State seeking greater coordination between Medicare, Medicaid

WASHINGTON–If you have two kinds of health insurance, one would think your care would be twice as good.

That’s not necessarily so when you are poor and elderly or disabled. Many patients who fit this description are covered by both Medicare and Medicaid, the nation’s two major government insurance programs.

But their coverage is often seriously restricted and has major gaps. Their care is disjointed and even ineffective. And it’s almost always expensive, often unnecessarily so.

In Connecticut, there are an estimated 100,000 so-called “dual eligible” patients-people who get some coverage from both Medicaid and Medicare. Many of these patients are chronically ill, seriously disabled, or both.

Because of programmatic restrictions, limited provider access, and minimal financial resources, they face some of the highest hurdles to getting the specialty care they need. At the same time, though, this small group is the most expensive segment of the state’s Medicaid population, representing about 20 percent of the program’s patients but nearly 60 percent of its costs.

Nationally, some advocates fear this population is particularly vulnerable right now, worrying they could fall victim, in many states, to the budget axe as governors across the country try to close gaping deficits.

In Connecticut, Gov. Dannel Malloy has not yet said how he plans to deal with state’s growing tab for the Medicaid program, although he has highlighted it as a budgetary problem he needs to tackle.

But Malloy’s office did give a green light to a new initiative by Connecticut social service officials, who this week submitted a federal grant application seeking $1 million funding for a new way to help “dual eligible” patients. With the grant, Connecticut’s Department of Social Services aims to increase the quality of care and reduce the cost of serving these patients.

“The potential is extraordinary for this initiative to improve both the quality and the outcomes and the costs in serving these individuals,” said Mark Schaefer, DSS’s Medicaid Director who took the lead on crafting the state’s grant application. “What’s different about this approach from past models is that it focuses on creating a local consortium of providers of markedly different kinds of services–home health, primary care, specialty care, hospital emergency departments, and community-based services and supports.”

He said the initiative was particularly attractive because if the state succeeds in reducing the costs of treating this population, some of the savings will flow back into Connecticut’s coffers.

Health care advocates in the state are generally applauding DSS’s move, saying it could be a model demonstration project under the new health care reform law. But they are wary about the details and the execution. Among other worries, there’s a fear that DSS may try to move this population into a managed care-style system, putting these very sick, poor patients at the mercy of providers’ bottom lines.

But no one disputes the need for a change in the status quo.

Right now, care for these patients is “highly fragmented, duplicative or unnecessary, confusing and often delivered in inappropriate settings,” a draft of the DSS grant application states.

Sheldon Toubman, an attorney with the New Haven Legal Assistance Association, describes their care this way: “It’s uncoordinated within Medicare, it’s uncoordinated within Medicaid, and it’s uncoordinated between Medicaid and Medicare. So there’s real plus in doing something about that.”

The state’s application, submitted to the Department of Health and Human Services, seeks planning money to create local “Integrated Care Organizations,” one-stop shops for dual-eligible Medicare and Medicaid patients to receive care that is overseen by a primary care physician, in coordination with a team of other providers, from hospitals to nursing home workers and anyone else who has contact with the patient.

“Care for dual eligibles is part of a national problem; Connecticut intends to be part of a local and national solution,” the DSS draft application states.

Ellen Andrews, executive director of the Connecticut Health Policy Project, said she recently visited such a facility in Boston. The health care team there described solving a health care mystery afflicting an elderly woman: severe rashes that had put her in and out of the hospital on numerous occasions.

After a “huddle” that included everyone from her primary care doctor to a bus driver who transported the woman to adult daycare, they settled on the culprit: her cat, which had fleas.

“The hospital staff couldn’t figure it out because they didn’t know she had a cat with fleas. They had to talk to her bus driver” who had seen the pet and suggested the source of the problem, Andrews recounted. “So they got the cat a flea dip, and the woman was fixed. And they probably saved tens of thousands of dollars on this woman.”

Under most other health care scenarios, flea dip wouldn’t have been a billable expense. But this innovative arrangement made for a cheap solution to an otherwise exorbitant health care problem.

Schaefer said the grant funding would help the state connect disjoined pieces and eliminate just those kinds of problems.

The idea is to “basically you draw a circle around this whole collection of providers,” Schaefer said, and ask them to shift their focus from each separate episode of care they provide to looking at “how well they’re serving the whole individual and how well they’re interfacing with the other provider.”

The idea, say both policymakers and advocates, is that more comprehensive and preventive care will save money by keeping patients out of the hospital and managing chronic diseases before they become an emergency.

The new Integrated Care centers will set up a “single point of accountability” for a patient’s care, the grant application states.

“Coordination of medical care, behavioral health care, long-term care and social supports is critical and lacking,” the DSS application states. “Providers often do not have complete information on an individual, leading to service gaps and duplication in treatment and confusion on the part of dually eligible individuals, their families and caregivers.”

Through the ICOs, patients will be able to “access a seamless continuum of enhanced medical, pharmacy, behavioral, and long-term services and supports, under one program,” the grant states.

Whether the state can deliver on these lofty promises is another question. HHS will award 15 grants in all, and it’s unclear how Connecticut will stack up in the competition.

Even if they do get funding, Toubman and others have some concerns about how the program will get put into place. Toubman said that DSS originally wanted to implement a form of managed care, known as “capitated care,” for the dual eligible patients. That would mean doctors and other providers would be paid a set amount for each patient, as opposed to being able to bill for each service provided as necessary.

Capitated care can lead, Toubman and others say, to patients being denied needed treatments because physicians or other providers realize they will not get reimbursed.

Under pressure from him and others, DSS has agreed to use a regular fee-for-service system if they win funding for the Integrated Care Organizations. But agency officials say they still want to examine the capitation option in the future.

Advocates also pushed back, with less success, against DSS efforts to put all dual eligible patients into this new program automatically, without affirmatively ensuring they wanted to try it out or even knew they were being shifted.

“This is a vulnerable population with chronic diseases and in some cases mental illness and in some cases confusion,” Toubman said. “It’s pretty obvious that people would end up in there even though they never intended to.”

Schaefer said his main concern was getting enough patients into the system to make it viable.

“It’s much harder to attract participants to some system they’re not familiar with. It’s easier to simply include folks by default” and then give them an  opt-out if they decide they don’t want to participate. “My concern as a purchaser is to have a project that’s feasible and had enough participants.”

This issue hasn’t been fully resolved; DSS agreed not to specify in the grant application whether they would have an automatic opt-in mechanism or not.

“That’s part of what we will work through” if we get the grant, Schaefer said.

Asked how successful the grant funding, if awarded, would be in reducing the state’s Medicare expenses and improving care for this population, Toubman said, “the devil’s totally in the details.”