Navigating Complex Systems: Policy Opportunities for Dually Eligible Individuals
March 28, 2024
1:00 pm-
2:30 pm
Virtual Event
Event Description
This webinar provided a deeper understanding into the role of Medicare, Medicaid, and private sector in providing care for dually eligible populations and discussed past and present policy efforts and strategies. Panelists also identified potential future directions and approaches to improve care for dually eligible populations.
This webinar was sponsored by the Association for Community Affiliated Plans, Santa Clara Family Health Plan, and Health Plan of San Mateo.
Learning Goals
- Develop a comprehensive understanding of the current landscape of healthcare policies and practices affecting dual eligible populations.
- Discuss public and private sector efforts at the state and federal level in serving dual eligible beneficiaries, identifying successes, challenges, and areas for improvement.
- Examine trade-offs involved in designing and implementing policies and programs for dual eligible populations.
- Discuss potential future directions and strategies for enhancing the care and support of dual eligible beneficiaries.
Speakers
Brianna Ensslin Janoski, MPH
Managing Director, ATI Advisory
Brianna Ensslin Janoski is a Managing Director in ATI's State Program and Policy Practice. She is focused on issues related to Medicaid LTSS and dual eligible populations.
Before joining ATI, she was an independent consultant who supported clients on projects related to managed care, Medicaid, Medicare, SHIPs, and integrating care for some of our nation’s most vulnerable populations. Most recently, Janoski served as the Associate Vice President of Medicare/MMP Product at Molina Healthcare. Here, she led the team responsible for more than 20 plan benefit packages, driving development, administration, and training of these products nationally.
Prior to this role, Janoski was a Director of Public Policy at Molina Healthcare where she supported its plans across the country on a variety of federal and state legislative, regulatory, and policy priorities. She focused on issues related to D-SNPs, MMPs, and MLTSS programs, notably spearheading the organization’s policy and advocacy around MMP enrollment growth and capitated Financial Alignment Demonstration program extensions, as well as D-SNP default enrollment and preparing for D-SNP rule changes.
Janoski received her Master of Public Health in Urban Health and Bachelor of Science in Health Science degrees from Northeastern University in Boston, MA.
Alice Burns, Ph.D., MPP
Associate Director, Program on Medicaid and the Uninsured, Kaiser Family Foundation
Alice Burns is an associate director of KFF’s Program on Medicaid and the Uninsured, where she focuses on overseeing the team’s quantitative research. Prior to joining KFF in 2022, Dr. Burns served as a principal analyst at the Congressional Budget Office. She led the agency’s research using Medicaid claims data and worked on issues related to long-term services and supports, private health insurance, surprise medical bills, and single-payer health care. Before her time at the CBO, she was a consultant with the Lewin Group and a research scientist at the George Washington University Center for Health Policy Research.
Dr. Burns received her bachelor’s degree from the University of Maryland, a Master of Public Policy from George Washington University, and her Ph.D. in public policy and public administration, also from George Washington University.
Michelle Herman Soper, MHS
Vice President of Federal Policy & Advocacy, Commonwealth Care Alliance
Michelle Herman Soper is the Vice President of Federal Policy & Advocacy at Commonwealth Care Alliance (CCA). She leads the design and implementation of CCA’s public policy agenda to advance health policy strategies which support individuals with significant needs. Most recently, Ms. Soper served as Vice President of Integrated Care at the Center for Health Care Strategies, where she worked with states, philanthropic organizations, federal agencies and health plans to improve care delivery and financing for individuals who are dually eligible for Medicare and Medicaid, and implement long-term services and supports and behavioral health reforms. She has served as a Special Assistant to the Executive Director and Acting Director of Communications for the Medicaid and CHIP Payment and Access Commission (MACPAC), and as Special Projects Coordinator for the Office of Chronic and Long-Term Care within the District of Columbia’s Department of Health Care Finance. She also held posts at Avalere Health and the National Conference of State Legislatures. Ms. Soper has a master’s degree in health science (MHS) from The Johns Hopkins School of Hygiene and Public Health and a bachelor’s degree in psychology from Tufts University.
Marcus Johnson, M.S., MSW
Advocacy Programs and Initiatives Manager, Independence Care System
Marcus D. Johnson is a dedicated advocate and leader, currently serving as the Manager of Advocacy Programs and Initiatives at Independence Care System (ICS). He is also a co-leader of the Civics League for Disability Rights (CLDR), a passionate volunteer-driven advocacy group empowering individuals with disabilities. Based in Harlem, New York since 1992, Marcus brings over 25 years of profound experience as a counselor, therapist, mediator, and advocate across diverse populations, with a significant focus on championing the rights of people with disabilities.
Since 2002, Marcus proudly holds the title of a Certified Rehabilitation Counselor (CRC), and he has been a practicing Licensed Mental Health Counselor (LMHC) since 2007. Demonstrating his commitment to education and innovation, Marcus was recently appointed as a lecturer at Yale University School of Engineering and Applied Science. Here, he collaborates with a fellow educator in teaching popular Mechanical Engineering and Materials Science (MEMS) design electives — Computer Aided Engineering and Advanced Design and Analysis of Machines. These courses uniquely concentrate on developing technology to empower individuals with physical disabilities, highlighting his deep dedication to creating inclusive and accessible solutions.
Marcus's remarkable journey includes overcoming adversity, following a motor vehicle accident that resulted in a spinal cord injury during his second year at The Juilliard School, where he was pursuing a Bachelor of Fine Arts degree in dance. This transformative experience fueled his drive to pursue academic excellence even further. With unwavering support from his loved ones, he achieved academic milestones post-injury. He attained two degrees from New York University — a Master's in Rehabilitation Counseling and a Bachelor's in Performing Arts Administration/Dance Education. He later completed his master’s in social work from Fordham University in 2007.
In his current role at ICS, Marcus collaborates with diverse stakeholders to prevent and resolve issues and cultivate constructive relationships. He excels in advocacy and mediation, using his expertise to address various concerns for members with disabilities, striving for an equitable and inclusive environment. Beyond his commitments at ICS, Marcus is an active member of several influential boards, including the New York State Independent Living Council, Inc.’s (NYSILC) Executive Committee, the Consumer Directed Personal Assistance Association of New York State’s (CDPAANYS) Consumer Board, Harlem Independent Living Center, and NYC Spinal.
Marcus's dedication has earned him recognition, including the prestigious Paul G. Hearne Leadership Award for People with Disabilities from the American Association for People with Disabilities (AAPD). His holistic approach is further demonstrated through his role as a Credentialed Alcohol and Substance Abuse Counselor (CASAC-T), reinforcing his commitment to helping individuals in multiple facets of their lives. Through his multifaceted leadership and advocacy, Marcus D. Johnson continues to make a lasting impact in disability rights and beyond.
Kate Massey, MPA
Executive Director, Medicaid and CHIP Payment and Access Commission
Kate Massey, MPA, is the executive director of the Medicaid and CHIP Payment and Access Commission (MACPAC). Before joining MACPAC, she was senior deputy director for the Behavioral and Physical Health and Aging Services Administration with the Michigan Department of Health and Human Services. Massey has over 20 years of operational and policy expertise in Medicaid, Medicare, the State Children’s Health Insurance Program, and private market health insurance. She has Medicaid managed care experience previously serving as chief executive officer for Magellan Complete Care of Virginia and vice president for Medicaid and Medicare and government relations for Kaiser Permanente of the Mid-Atlantic States. Massey’s policy experience spans private and government sectors. She worked for Amerigroup, where she established its Public Policy Institute and served as executive director. Prior, she served as unit chief of the Low-Income Health Programs and Prescription Drugs Unit in the Congressional Budget Office and led a team focused on Medicaid, CHIP, and private health insurance market programs at the Office of Management and Budget. Ms. Massey has a master of public affairs from the Lyndon B. Johnson School of Public Policy at the University of Texas at Austin and a bachelor of arts from Bard College in New York.
Presentation: Speaker Presentation
Event Resources
Key Resources
Additional Resources
Experts
Arielle Mir, MPA
Arnold Ventures, Vice President of Health Care (Complex Care)
Hemi Tewarson, J.D., MPH
National Academy for State Health Policy, President and Executive Director
Joseph Antos, Ph.D.
American Enterprise Institute, Wilson H. Taylor Scholar in Health Care and Retirement Policy
Cindy Mann, J.D.
Manatt Health, Partner
Kate Rose, MPH
Welsh Rose, Founding Partner
Amber C. Christ, J.D.
Justice in Aging, Managing Director of Health Advocacy
Sarah Barth, J.D.
Altarum Medicare-Medicaid Services for States, Executive Director
Judith Feder, Ph.D.
Georgetown Public Policy Institute, Professor of Public Policy
Jose Figueroa, M.D., MPH
Harvard T.H. Chan School of Public Health, Assistant Professor of Health Policy & Management
Harvard Medical School, Assistant Professor of Medicine
Eric T. Roberts, Ph.D.
University of Pennsylvania, Associate Professor of Division of General Internal Medicine
Transcript
0:04
Welcome and good afternoon. My name is Allison Jones. I’m Director of Program Strategy and Management here at the Alliance for Health Policy. We are a non-profit, non partisan organization dedicated to helping policymakers and the public better understand health policy, the root of the nation’s healthcare issues, and the tradeoffs posed by various proposals for change. We’re so thrilled to be presenting today’s webinar, Navigating Complex Systems. Policy Opportunities are duly eligible individuals. The Alliance has served as a trusted educational resource for the health policy community for more than 30 years. And today’s discussion will provide a closer look at policies impacting the over 12 million duly eligible individuals covered by Medicaid and Medicare. Today you’ll hear about the challenges, duly eligible individuals face and navigating your coverage and accessing essential care. And you’ll also learn more about the opportunities and policy efforts to address these challenges to improve health care experiences and outcomes for this diverse population.
0:58
We’re excited to showcase different viewpoints and considerations during today’s webinar, that will hopefully help you in your work and inform future health solutions for improving our health care system before we get started. I want to take a moment to thank our sponsors. Today’s webinar is generously supported by the Association of Community Affiliated Plans, Santa Clara Family Health Plan, and Health Plan of San Mateo. Thank you so much for your support of this program and for joining us today.
1:25
I also want to share a few quick logistical notes. Please be sure to follow the Alliance for Health Policy on LinkedIn to stay informed about upcoming events like this one.
1:34
You can also find us on Facebook and YouTube.
1:36
Today’s panel includes a Q and A session at the end, and we encourage you all to be active participants. So, please feel free to share questions at any time.
1:44
You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.
1:49
You can use that speech bubble to submit questions that you have for the panelists at any time, and we’ll collect these and address them during the Q&A.
1:56
Throughout the webinar, you can also chat about any technical issues you may be experiencing, and our team can assist you.
2:02
After the discussion today, I encourage you to check out the additional resources we have available on the event page on our website. And, of course, if we don’t get to your question, 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.
2:17
With that, I am so pleased to introduce our moderator for today’s webinar Breach in ASCII.
2:23
Regent … is Managing Director and …, State program, and policy practice.
2:28
In this role, she leads … work with States related to design and implementation of programs and policies for dual eligible populations, individual with long-term care services and supports needs, and other Medicaid and non medicaid eligible populations.
2:42
Before joining API, for you as an independent consultant who supported clients on projects related to Managed Care, Medicaid, Medicare, and chips has also held positions at Molina Healthcare. And the Center for Health Care Strategies, where she worked internationally on policy and program design implementation efforts, aimed at reducing the complexity of care for duly eligible individuals and ended the individuals with LTSS needs. You can read more about her background and the bios of our other panelists on the Alliance Website. And now, I’ll turn it over to Breed to introduce our other speakers.
3:17
Great, Alison, thank you so much.
3:18
It’s a pleasure to be here with everyone today to discuss this really important topic.
3:23
My team at ETA Advisory is fortunate enough to spend a lot of time working with states and other partners to advance models to improve the systems that serve dual eligible individuals. And so, I’m delighted to be a part of this conversation with some leaders in this space.
3:36
So, it’s my privilege to introduce our panelists for today’s conversation.
3:40
First, we have Marcus Johnson, who is a dedicated advocate and leader currently serving as the Manager of Advocacy Programs and Initiatives at Independence Care System.
3:51
He is also a co-leader of the Civics League for Disability Rights, a passionate volunteer driven advocacy group, empowering individuals with disabilities.
4:00
Based in Harlem, New York since 19 92.
4:03
Marcus brings over 25 years of profound experience as a counselor, therapist, mediator, an advocate across diverse populations, with a significant focus on championing, championing the rights of people with disabilities.
4:16
Next, we’ll hear from Alice Berns.
4:19
Alice is an Associate Director of …
4:21
Program on Medicaid and the Uninsured, where she focuses on overseeing the team’s quantitative research prior to joining PFS.
4:28
In 20 22, doctor Berns served as a principal analyst at the Congressional Budget Office.
4:33
She led the agency’s research using Medicaid claims data and worked on issues related to long-term services and supports private health insurance, surprise medical bills, and single payer healthcare.
4:46
Next, we’ll hear from Michelle Herman’s Soper, Michelle is the Vice President of Federal Policy and Advocacy at Commonwealth Care Alliance, or CCA.
4:54
She leads the Design and Implementation of … Public Policy Agenda to advance Health policy strategies which support individuals with significant needs.
5:03
Most recently, Ms.
5:04
Soper served as the Vice President of Integrated Care at the Center for Health Care Strategies, where she worked with states, philanthropic organizations, federal agencies, and health plans to improve care delivery and financing for individuals who are dually eligible for Medicare and Medicaid, as well as, implement Long Term Services and supports and behavioral health reforms.
5:24
And then finally, we’ll hear from Kate Massie, Kate is the executive director of the Medicaid and chip Payment and Access Commission or backpack.
5:32
Before joining backpack, she was Senior Deputy Director for the Behavioral and Physical Health and Aging Services Administration with the Michigan Department of Health and Human Services.
5:43
Kate has over 20 years of operational and policy expertise in Medicaid, Medicare, and state chip program, as well as private market health insurance.
5:54
So with that, I’m going to hand it over to Marcus and he can kick us off.
6:00
Yes, Good afternoon, everyone, and I’m so happy to be presenting here with this great group of panelists. Again, my name is Marcus Johnson, And I’m the Manager of the Programs and Initiatives, that independence care system. We are health whole dedicated to assisting people with physical disabilities and chronic illnesses to live independently in the community.
6:17
And how we do that is by providing disability companies here.
6:22
I’ll get a little bit more into detail as we go along with that, but my pronouns are he and him. And, again, I’m happy to be here with you today.
6:30
The first slide, here, we go, again, Margaret Johnson. We can move on to the next one.
6:36
Yeah, Let’s talk why advocacy is important. I want to say straight off from the back, I’m an individual with a physical disability, with the lived experience, and in thing that I’m dually eligible.
6:49
But I have chosen to just stay, receive the benefits of Medicaid beneficiary at utilizing the services.
6:57
And I’ll get into detail with that, why I’ve chosen that route, of being a Medicaid beneficiary, instead of Boeing Duly, which effect eligible to do so.
7:09
So, again, let’s talk about the voices of individuals with disability.
7:13
Fact, people with disabilities have high rates, are high rates of chronic health conditions, get poor access to health care, which is, unfortunately, the truth.
7:22
Another fact, the need for disability training for healthcare providers is well established, and it is well established, and the work, we do it, specifically for disability rights, will indicate why it’s so important, and the chance to change the alcohol policy, Public policy, if you see here the fact, people with disabilities who have a combination of Medicaid and Medicare, click off into all lesser benefits, provider networks, by an adequate care co-ordinator, or a niche co-ordinators like that knowledge of experienced with people with disabilities and navigating complex healthcare.
7:59
And it is complex because the needs of are people utilizing the services, especially those with physical disabilities, have a different need when it comes to durable medical equipment. And the CDC always indicates the number of people with disabilities is the highest rate of the marginalized group.
8:16
That continues to grow year after year at that point. And to keep that 61 million adults with disabilities living in the United States, one in four: 27%.
8:27
And we’re one billion strong.
8:29
You can go to the next slide.
8:33
Here we go. Social determinants of health.
8:36
Look how disability magnifies the difference between people without disabilities and people with disabilities.
8:44
Look at the poor access to health care, 12% without disabilities, or upset people with disabilities.
8:51
Low income, 12 people with disabilities, winning a profit in up employment.
9:00
We’re not even talking about just the disparities, but if you just look at the employment with what people without disabilities is, 65%, when the community of people with disabilities is 17%, no high school diploma.
9:14
Look at people with disability thinking, 23% and up, in an adequate transportation.
9:20
Any of us in your, of course, katrina’s transportation is always the high impact, could throw in the community of disability, disability, and people in jail will making it, the medical appointments, safely and on time to get the adequate queer, adequate, adequate care. And those with the mixed model.
9:41
It can be that much more challenging.
9:43
We can go to the next slide.
9:46
Here we go civically for disability, right?
9:49
Independent care system, ICS, independent care system and civic fleet we’re always collaborating with other organizations.
9:56
In independent care system has always incubated the civic fleet hard work. And if you see here, we’re independent volunteer led a group of New Yorkers with disabilities, and we advocate and are real issues, whether it be from transportation, the inadequacies and inequity of health care of getting into medical appointments.
10:17
And even if we get in, do have the adequate equipment to assist us the way we need to be assisted. Why are individuals with disabilities. But obviously it uses to this very day still being examined.
10:30
In the wheelchair or motorized wheelchair, Independent Care System works with a pillow, individuals and that are experts and we look for independence, health, and mobility.
10:44
Mobility is so important.
10:45
If we don’t have the added wheelchair, whether it be more device or manual, we can’t get out of our homes to be to get the adequate health care.
10:57
And then again, when we get to those facilities, are there to address our health needs. We can’t even get any at the time because they’re not fully accessible to meet the needs of a population that is the highest growing majority population in America.
11:14
We can move on to the next slide.
11:19
Duly eligible eligible challenges. Let’s look closely for a minute.
11:24
Assessing the care and services needed to remain independent in the community is complicated to the differences in Medicare and Medicaid coverage for wheelchair medical supply.
11:35
And it’s so important. I just want to give you example.
11:38
For instance, when you’re on Medicaid, they look for more of the medical model and address the needs, a medical stick to a wheelchair, a motorized wheelchair. They’re looking for mobility in the home.
11:55
People that need the services are not just in the home, They have to go outside of that.
12:01
So they’re looking at a medical model, with Medicaid, shut the option, venturing out of our homes.
12:11
In a safe cheer that meets our needs that make it to a medical appointments.
12:15
We’re about with Medicare.
12:16
So that combination can be very challenging when you are looking to obtain a chair, that it’s equitable to meet your needs and you’re going for signatures from your primary doctor for Medicare and it, you go over the allotted time. Did you?
12:36
You have to start the whole process again to optimal the proper documentation needed to go and get a wheelchair that meets the needs of you. Living in a community, independently deposited on fee is unnecessary.
12:50
And despite the fact that the Centers for Medicare and Medicaid services are structured, the State Medicaid directors to authorize services based on medical need of a member and not to be quiet and reply denied any soldier allergy, I can’t tell you how challenging it.
13:08
People in the community and disability have come back, and I’ve had to start the process again, and again, because of the leap signatures needed, to get the wheelchairs or whatever durable medical complex equipment they need on time to live independently in the community.
13:27
We can go to the next one.
13:31
Include our experience. So this is a very important slide. I had to add the care of individuals is not complex, system that is not complex, equal, if not equitable.
13:45
And that’s what we moved from social, disability rights to disability justice.
13:50
I don’t want, Everyone, health has been that equitable that meets my needs. And how can we do that?
13:58
Include people with disabilities on advisory committees, to inform plan design.
14:02
Any shorter needs, met without daily struggles, always establish adequate reads covering essential services for independent living, such a complex rehab technology at home care.
14:14
And if you are aware of the home key, see in which law and the rest of the country’s obligates point it’s so challenging the key appeal workers working in and working with people that need the services.
14:30
If we don’t have those services, we get them in the community independently and implement care co-ordination like disability competent providers, creating person centered care plan that will maximize benefit.
14:45
We can move to the next one.
14:49
Thank you, and if you have any more questions or information needed for me, you can see my name is mark johnson at … dot org.
14:58
Thing you can think before, Alice?
15:07
Thank you, Marcus, That was a great level setting for us all, Perfect, to kick off, and I’m really delighted to be here to talk about dual eligible individuals and some of the paths to integration in Medicare and Medicaid.
15:21
So, I think we could dive in with the first slide.
15:28
There we go.
15:30
In 20 21, there were nearly 13 million people with Medicare or Medicaid.
15:34
I’ll be using the term gali eligible individuals to describe them.
15:39
Most of those people, nine point five million, has Medicare on what we call for Medicaid, which means they’re eligible for Medicaid benefits, such as long term care and behavioral health, for the remainder, about four point eight million medical pleas for just Medicare premiums, and in most cases, Medicare costs.
16:00
Dual eligible individuals represent a small percentage of Medicare and Medicaid enrollment, but a larger percentage of spending because of the higher per person costs.
16:11
And this is one of the reasons they’re of such interest to policymakers.
16:15
In 20 World Tool, the Medicare program spent over $23,000 on the average, fully, dual eligible individual. And the medical program spent an additional nearly $20,000. And if we look at how those costs compare to Medicare enrollees without Medicaid or Medicaid enrollees without Medicare, there’s just so much more significant.
16:40
And so, policymakers are looking for solutions that address the co-ordination challenges that Marcus raised, but also ones that might reduce federal spending. Next slide, please.
16:54
90% of dual eligible individuals have annual incomes, below $20,000 a year, 40, 40% have incomes below $10000 a year.
17:06
Nearly half report that they aren’t fair or poor health status.
17:10
Nearly half require assistance with activities of daily living, such as verbal, fado and dressing oneself.
17:19
Despite those commonalities, dual eligible individuals are a really diverse group.
17:24
And so, policymakers faced this challenge in balancing simplicity and efficiency with things that are flexible enough to meet everybody’s needs, Nearly 40% of dual eligible individuals are under age 65, and have a long-term disability.
17:42
The remainder are 65 and over, 13% live in a facility, such as a nursing home.
17:49
Dual eligible individuals have a wide range of both physical and mental conditions.
17:54
They span chronic conditions, such as cancer or heart disease, physical disabilities, developmental disabilities, memory issues, such as Alzheimer’s and mental impairments, such as depression or substance use, return to the next one.
18:12
There’s a long history of efforts to integrate Medicare and Medicaid and a lot of current options available, but let’s take a step back at first. Understand how do people get Medicare and Medicaid?
18:25
With Medicaid in fee for service Medicaid enrollees see providers that take Medicaid and the state pays for those costs.
18:33
In Managed Care, the state pays a private plan and then that plan is responsible for delivering the services.
18:41
What makes Medicaid managed care different from …
18:44
care and say private health insurance or Medicare Advantage, is that there’s often services carved out of the managed care arrangement.
18:53
And so we usually think about Medicare, Medicaid as is it comprehensive, covering most services that people need or non comprehensive coverage. Just a few services may be covering just behavioral health care, just long-term care or just a dental care.
19:09
The most important part of all of this for dual eligible individuals is that the service is most frequently carved out into these separate plans are excluded from comprehensive managed care.
19:20
Also tend to be those services that are most important for people who have Medicare long-term care, dental care. It’s expanded behavioral health services, things that are not part of the traditional Medicare benefit package.
19:38
Furthermore, many dual eligible individuals are actually enrolled in multiple different Medicaid plans, in addition to medical.
19:46
Turning to Medicare into this little Medicare beneficiaries can go to any provider that takes Medicare, which is most providers, Medicare beneficiaries enroll in a private plan, and then the plan covers services, much like Medicaid Managed Care.
20:03
Then we have three different types of dual eligible, special needs plans, or D steps, which are plants that are targeted towards dual eligible individuals.
20:14
They have contracts with the federal government, but they also have to contract with state government.
20:20
Co-ordination only SNP’s provide varying levels of co-ordination. Really dependent on what the state requires of them.
20:28
How we integrated these snips were only available starting in 20 21.
20:33
And for those they must also offer some type of medical care plan in the same counties where they offer a snap.
20:42
There’s no requirement for the same people to be enrolled in both plans. It’s more just that the organization has to have a presence with both Medicare and Medicaid in the same county.
20:54
The fully integrated or five D D steps must offer a Medicaid Managed Care plan that complements the Medicare Advantage plan.
21:04
Now, there’s no current requirement for the same people to enroll in both plants, but there will be starting with 2025.
21:13
Lastly, we have what I call Joy Options and poses. The first, this provides comprehensive medical and social services to individuals, it just 55 and older who need a nursing home level of car but can live safely in the community.
21:30
Under case the organization that has financial responsibility provides all of the services. Again, both the medical and social services, the Medicare and Medicaid.
21:42
The Financial Alignment Initiative was a demonstration program which allowed states to develop pilot projects to provide integrated care to dual eligible individuals.
21:52
All states that participated except for Washington use Managed Care organizations to implement the programs. Those Managed Care plans were called among peers or Medicare or Medicaid plans.
22:05
Those plans will be ended by 2025 with the expectation that most will be transitioned into the spidey piece.
22:15
Next slide, please.
22:19
Despite all these different options, just all of over half of dual eligible individuals are still enrolled in traditional Medicare.
22:28
And enrollees who are enrolled in traditional Medicare tend to be disproportionately non hispanic white, and American Indian, Alaska Native, under the age of 65 and living in rural areas.
22:41
Roughly 20% of dual eligible individuals were enrolled in Medicare Advantage plans that will not really specific to dual eligible individuals.
22:52
Then, among the rest of the group, really another 20% were in record a nation only the SNPs, again, those are the ones with the fewest requirements regarding integration between Medicare and Medicaid.
23:07
This moment palettes have implications for proposed policy options to move more people into plans such as finding the steps.
23:16
First, for current enrollees, there can be significant disruptions to care if they’re required to transition away from their current coverage.
23:25
For both current and future enrollees, there’s a lot of issues of plan and provider capacity, given the number of people who might have to transition.
23:34
Again, the vast majority of people are not in these joint or highly integrated arrangements.
23:42
Among the different coverage options, the only option that has consistently demonstrated improved outcomes is the pace program, which enrolled only about 50,000 people in 20 12.
23:55
Next slide, please.
24:01
Because the SNPs have to contract with the state governments, thus, contracting arrangements represented an opportunity for states to enhance the level of integration in the D steps.
24:13
In 20 20, …
24:14
asked the states about the requirements included in our contracts with two steps, and 29 states reported at all requirements beyond the federal ones.
24:25
one caveat is 16 of those states have multiple types of these steps, and so we don’t know if these external requirements apply to all of these steps, or only the most highly integrated, such as the five easy steps.
24:39
one of the areas with a lot of oxygen was supplemental benefits with 17 statesville courting requirements, related to supplemental benefits.
24:49
So these requirements are aimed at ensuring that the Medicare supplemental benefit, which are beyond traditional Medicare, but those complement rather than duplicate the Medicaid benefit package.
25:05
They are also focused around ensuring that the two products wrap around each other appropriately. So, for example, if the Medicare Advantage plan offers supplemental dental coverage, that, instead of duplicating the Medicaid dental coverage, it would cover the services that Medicaid dental excludes.
25:24
Another area, but there was a lot additional requirements for administrative integration.
25:31
And that sounds really boring on its Facebook for a person who’s involved.
25:35
I could imagine this would be really helpful, because what it means is, instead of the person getting separate brochures for Medicare or Medicaid listing, things like their provider networks, the process for prior authorization, they would get one set of documents that explains the joint process.
25:53
Similarly, the unified grievance and appeals system is intended to address things like the wheelchair problems that Marcus was raising, where instead of having to go through the Medicare appeals process and then the Medicaid process, there’s a single process for the plan as a whole, And so, those are some of the states are doing. It’ll be interesting to see what state and federal policymakers come up with next. Last slide, please.
26:24
And I’m looking forward to our discussion and learning more from my fellow panelists. Thank you.
26:37
Thank you so much, Alice. And, again, my name is Michelle so far.
26:40
And very, very next slide, please.
26:46
Next one. Thank you.
26:50
So I wanted to just kick off by quickly telling you all a little bit about the Commonwealth Care Alliance, our CCA, which is an integrated, not for-profit, mission driven health care system that offers high quality health plans and care delivery. Platforms for individuals’ significant needs most of our members are dually eligible and are involved in 1 of 2 telegrams. Just harking back to Alice is very helpful. Slide that showed the different types of coverage options for ….
27:23
We offer a fully integrated D snap and a Medicare Medicaid plan. I’ll tell you a little bit more about those in a second in Massachusetts. We also have … and other SNPs in Michigan and Rhode Island, along with additional Medicare Advantage plans. Next slide, please.
27:46
Thank you. So, our two big bands, like I mentioned, our integrated plans for actually eligible individuals. On the left column is a profile of our members to enroll in one Care, which is a Medicare Medicaid plan.
28:02
Like Alice Advices a temporary demonstration that will transition to a decent at the end of 2025 in Massachusetts And the one Care Program, HHS goals.
28:17
The one Care program involves individuals age 60 foreign yonker, average ages tension.
28:22
And nearly half of our members in one care have serious mental illness. And many individuals have a substance use disorder or physical disability.
28:33
On the right side is our senior Care option program. This is a fully integrated snap, and you can see it and it’s much older population. It is open to Julie eligible individuals age 65 and older, and our average age is 75. It’s a different profile.
28:50
We clinical profile, rather at nearly half of our individual, has, and in our school plan, has four or more chronic conditions, more than half of diabetes, and it’s also a very diverse population where more than half, nearly two thirds, primarily speak a language other than English.
29:09
Next slide, please.
29:14
So, I just, I was asked to provide some thoughts about, what are the sort of the key principles are key elements that are involved in integration from an integrated health plan perspective? And then also from a state perspective, because before I joined CCA and spent nearly 10 years at the Center for Health Care Strategies, where we work and the CFTC has still works with states that are designing, implementing and operating integrated care.
29:42
So starting with from an integrated health plan perspective, I want to sort of run through some of the programs that are some of the elements rather that we think make are essential to program success. The first one is enshrined. There is one accountable entity to provide the full range of Medicare and Medicaid services. And different states have different designs where they might carve out services are plants only offer certain services that, we think, you know, given the heterogeneity. And also significant needs that Julie eligible members, the most effective programs, cover, medical services, behavioral, health, long-term service, and supports, and also social services.
30:21
You know, this, really, I think, alliance incentives and is the most effective program.
30:28
I’ve also seen a CCA began as a primary care clinic in Boston in the 19 seventies, serving the most vulnerable individuals in, in the city. And for these programs to work, it needs to be run and managed by plans. Or other entities at a deep level of expertise around Campbell and administrative requirements. And we think it’s critical that these programs are targeted and designed for the populations that they serve. And that the entities involved in them are very much equipped to provide the right care at the right time.
31:03
Program Flexibilities is so important.
31:05
And I think we saw this firsthand with our one care population, because it was a demonstration program that had way more flexibility than sort of a traditional Medicare or Medicaid plan. We were able to, I said we CCA as well as the State and CMS, are able to directly incorporate beneficiary and family feedback into program design. And this is really, really essential. And one of our phase, one of my favorite programs at …
31:33
to talk about is our member of License program, which is a very structured formal platform for our members to provide feedback on program design and operational decisions at CCA and having that flexibility To receive that empire is essential. And, you know, we definitely heard that point made on it there today, which is a great one.
31:56
Also, having the flexibility to be able to meet our member, social, or health related social needs is essential. And we also talked a little bit about that today. The 2022, we provided services for about two thirds of our members to meet social needs, and in some cases, these are more important than medical care in terms of health and wellness outcomes.
32:20
In terms of enrollment on our one care side, again, we’ve had some very positive experiences of passive enrollment, whereby individuals who become eligible for one care after a series of letters and notifications, are passively enrolls in the program with an opportunity to opt out if they choose. And we think that this has been essential in promoting integration must once people are involved in the programs. And our satisfaction rate is extremely high and also allows CCA a not for-profit health plan, to focus our resources on care delivery.
32:56
Instead of enrollment and marketing and sales pitch, you know, has been incredibly, incredibly helpful for us, too.
33:05
We advocate for either a separate or more likable payment and quality systems for dually eligible individuals. We think a targeted financing quality approach is essential. For example, we have some concerns about whether the Medicare Stars program, which measures quality and the Medicare Advantage program, is applicable and adequately assesses quality for this population. We think involving state measures to assess the adequacy of Medicaid services to you for this population is very important. And also, we are, you know, encouraging more conversations about risk adjustment, and making sure that long term services and support seeds and functional needs and social risk factors are adequately incorporated into risk adjustment.
33:56
I’m almost done with a slide. A strong partnerships, I think, is essential in our one care program.
34:00
We have a three-way contract with both CMS and the state, which ensures that we have people the right at the table, know, helping to oversee the program, and so that we can get feedback from both of our both sets of our regulators. It’s essential and Alaska has integrated financing. This is sort of, a Blue sky asked me, Even though we do have programs like our …, By, which we can use one Finance Financing stream to cover all the services we need to cover for our members rate and Medicare Medicaid herself set separately.
34:35
So I think this is something that would be very important to achieve, because when rates are set separately, you have the Medicare rates and Medicaid rates doesn’t often bring into account whether investments in one program can offset funding or sending an affair last night.
35:00
I just want to switch to the State perspective to just based on, you know, My experience. There are so many more resources available now for states, but that doesn’t mean that can be actually maybe about a decade ago, But that doesn’t mean that there’s not actually need for resources. I think Medicare expertise, first and foremost, is essential for states.
35:21
Most states don’t have dedicated staff focused on Medicare, which, which is understandable, but this has been really important to several of them, more successful state approaches to advanced integrated care.
35:35
So, this is understanding decent contracting, wheat, and hours, just provided a great overview of the way states contract with …, and then also just understanding basic Medicare Advantage functions, like how plans and health plans are paid, what the timeline for play, et cetera.
35:54
There are many technical assistance opportunities that states can take advantage of. The Medicare Medicaid co-ordination Office at CMS is a fantastic partner states, helping them set up programs. They have an equally incredible contractor, the Integrated Care Resource Center, which provides free resources for states to help them along as well as one-on-one coaching. And then other plans are other states rather have sought out support farm dedicated consultants to you to help them design their programs.
36:25
Data is essential.
36:27
Before starting to design a program, states are the initial understanding who is duly eligible, where they get services, where they plan, what services mean. Really understanding how to access Medicare data from a state perspective is really important.
36:44
The state infrastructure is related to resources. I think just understanding staff capacity, or the staff capacity, there are 1,000,001 things on the desk of an individual, working in a state Medicaid office at all times.
36:58
So, really understanding what takes that bandwidth and how this fits in, because it really does need a dedicated a dedicated work stream and selfless ambition.
37:10
Also, going back to sort of key resources, and it is all inter-related. The knowledge to help develop a very targeted program is really essential and making sure that the right plans are in place that have the expertise on the right are vitamins are in place for oversight.
37:28
Not on assigned it very important, is the presence of a champion, usually a leader in the Medicaid agency, that can sort of ensure, sort of oversee and ensure that the States have the resources and attention they need.
37:43
Am committed to, engaging stakeholders is essential. This starts with members, are beneficiaries rather, and their families. Engaging providers is also very important. In most cases, providers are an essential source of chested health information and really make a difference as to whether or not individuals want to enroll in these programs.
38:04
For states getting started, it’s important to take sort of a temperature check of where key stakeholders across the staff jam feel about integrated care and what information is essential to be provided in a transparent way to ensure that all state console, all stakeholders, are onboard, answer it at an asset.
38:23
And then, lastly, commitment to outreach and education support around enrollment is essential. New enrollment processes are incredibly challenging, incredibly overwhelming, and, you know, still, you know, 10 years into the one care program, for example, even longer for the scalpers. We’re still working closely with the state and CMS on helping to educate about the value of integrated care and provide those supports.
38:52
So, thank you so much, and with that, I will turn over the last presentation to Kate.
39:00
Great, so good afternoon, everyone.
39:03
I have the benefit of being last and Q, which means I get to put a finer weight, and all of the really relevant takeaways that my previous colleagues have already emphasized. So my name is Kate Massie, I’m representing the Medicaid and chip Payment Access Commission.
39:21
There are three things that I really wanted to impress upon all of you during this afternoon’s discussion. First, I wanted to just discuss a bit about the data resources that mac pack makes available to the policy community.
39:35
Then I wanted to talk about Mankind’s general approach towards research and where we’ve been focusing and what some of the consistent themes are that have emerged from our research. And then third, I thought I would highlight for you, just a portion or a snippet of some of the recommendations of the Commission has voted on and endorse that are really relevant to the conversation that we’re having about duly eligible beneficiaries.
40:01
Next slide.
40:06
So Alice did a fantastic job of providing a data picture or what’s going on with dual eligible beneficiaries. I’ll just emphasize a couple of additional points, and these points are drawn from our dual eligible data books. So this is a publication that backpack releases on an annual basis.
40:24
We do this in partnership with Medpac, which is the Medicare Payment Advisory Commission, and this is an opportunity for us to kind of see from a data perspective spending, trends, enrollment, trends, kind of the profile of duals at a programmatic level. And our focus at map pack has been on developing a body of work tied to dually eligible beneficiaries. Part of this is driven by the number of individuals who are dually eligible, right?
40:55
So Alice had mentioned close to 13, so we’re carrying twelve point eight million individuals as being dually eligible and then it’s just the totality of funding that both the federal government and states are spending on this population. So approximately $494 billion annually.
41:14
There’s also the dynamic the Alice talked about where for a relatively small populations are driving a large amount of spending, And so that has generated a lot of interest, not only from commission staff who really want to make sure that we’re providing good analyzes for the policy community, but also by the commissioners themselves.
41:35
Next slide.
41:39
Alice spoke a bit about the diversity. Just wanted to put a finer point on it. Dual eligibles are more likely to be female. They’re also more likely to be Black and Hispanic. So it is a very diverse population. Want to make sure that when we’re thinking about policies, we’re incorporating those very perspectives in the potential policy solutions that we’re identifying.
42:04
Next slide.
42:08
Then I wanted to talk about how … approaches its work. So for those of you who are unfamiliar with not PAG, Legislative Branch Agency, and we are charged with making recommendations to the Congress, the HHS Secretary, as well as states. And one of the key values that backpack hold, very dear and close, is that all of our recommendations must be data driven and evidence based.
42:35
So we kind of hold ourselves apart from maybe other policy organizations within kind of the DC sphere, We’re not a think tank. And we’re not thinking about maybe creative or innovative ideas. What we’re doing is trying to really look at the data and follow what the data tell us in terms of our analytics. So all the recommendations that I’ll talk about later on really have an evidence base from which to draw on.
43:02
The other issue that just helps to put our recommendations and our work in context is that per our foundational statute, we are intended to focus on Title 19, which is the underlying Medicaid statute as well as Title 21 which isn’t as relevant here.
43:18
But I think, you know, one of the issues that always plagues dual eligibles is this notion of fragmentation and siloing, And, in this sense, we as a commission within narrow charge, have that same challenge. Which is, the view that we look at when we’re evaluating policy for tools, really, is through the Medicaid lens, and it’s not through a joint lens in partnership with Medicare. Sometimes we do work with Med Pac, as I mentioned with the duals data book.
43:48
But oftentimes, when we’re doing our individual work, we’re looking at it from the point of view of oftentimes, states.
43:55
And what we really want to start with is a policy question that is non biased, that helps to identify what the potential policy levers are that states have to influence outcomes.
44:09
And one of the areas that states really have an opportunity to exercise flexibility might be, for example, eligibility and eligibility policy.
44:20
So we’ve spent a fair amount of time working on Medicare Savings Programs.
44:26
Those are programs that help parcel tools as ALS explain those who go to Medicaid for support with premiums or cost sharing.
44:36
Help understand and kind of explain what those programs are, What flexibilities and what options states have to design the right eligibility policy for tools that fit into their state context.
44:50
The other policy lever that states have is tied to delivery system.
44:54
So, a lot of times, we’ll be talking about Managed Care, because that is the predominant delivery system through which states can achieve integration. There are states, as Allison mentioned, like, Washington that really use fee for service as their chassis for providing care, but Managed Care is kind of the central game in town.
45:15
And when we’ve looked at Managed care, we’ve looked at some of those joint programs that Alice described earlier, like the Medicare and Medicaid plans. They were authorized by CMS through specialists or E.
45:27
Those have been great vehicles for integration. They’re actually in the process of winding down right now. So, map pack has been following the progress that states have been engaged and to make sure that those transitions from the MFP model to the Next Generation model are occurring seamlessly hopefully, with minimal disruption for beneficiaries.
45:50
Then we’ve spent a fair amount of time working on decent related policy at least the Medicaid side of it. So it was really interested to hear Alex’s talk about state Medicaid agency contracts or snacks. That’s been one of the focus points that we have engaged in during our work. This analytics cycle, and I’ll talk a little bit more about that in their recommendations.
46:13
I think one of the things that has been most striking to us, as we’ve talked with states, and, as I mentioned, we’re evidence based, data driven, and qualitative information is one of the key foundational elements of a lot of our research.
46:29
And talk to states, State Medicaid agencies, stakeholders in states, providers, and states, right. Kind of everyone who’s participating actively in the Medicaid program.
46:40
What we hear a year after year, regardless of how the policy question may change, is that Steve’s may not have a full incomplete appreciation for the Medicare Program and how best to wrap around. So that view versus. Michelle’s point when she was kind of ending with fundamentals of how to achieve integration.
47:00
And then the second point is, states are really scrapped in terms of capacity.
47:04
So, even if they have a desire to work on new, innovative approaches to integrate care for duals, they’re also kind of distracted by a lot of externalities that influence how much time and resources they can put towards new initiatives. So examples of that right now would be all of the redetermination work that’s coming out of the end of the public health emergency.
47:31
We just saw yesterday that CMS released its final eligibility and enrollment rule, and more of these, quote, unquote, … rules are anticipated to drop in the coming months.
47:42
And the implication implementation timeframe for those rules is multiple years. And when you’re talking about a state agency that has constrained resources, it becomes really hard to figure out how to prioritize.
47:57
So that leads me into next slide. Some of the recommendations that the Commission has previously made.
48:05
We talk a lot about integrated care, but why is it that we’re focusing on integrated care?
48:10
And it actually goes back to some of marcos’s first points, which is that care can be fragmented, especially in terms of how beneficiaries experience the care and health outcomes can be core. And we at the commission have been looking at integrated care as a solution to some of those issues, because integrated care has the potential to improve overall health outcomes, as well as possibly generate some savings for the federal and state government.
48:42
And so, in June of 2020, in our report to Congress, we issued a recommendation to Congress to provide additional federal funds to enhance state capacity.
48:52
That’s in direct response to information that we’ve collected in June of 2022, and this was also reiterated in June of 2023, we have a recommendation to Congress to require all states to develop a strategy to integrate Medicare and Medicaid coverage for full benefit, dual eligible beneficiaries. And the recommendation is relatively specific, because we actually identify what the components are of an ideal strategy.
49:22
And it ties back to what I had just said, which was, What do states have kind of control over? What are the policy levers that they are able to exercise? So that includes the integration approach, which is really, how does care delivered in a Managed Care environment isn’t in a fee for service environment.
49:43
What is the, or what are the parameters of eligibility and benefits covered, what type of beneficiary protections are incorporated into the program and how our state’s engaging beneficiaries as well as other stakeholders in the development of a strategy. It really meets the needs of people who are engaged in the system on a regular basis.
50:08
Then the other elements are, include data Analytics, as well as quality measurement, because we really want to make sure that we’re focused on and able to track outcomes.
50:20
This year.
50:21
Next slide, we’re going to be voting on in our April meeting, a couple of recommendations that came out of our work on State Medicaid Agency contracts for Snacks. And just as a reminder, these are the contractual vehicles that States use to provide expectations to use net operating in their program.
50:45
Similar to what Alice and …, we actually looked at all of the smacks that we’re currently approved by CMS.
50:51
And what we were trying to figure out was whether or not there were any themes, but then also, whether or not there were any requirements that really should be applied to DCPs operating in every state.
51:04
What we’re asking the Commission to consider in our April public meeting, all those backpacks business is conducted in public and that is where the commission nurse will have an opportunity to endorse some of the work that staff have been plugging away. I will be a recommendation directed to states to select in their smack. The opportunity for … to provide care co-ordination data, as well as Medicare Advantage encounter data to the state.
51:35
So that not only can the state start looking at health outcomes, but they can start to really build a foundation for overseeing decent performance in their seats in their markets. Because that was something that we observed was relatively uneven newburn looking across all Medicaid programs.
51:55
We also are taking an opportunity to reinforce the CMS should issued guidance to states, kind of giving them tools to develop an integration strategy. If it’s not a requirement that Congress may impose, it’s something that the state can do individually. And so we’re encouraging CMS to provide States with appropriate technical assistance to not only develop their strategy but also to think about how smacks can be, a core component of that strategy.
52:27
So next slide, I just want to maybe end here, and then turn it back to briefer questions. Really appreciate, again, the opportunity to talk about some of the work of the commission that’s engaged.
52:45
Great. Thank you, Kate. And thank you, everyone.
52:48
And I think if the whole panel can come back, on camera, will start the Q and A We’ve received a number of questions from the audience so far.
52:59
So thank you, everyone that’s submitted and please, you can keep them coming and we’ll do our best to get through everyone’s questions.
53:07
We have, we have a good chunk of time left so hopefully we can, and I’m gonna start with a question that keeps us kind of at this big picture coming off of Kate’s Cates remarks. And also, it’s, it’s getting to lunchtime maybe in California. So, I like this audience members description about spaghetti here.
53:26
So, so, Kate, you spoke to some of the recent mac pack recommendations, including one, to provide more capacity, the states, to develop integrated programs, and one to require every state to develop a strategy to integrate coverage for full benefit dual eligible individuals.
53:43
Curious a few parts to this question. So, what do you see as key considerations in the path to having that integrated option? Every state?
53:51
What are the biggest barriers, and then specifically, the description here?
53:55
So there’s a spaghetti bowl of different models right now available Some for similar populations with bearing implications for the quality, the safety equity, person centered ness of these programs. So, what are, what is the conversation? What are the considerations for moving to a national system of national standards, national oversight.
54:17
And I can maybe start with you, Kate, and certainly welcome others to jump in as well.
54:22
Sure. So, I mean, I think that one of the themes that has really emerged is this idea of state capacity. And I’ve mentioned, you know, some different policy issues that are coming down the line that will require a fair amount of implementation activity at the state level.
54:40
I think the, um, some of the other considerations and potential barriers, really, is this issue tied to delivery system.
54:49
No. Like I said, Managed Care really is one of the central vehicles for integrating care.
54:56
But, there’s also this challenge that, when we talk with rural states, for example, or states that don’t already have a Managed Care infrastructure in place, on which to build the kind of ideas for how to integrate become more challenging. And I think Washington has hit this, kind of, They found their magic bullet.
55:17
It really works in their state, but I’m not sure that that is as transferable, too, other environments. And so, I think states are really grappling with this, which is what is the mechanism to integrate when there’s not a strong infrastructure in place?
55:32
And I think the other thing that, you know, we’ve observed is that it gets a little bit to the point that Michelle made, in terms of stakeholders, but then, also providers, is that when you get to varying levels of integration, and you have such an array of services, that includes the acute care, the LTSS, the behavioral health, et cetera. It becomes, also think, challenging at a state level, to kind of bring everyone in and bring everyone along, right? Because a lot of times, there might be a lot of history in terms of why providers provide their services in a certain way under a certain program with certain parameters. And the pastors integration can be somewhat disruptive. And that’s always scary when you’re thinking about systemic change.
56:23
And I can, I can add to that a little bit. I mean, I agree with everything that Kate just said. I think, you know, ultimately, at the end of the day, these programs were designed separately, and have statutory authority, so it based, you know, based in laws, made by Congress, you know, 50 plus years ago. And I think that they just, they were not designed to work together.
56:45
So, I think when you’re looking at trying to apply, you know, some of that principles that we’ve all touched on in, VR, in our, sort of, our, with, our various perspectives to one national program, I think that’s challenging. Because you have these, the statutory language in place that can’t be changed unless the actual statute, unless Congress passes a new law to change it.
57:11
So, I think that, you know, the financial alignment demonstrations for like an inmate, which and we’re a part of length or one care program, was an amazing opportunity designed by the Medicare Medicaid co-ordination office to waive some of those once.
57:27
So, that, so that states and the federal government work together to design more flexible programs. But I think absent that waiver flexibility, or demonstration flexibility, it’s really challenging.
57:39
You know, I think, too, know, the states Julia eligible individuals receive coverage from both step met: the Federal Medicare Program, and the Medicaid program, which is a state and federal program. So, I think that there’s a considerable amount of variation between the state programs in terms of what’s covered, how a moment works, you know, how people receive services. Particularly, for this population. How to the extent to which individuals receive services that allow them to stop reside in their homes, and their communities is very different across the board.
58:14
And I think that, I mean, I think having a national has done that led to sort of reduce some of the noise with thali.
58:23
No tens of options, you know, that people have no at their fingertips. Which can be very confusing, would be an incredible goal. I just think that there are many systemic challenges to work through to get to that point.
58:39
Absolutely. Marcus, or else, I want to give you both an opportunity as well. If you want to respond there, we have plenty of other questions I can take us to as well.
58:47
Well, I just want to respond in that I’m a part of this panel here, because I’ve heard a lot about the stakeholders in the beneficiaries receiving services.
58:57
It’s so important to always remember, before me two components to integrating off the snip programs.
59:04
We are the attitudinal barriers have to change.
59:07
We have to take that mindset shift though, realizing the stakeholders need to be part of E-commerce solution at all times They have to be part of the conversation. And I know as a person with lived experience with a disability, a lot of times they’re going to speak, and I’m like, We as the community.
59:22
How you make decisions: one narrative, you have the license to speak to, then we have a digital company, … from the medical festivals.
59:30
All these medical profession with knowledgeable of the of the individual within a community serving, what about the disability company, services from providers, other providers?
59:41
App to understand thing.
59:43
This is a durable medical clinic they can’t wait around 5 or 6 months for a wheelchair that they need to go to the medical appointment to be serviced.
59:52
And, I’m really glad to be part of this conversation with the panelists that we’re on the same page in the sense that having this take hold this be period and have the opportunity to speak to it. And so, we can make real changes.
1:00:15
I just had one quick follow up no occurring … point about the fee for Service Conundrum.
1:00:22
And it is true for some states where they just don’t have a robust Medicare Advantage or Medicaid Managed Care plan market to begin with.
1:00:32
But even in states that do have fully integrate managed care options are still people, all traditional Medicare and Medicaid fee for service. They’re still carved out services.
1:00:44
Also, I think that having evil states with the Managed Care option, what is the alternative for people who don’t want to be in Medicare Advantage?
1:00:53
Is there a meaningful integration option that doesn’t involve some type of Medicare plan in those states?
1:01:02
Absolutely. That’s a great point.
1:01:04
And I think I think there is some, there are some conversations absolutely happening in that space, so some states and maybe some movement that we’ll see.
1:01:13
I’m, we received one question. This is we haven’t talked too much.
1:01:17
This has been mentioned, but pace, so we’re talking about these SNPs. We’re talking about Medicare Advantage.
1:01:24
There are conversations about the quality of peace. It’s a fully integrated program.
1:01:29
I don’t know, Alice K, if you want, if you want to start here, in terms of what are the considerations to scaling up, we’ve seen that, um, what are the considerations there?
1:01:43
I just, I’ll just say a couple of things, So I would say, stay tuned, because I didn’t really have a chance to talk about … feature work, but piece is on the agenda.
1:01:53
A lot of the projects that we engage in, have, like an 18 month plus runway, because we are doing such an intensive research, but we will have presentations in the upcoming cycle tied to Pei’s. I think that.
1:02:06
Speaking more from my state had when I was with Michigan, I think one of the challenges with piece really is the bricks and mortar approach and the price of entry. Because pays providers really need to fully invest in a piece site.
1:02:24
And that requires a fair amount of capital infusion that needs to occur before the first beneficiary walks through the doors, And so I think that’s one definite issue types of pays. I think the other is the placement of the pace site itself.
1:02:39
Because you need to have a certain number of beneficiaries enrolled in order to make sure that the business model is sufficient, and while I think some beneficiaries, for example, in rural areas, may be highly interested in peace, there are considerations about drivetime, proximity, kind of things like that. And so I have personally found in terms of how I observe the peace program.
1:03:07
Evolving is that it’s usually in more urban concentrated centers. But Alice, what would you say?
1:03:15
Well, I agree with you completely.
1:03:18
The other piece of it, I guess there’s a couple of pieces.
1:03:21
one would be the risk component. You get the model off the ground. You end up with pretty high risks for a provider group to absorb.
1:03:30
The current bipartisan discussion draft tries to get at that by adding risk corridors to support near post programs, but again, you’re asking the pie, that’s all you’re asking the provider group to take on a lot of financial risk for our population. That, by definition, has high medical spending.
1:03:49
I think the other piece that I don’t know a lot about is, but what this model translate to other groups. People under age 55.
1:03:58
People who may not need an institutional level of care but could be at risk for institutionalization.
1:04:05
Maybe some people with behavioral health conditions, how can we take the best practices of pace, the things that work really well in that model and apply it to people who don’t currently meet the pretty limited coverage.
1:04:20
With that, Allison, I think some of the conversations we’ve had has definitely has looking at pace if looking at the Medicare Medicaid plan, a capitated financial.
1:04:29
I’m a demonstration of that phasing out and thinking about how we can extract the best of these models and scale more broadly.
1:04:37
And I think that’s, that’s a real big piece of the conversation, I think that’s happening now, and that will continue to happen and evolve over the next coming years.
1:04:46
And I think with that, I’m, we received a question about how these steps, which are the primary platform of a lot of the integrated care conversations that we’re having now, a lot of the integrated care enrollment today. How these are fundamentally Medicare Advantage plans, which means they have federal requirements, even though they are operated at the state level. And they are really special. And that states have that state Medicaid agency contract that many of you spoke to, the snackbar or snap.
1:05:15
So, we, we received a question about how states can use that to adjust the snaps to meet their beneficiaries needs in their state. So, I think, Michelle, I might pitch this to you first from, both from a plan perspective, but also from your, your experience, working at the Center for Health Care Strategies. What flexibilities do states have to adjust to their program and what are those limitations that we’re aware of today, in terms of how far they can push those models? Now, that’s a great question, and I think I’m Alice, I’ll say about two and a lot of those details as well. And she had a great slide that sort of outline some of the most common ways states have easiest contract.
1:05:56
So, for a smack, a state Medicaid agency contract, all of DCS that participate in a state must have a signed contract.
1:06:06
So, I think, just, even just that, give states a lot of power.
1:06:10
A state does not have to sign a smack with any plant. I mean, they have total discussion about which plans they assignments. So, that’s, sort of, you know, Step one is, they can, basically choose who provides the services in their state. And there’s also, I mean, they really have a lot of flexibility, there, should have a minimum threshold.
1:06:31
That requires a plan to acquire any Medicaid benefits and report on some inpatient admission information, That’s sort of the threshold. And the change can really build upon that by requiring certain benefits by requiring … to also provide Medicaid benefits so far. And that can look a number of different ways. I mean, one of the ways that Massachusetts, just as with our skull program, which I think, is a very effective way to do this, is they Lynette depopulation enrolled and Scout who dwells in Massachusetts unique, why they have to sort of H programs that are defined by age. And then on the …
1:07:14
snap day limit, enrollment to jewels, and also to require states to provide embracing, the states, I’m sorry, require the plans to provide every single service, Medicaid service, that would otherwise be available to individuals who are dually eligible and Massachusetts, if they were to enroll in fee for service. So, we have a targeted program designed for the population and also that must cover all service as required. States can require data. They can write plans to share data, they can McGuire around quality and that checks utilization. No, any, basically, any report that you want to see from a decent at the state can require it.
1:07:59
Certain benefits covered, they really do have a lot of flexibility. States can a few marketing materials to make sure that what a plan says about what they cover and Medicaid is actually true.
1:08:11
I mean, there’s, there’s a lot of levers that states have with this map, I do think that there are some limitations, you know. And some of the things that we’re concerned are, you know, we’ve been concerned about, for example, when our one Care program will share my Demonstration Authority and Medicare, Medicaid plan to it.
1:08:30
one is sort of the flexibility that I, that I noted in one care, that advocacy community and in Massachusetts is robust and powerful and it kind of off.
1:08:42
And they worked very hard to give input into program design and operations, really an average staff.
1:08:51
And the state has been able to make a lot of changes to the one Care program and implement several flexibilities that might be more challenging under Medicare nach Platform.
1:09:03
The integrated financing point that I mentioned earlier, where even if ultimately, a plan covered services and receives funding for the fall program, rates are still set on the Medicare side, through the Medicare sort of rate setting a pilot. On the Medicaid side and combined, So, again, it’s great to have the full pot of money, that is essential, but if you asked, for example, is making investments and long term services and support to keep people out of the hospital and out of nursing homes and meeting their needs in the home?
1:09:37
The Medicare rates heading immunization data is not is getting, you know, you’re having reductions on the Medicare side, but you’re not as you might be spending more on the Medicaid side, but that is not incorporated in sort of the big picture. So I think at the integrated financing, it’s is a big piece that’s missing.
1:09:57
Oh.
1:10:00
And I think that makes me the the integrated financing is going to draw me to the next question here that we have from the audience. And Marcus, I might ask you this one.
1:10:10
First is, so this question is talking about the 11 15 demonstrations and how they allow Medicaid to pay for things like housing and food and health related social needs.
1:10:22
So thinking about that in the context of dual eligible individuals and how integrated programs can provide a totality of services, in theory, for beneficiary’s needs.
1:10:34
Can you speak to all of the, the need, the value, the results that we’re seeing, for, for programs that address health related social needs? What’s, what is the need there, and how can these programs be designed to support individuals?
1:10:49
Every other, though, it’s great.
1:10:50
I mean, just bring your whole 11, 15 waiver If you look closely, this was the first year of the word disability with even mentioned in the dilemma 50 waiver.
1:11:02
And that’s a big, a big accomplishment, but you’re bringing up best practices, a lot of dual eligible program, the program. So how do you integrate it with the best services, meet the needs.
1:11:16
Those are, all the inequities are visible is they need to come from a preventative approach rather than, let’s wait for the person to be injured in the service, in address it.
1:11:29
If it’s put that much more high chip or meaning, the monetary to people, and most importantly, it’s impacting the individual needed services. in a negative way. We’re going to innovate in bed for months on end, medical facilities.
1:11:44
And so the, with the 11 15 waiver, many of us going out, Albany speaking to the Medicaid director, you can do different legislative and bringing to the attention that you need to come to them.
1:11:59
Your constituents, in understand how, what is provided at this point, is not meeting the needs.
1:12:06
And it’s really not imply that introducing words like disability to the waiver, but it’s still not as relevant as it needs to be to address it.
1:12:17
So, in the community, we’re not getting, you know, we, you know, we mentioned about the snip thinner and on how it appears to address certain need. But, it, really, when you live the lived experience, it’s challenging to get those services in the week.
1:12:36
That is, you know, more readily available. We don’t have the week.
1:12:41
We have the community doesn’t have to wait to get a motorized wheelchair.
1:12:46
Wife to in six months to get the pandemic was a big factor in putting a lag on complex durable medical equipment OK, but it needs to really come back together and building the needs of the community.
1:12:59
I think the other thing I would add to marcus’s comments, on health related social needs in general, and this is kind of in addition to bits, like somewhat outside of the 11 15 waiver. And we haven’t talked about it yet, really is the model of care.
1:13:13
Right?
1:13:13
And I don’t know, Michelle kind of pull you into this conversation, but one of the key aspects of D snips that are not required of just none dease new Medicare Advantage plans is a model of care.
1:13:27
That’s really supposed to be talking about how the plan is approaching care, care co-ordination. What is their philosophy? What do they think about? supplemental benefits, wrap around, benefits, things like that.
1:13:39
And, from my perspective, again, just like more from the state side. But, I was expecting when we were kind of talking about models of care that things like social determinants of health and health related social needs would be addressed. And, Michelle, I don’t know if you, if, you have anything to say to that as well?
1:13:59
Yeah, that’s a great point. And at like, a huge, our mission that I should have brought into the question around, what can states do with their distant contracts? And I know I’m definitely, states, have done this with the three-way contract that governs the and then she is and the financial alignment demonstration.
1:14:14
In addition to G Snaps, you’re acquiring a meeting, way more robust care model, compared to other Medicare Advantage, and states can have that, you know, they can use their context at retirement.
1:14:29
So there are no pages, and pages, and pages, …, Massachusetts, around our models carry, you know, what the care management ratios need to be, how the management process needs to work.
1:14:44
Massachusetts, even, and this is another flexibility in our financial alignment demonstration, created new services that were not available under the Medicaid program related to community based, behavioral health care, other, and other sort of, health related social needs, or requirements, that, there are no handoffs and handoffs with, You know, sort of a next step around. Getting people connected to the right terrorists is even if Medicaid doesn’t pay for everything. So, just to be clear, to, Medicaid. Doesn’t pay for everything, but there is definitely a co-ordination element that plans can help them.
1:15:19
You know, they identify a need through an assessment, can help ensure that their members are connected to the right place, to help get that need met. And I think that’s essential.
1:15:30
You’d like to the whole, the whole thing by itself.
1:15:34
That is, really, that’s a very, very important element tag, making sure this disguise, right?
1:15:43
That’s a great point.
1:15:44
And I think that, in terms of what’s, what’s coming next and the movement, we might see along those lines, in terms of model of care, sometimes models of care on the SNPs, on national plans.
1:15:55
You’ll have a different or same model of care in multiple states.
1:15:59
But I think moving forward, we can see what’s called the single contract, or the single each contract pathway.
1:16:04
And we may see more of that coming around and states leveraging that so that they can really have tailored models of care for their individual populations and leaning into that lever more tailored to their specific cultural populations and demographic needs them in the state.
1:16:22
And I think that makes me, that actually leads us into another.
1:16:27
one of the questions we received is about the, the data gaps that states have and how they have limited insight into data. So we know integrated care programs solve that to a certain extent for, you know, having a plan, have line of sight there.
1:16:42
But does anyone want to take this one in terms of thinking about the data and reporting gaps for for dual eligibles and how we can start working towards having states have a bigger picture, a more full picture of care needs and what folks are getting.
1:17:02
Good question.
1:17:04
Yeah.
1:17:08
So, I can start again, but I have a feeling that Alice is going to basically can tag team with me.
1:17:15
So, the data gets a real. I think that one of the things that I have mentioned in my comments, I reference the duals Data Book and I know that they’re kind of like other folks about town who are trying to help elucidate the situation with tools, the policy issues. Because I think data driven policy solutions are usually the ones that get the most traction.
1:17:37
We have found, for example, that trying to match and marry, Managed Care, encounter data is challenging, So that’s one of the projects that we’re currently about to kick off in partnership with Medpac, which is, can we talk a little bit more about utilization? Can we shed light on beneficiaries experience in Managed Care, that, right now, is a gap for us, that we are very interested in trying to fill.
1:18:06
I think the other issue, is that states also have a lot of gaps.
1:18:10
I think, when we’ve talked with states, they don’t always know, kind of, exactly, where their jewels are. And I know that that sounds kind of nutty duals, can be in Managed Care. But, then, they can be in, you know, different health plans. But, then, is that aligned enrollment with their Medicare Health Plan? They’re not always getting, I think, good and up to date information from CMS about Medicare enrollment. Which means that when they’re trying to craft integration strategies, sometimes they’re doing it a little bit blind. And I think the resources that Michelle mentioned, like ICRC are invaluable in, trying to help states, try to plug some of those holes. I think the other thing that maybe I’ll say before handing off the time is that was one of the things. This kind of notion about data.
1:18:59
And trying to build a basis for being kind of smarter and more informed about the questions that states are asking, the questions that federal policymakers are asking, That’s what led to the proposed recommendation that we’re presenting in front of the Commission in April, Which is a recommendation that states are systematically collecting care co-ordination data, and Medicare advantage data. I think they will be heard when we talked with states, candidly is that if they get MA data, they’re not 100% sure they know what to do with it. Or it’s a little bit intimidating.
1:19:33
And that goes back to some of the other things we’ve talked about in terms of states, not always having, like a really sharp understanding of all the nuances of the Medicare program. And no one would expect them to, unless they’re going to be the, kind of the ones driving the solutions on dual eligible policy.
1:19:50
So we’re hopeful that the first step is collecting the information, and then the second step is kind of trying to then dig in and figure out what findings, what patterns, way in anomalies States can find that will hopefully lead to other more targeted conversations within them, as he, within the Medicaid agency, but also with the DCP to kind of figure out what’s going on in the ground.
1:20:19
Thanks for starting, Kate.
1:20:22
I think I agree with everything you said. Again, I sort of think about the data gaps as we have to sort of separate sets of problems.
1:20:31
And the first is what I would call enrollment problem, which is just the fact that eligibility or plan enrollment systems don’t talk to each other.
1:20:40
Also, on the Medicaid side, the states may not know, which people who are Medicaid only, they turn 65, did they will …, do they qualify for these programs? How does that transition work? This is not a seamless or integrated experience.
1:20:59
That’s just for even if the people have both Medicare and Medicaid. That’s not even getting into this plan alignment concept.
1:21:08
And I think the plan alignment is an interesting one and raises some tradeoffs.
1:21:13
I believe California has been experimenting with trying to auto assign people into Medicare plans.
1:21:20
Wait, there’s a whole bunch of Medicare freedom of choice, was things to iron out there.
1:21:26
All the, frankly, equity issues of people without Medicaid are not being auto assigned into Medicare Advantage plans.
1:21:36
Is hard to implement these fully integrated these steps, if the same people aren’t enrolled in both the Medicare and Medicaid pieces of it.
1:21:46
The alternative data, I would agree, is a big issue, Both looking at the data, the complete list of the data are the plans, some mobile data, to CMS, and the state. This is both the Medicare and Medicaid plans.
1:22:00
My understanding is for the Medicare Advantage plans that offer supplemental benefits, are not required to report toddler data.
1:22:09
Anybody.
1:22:10
And those are the benefits that with Medicaid covered square, co-ordination, and integration is really important. And so, the fact, there’s really no oversight or eyes on those data, seems like a pretty big barrier.
1:22:29
Anyone like to respond to that?
1:22:32
So, I do think it can be a barrier.
1:22:34
I think that, in a de snap setting, States can required SNP SharePoint, that they cannot do that for Medicare Advantage plans outside of a decent, because there is no sort of contracting authority, or any type of, like, linkage between a standard Medicare Advantage plan and a state. So, that’s why that would be a blind spot.
1:22:54
And CMS has proposed, and nothing has been finalized, but has proposed some regulatory changes to make supplemental data, a supplemental benefit data, more transparent, cell improve.
1:23:09
But, yes, I think that, that there are, definitely, I think, particularly outside of the …, snap, an MMP space.
1:23:18
Gaps in Medicare Advantage data, shangla states, again, it’s, and I don’t think it has, and, not necessarily, because, plans, literature data. I think it’s, there’s just not a mechanism by which that happens.
1:23:32
No, and all sort of formal process.
1:23:36
Absolutely. I think that that’s a conversation we’ve certainly had with a number of states in terms of what that looks like. And how How that’s actualized, And there, there are a lot of people, I think, interested in figuring out how to make that work.
1:23:48
And, Kate, I want to go back to where you are.
1:23:50
Where you started, I think in this conversation is so much developing these programs I’m working with State Medicaid agencies is getting an understanding of where their dual eligible beneficiaries receive care today.
1:24:03
So when you’re thinking about designing these programs, it’s a lot of kind of the first step we take in conversations with states.
1:24:10
This is trying to just map out a grid of where your population sets among the various scenarios, in terms of receiving Medicaid and Medicare today, so I think that’s a really important first step. Is to have that enrollment line of sight at the state Medicaid agency.
1:24:26
And, and I know we’re, we’re coming up on time here, so I wanna be mindful of that. We have, we have one question that’s kind of the big picture question, and if anyone can solve this, they get some sort of prize.
1:24:38
So, this is, how can we help states understand how Medicare drives the trajectory for preventive primary care, clinical care, and long-term care, which impacts the care costs of complex populations covered under Medicaid. So they really need to pay attention to Medicare.
1:24:56
How do we solve that, or how do we move the dial there?
1:25:07
Oh, OK.
1:25:08
Am happy to just throw out a suggestion. Again, I’m not solving any problem. I said that this is not the end all, be all solution, that 1 1 thought. Is that again, going back to the financial alignment demonstrations, I think, you know, one of that, I think most innovative features of those demonstrations was a shared savings component where if a, certain sort of, quality thresholds are met.
1:25:33
States could share in the savings.
1:25:37
Yeah, I’ve heard to Medicare So basically this means that if a state invested a lot of services and supports behavioral health services or other Medicaid services and impacted Medicare utilization, so, for example, faces an inpatient admissions, our emergency department visits, or what have you, States were able to share some of those savings. But health plans are sort of taking the top rates prospectively. …
1:26:07
mentioned in Washington State the state through the managed for service actually hit all their metrics are able to recoup you know, millions of dollars in savings that went back to the State based on what the Medicaid investment was able to achieve on the Medicare side.
1:26:24
So, in terms of, you know, a way to pay attention to what Medicare does. I think financial incentives are one very compelling app to do that.
1:26:38
And Marcus, can I ask you, in terms of the individual perspective, where have you seen movement and attention paid to improving integrated care programs? And paying attention to that dynamic with Medicare?
1:26:49
What, what can everyone be doing?
1:26:51
Well, I know I want to go back to when you were all speaking on the data, the quantitative data is so important.
1:26:58
I must re-iterate that the data is so important and we saw during the pandemic, especially in New York State here, we notice that there was a scramble to see how many people in the community had a disability.
1:27:13
It would need that, external or extra services to meet the needs.
1:27:17
There were no numbers, there were no numbers. Go into your agencies and wind up in your own personal life when you call for medical appointment.
1:27:26
Is the representative?
1:27:29
Do you need any accommodations, or your wheelchair user, when you come into the medical facility?
1:27:33
Those numbers are not being respected, they’re not even being asked, so Medicare and Medicaid to reason about them, to the end, who the service, in what service.
1:27:44
And I really believe that it’s one of the big components.
1:27:47
When you understand your demographic, who you’re servicing, you can provide better services.
1:27:53
But if you just leave in a ***** nilly in the air, you don’t know what you’re up against, and, therefore, leaving the member.
1:28:01
We call them our Independence care system, the member in a place where services are not going to be co-ordinated, the best meetings.
1:28:14
I think that’s critical. And, Allison, I want to be mindful.
1:28:17
We are two minutes out, I think this is a really valuable conversation, and I want to thank, um, Mark, S K, Alice, Michelle, around my, around my zoom screen here, and this is a wonderful conversation and I’m privileged to be a part of it.
1:28:31
And I think this is ending here in terms of eliminating the individuals that that these programs are serving and who these populations are and the diversity of them and their needs is really a critical point to end on.
1:28:43
So, I think with that, Alison, I’ll turn it over to you.
1:28:48
Thank you so much free and Marcus, Alice Michelle NK for joining us today and for all the important work that you do to improve health care and outcomes for dually eligible individuals. I also want to thank all of you who took time to join us on today’s webinar. We hope you found this discussion and formative and we’ll be able to take some of what you’ve learned here today and use it in your work. And before we go, we want to hear from you. We appreciate you taking a few minutes to complete the brief evaluation survey that you can see here. You’ll also receive it via e-mail later today. And I think our team has put it in the chat, as I speak.
1:29:20
here at the Alliance. We host educational webinars, and in person events throughout the year, and we invite you to follow our LinkedIn, or visit our webpage to sign up and receive the latest updates about our upcoming programs. Please keep an eye out later this spring for an invitation to join us for a virtual conversation on health policies that will be front and center during the Presidential election cycle this year. And we’re also excited to announce that our 2024 Signature Series will be on AI and Health Navigating New Frontiers. And our public summit will take place on july 25th this summer, so stay tuned for more information. As a reminder, a recording of this Webinar, and additional materials, including the slides, will be available on the Alliance website. This concludes today’s discussion. Thank you all for joining, and have a wonderful rest of your day.