all of those important topics.
1:23:57
But Tim was describing that it’s a real opportunity for Medicaid to come in and make sure there’s alignment between what the integrated care team looks like and who’s the point in terms of care co-ordination and care management for populations.
1:24:13
I’ve also strongly encourage states to be leveraging the model of care, to be very specific, as Tim was talking about, to the state that you’re in and lay out the fragmentation points and how they’re gonna care co-ordinate. And know that if IDD long term care services on the Medicaid side are done by a sister state agency. That’s who they’re co-ordinating with.
1:24:35
In terms of if somebody has an inpatient setting or an emergency department, that they need to co-ordinate with that entity, or if there’s behavioral health services, and they need to co-ordinate with the behavioral health at the State around that, or the, at the provider level. Some states prefer, you know, particularly for certain populations that that care co-ordination will be done at the provider level.
1:24:57
So, no, sort of, you know, if it’s more like graduate level work on the Dual space and how States should be thinking about it.
1:25:05
But there’s incredible opportunities to be very specific in terms of what the expectations are within that model of care, for the plans to make it identify and be used as a tool for that state and the unique aspects of that state.
1:25:21
This is going to start to look.
1:25:23
The first plan, I was a member of First Capitated plan CMA.
1:25:29
They’re there, their model of care is based on the idea of the dignity of the person, and advancing independent living in London at the time recovery model, But recovery was implicit in it.
1:25:41
And so, it’s It’s so health goes not just a means, and then end, but healthcare as a means towards supporting pupils, civil rights, and their dignity.
1:25:50
And, and really important ways of doing that are true.
1:25:54
And in operationalizing independent living principles, I mean, we would not have HCBS.
1:26:02
If not, for the independent living, right then, the linear movement, we would not have the institutional people at this resistance to people with psychiatric and mental health diagnosis. If not for the recovery movement.
1:26:15
And we can, we know that those, those, those Damon, the Civil rights based models work, and if the medical system, and it, and these are this is important together, you get much there are outcomes, And I think more and gaze of folks in society, and improved health outcomes exist.
1:26:38
Than we have today.
1:26:39
If we just try, it is, but as Tim was saying, is, is that single model of care that says face it, one way of doing things, and we’re always trying to fit that square peg into the round hole, It’s just not going to work.
1:26:55
The commercial models need to shift to ensure that they’re there actually designed to meet the needs of the populations that they’re being paid to serve.
1:27:12
I’m gonna give you each a second for a parting shot. We have about a minute, and if there’s anything, you know, top of mind, that you just really want to underscore here, in terms of the opportunity before us, and I would welcome your thoughts on that, Tim, I’ll go to you first.
1:27:29
If you’re with a state Medicaid agency, call me, because we’re here to try to be helpful to you, and every state resource, totally, they may be, can benefit from doing more to talk to those people who are dually eligible in the state and learn from their experiences and drive it towards improvement.
1:27:53
Tom, If you’re at the state, put something on your list for 2024, that you’re going to advance overall care for the dual eligible population.
1:28:06
MS: I, a deep respect for Medicaid directors around the country and for CMS, and what you’re trying to do.
1:28:16
And I think we have.
1:28:21
Is that what you put together, Tim?
1:28:24
And moving towards more integration of the voices of folks who are actually benefit from the service, or, or accessing services, I think, is really important to be done in an authentic way, and in a measurable way, so that we can actually see how the voices of folks who utilize these services, impact policies, and what the outcomes are from those policies.
1:28:47
So, I think, I think that’s a really key step in this.
1:28:52
I want to thank you all for a really powerful discussion today, and have shared so many practical suggestions with our audience. And just greatly appreciative for all your continuing efforts in this space. And, Allison, I will turn it back to you to close us out.
1:29:08
Great. Thank you, thank you, Allison, Dennis, Tim, and Tom, so much for joining us, and for all the important work you do to improve policy and health care for Dually Eligible Individuals. I want to thank all of you who took the time to be here with us today. We hope you found this discussion informative and we’ll be able to take what you learn and use it in your work.
1:29:28
I also, again, want to thank our wonderful sponsors, the Association of Community Affiliated Plans, the Scan Foundation, Santa Clara Family Health Plan, and the Health Plan of San Mateo for their support of this work.
1:29:40
And we want to hear from you. We appreciate all of you in our community and our network. We want to know what we could be doing better, what we could be bringing to you in terms of resources and information. So please feel free to share that via e-mail or complete our evaluation survey, which will put that link in the chat there.
1:29:59
Here at the Alliance, we host educational webinars, and in person events throughout the year. So please do follow us on LinkedIn, or visit our website, or sign up to receive e-mail updates about our upcoming events. We invite you to join us in January for our annual health Policy Forecast, and please keep an eye out for that invitation to register in the new year.
1:30:19
As a reminder, a recording of this webinar and additional materials will be available on the alliance website. This concludes today’s webinar, Navigating Complex Systems: Karen Policies for dual Eligible Beneficiaries. Thank you so much for joining us today.