State trying to improve care for high-need, high-cost clients

They represent a tiny segment of Connecticut’s population, and less than 10 percent of those who get their health insurance through the state’s Medicaid program.

But a group of just over 57,500 people represents nearly 40 percent of the cost of Medicaid, the largest single item in the state budget. The group includes poor seniors and younger adults with disabilities who receive coverage through both Medicaid and Medicare. Their care costs more than $3 billion a year — an average of $53,500 per person, or 55 percent higher than the national average.

Sheila Amdur

Sheila Amdur

And despite the price tag and dual insurance coverage, state officials and advocates say, the health care they receive is often inadequate. There’s little or no coordination between the various health care providers they see, or between the two programs that cover them. Some struggle to find doctors who will treat them at all, or can’t afford copayments on medications they need.

“They’re the poorest of people in Medicare. They essentially have some of the most chronic conditions, much higher degree of disability. It’s a disproportionate representation, particularly the under 65, of people with serious mental illnesses,” said Sheila Amdur, a longtime advocate for people with mental illness. “And there are specialized systems that work with particular kinds of issues for those folks, as there are for people who are elderly, but those specialized service systems often do not work with the primary care doctor closely, or the hospital. So there’s a disconnect between the various support services and primary health care and specialty services.”

State officials are hoping to design a better system and are applying to run a federal demonstration project that could net the state additional funding if it saves Medicare money.

The model, outlined in a draft application slated to be submitted to the federal government next month, calls for improving care coordination, in part through creating “health neighborhoods” — teams of health care providers who would take a more holistic approach to a person’s care. They would focus on preventing and addressing problems, making sure care received in various settings is aligned, even addressing a person’s living environment and housing if necessary.

Amdur, who leads the committee charged with designing the model, described it as “drawing lines between the dots” to connect various parts of the health care system.

The three-year demonstration project, if approved, would be one of several public and private initiatives across the country aimed at coordinating patient care with the goal of saving money and improving health. So far, the more high-profile federal initiatives haven’t taken hold in Connecticut; earlier this week, state officials learned Connecticut was not selected as one of the states to participate in a program that would bring bonus payments from Medicare and private insurers to primary care doctors who coordinate patients’ care.

Similarly, the federal government this week announced the selection of 27 networks of health care providers to participate in a Medicare shared savings program known as Accountable Care Organizations. No Connecticut groups were included, although some could participate in the coming months or years.

There’s little dispute about the need to improve the way the more than 57,500 Medicare-Medicaid recipients — referred to as “dual eligibles” — receive services in the health care system. (Another 6,000 or so dual eligibles are enrolled in Medicare Advantage managed care plans, and would not take part in the demonstration project.)

“This population needs to have their care coordinated,” said Sheldon Toubman, a lawyer with the New Haven Legal Assistance Association.

But some aspects of the model described by the state Department of Social Services in the draft application have drawn criticism from advocates for Medicaid clients, representatives of health care providers and other members of the committee involved in the model design.

Chronic diseases, dementia, uncoordinated care

Those with both Medicare and Medicaid coverage include people with some of the most significant health care needs.

Just under half are seniors, most of whom are over 85, and nearly all of whom have at least one chronic condition. Many have neurological disabilities, such as dementia.

The rest are blind or have a disability, including more than 22,150 people with serious mental illnesses and more than 9,200 with developmental disabilities.

More than half receive long-term care, either in institutions like nursing homes or in home or community settings.

Their experiences suggest the pitfalls of uncoordinated care. Almost 29 percent of dual eligibles who were hospitalized in the 2010 fiscal year were back in the hospital within 30 days, a key indicator of problems in the transition from one care setting to another. Almost 10 percent returned to the hospital within a week.

In part, that could reflect challenges of having both Medicare and Medicaid. The two programs have different rules and cover different things, making it difficult to coordinate a person’s care as he or she transitions from a hospital to a nursing home, or from a hospital to home, for example.

Until this year, the state’s Medicaid program provided no care coordination for dual eligibles; it simply paid a fee when they got care, with no oversight to track duplicated tests, medications prescribed by different doctors that could interact badly, or avoidable problems that could land a person in the emergency room.

All Medicaid recipients are now covered through a new model, known as an administrative services organization, or ASO, that includes care coordination. The state is also encouraging primary care providers to serve as “medical homes” for Medicaid patients, taking on additional coordination responsibilities in exchange for additional payments.

Connecting more dots

Under the proposed demonstration project, dual eligibles would get even more care coordination. Those with the highest needs would receive intensive care management that includes, among other things, an in-person assessment of the person’s needs, the development of a care plan that the client agrees to, and short- and long-range goals.

Those with lower levels of risk would get care coordination to help with transitions between health care settings, such as from a hospital to a nursing home or hospital to home; addressing health care crises like a broken hip; or getting referrals to specialists or service options.

That care management and coordination could be done by either the ASO or through one of three to five newly created health neighborhoods — networks of providers who work together.

Patients in health neighborhoods would also have access to other services, including multifaceted interventions to prevent falls, nutrition counseling that addresses not just weight but social isolation and chronic conditions, or help from pharmacists with managing medication therapy.

Paul DiLeo, deputy commissioner of the state Department of Mental Health and Addiction Services, said during a meeting Thursday that the proposal, while in need of certain tweaks, moves the system in the right direction, largely because of a lack of links currently between physiological health and behavioral health. People the department serves die 20 to 25 years earlier than their peers, he said.

“They’re not dying from schizophrenia,” he said. “They’re dying of comorbid conditions.”

As an example of the coordination that could happen, Amdur pointed to New Haven’s Cornell Scott-Hill Health Center, which now provides primary care medical clinics in three area mental health centers.

Dispute over design details

But some parts of DSS’ draft application have come under fire from members of the committee that developed the model.

Like other health care providers in Medicaid and Medicare, those who participate in the demonstration would receive fees for the services they provide. But according to the application, the program would also provide start-up funds for health neighborhoods, quarterly payments meant to compensate for care coordination activities, and performance payments that would be based on meeting quality targets.

Mark Schaefer

Mark Schaefer

The application says the performance payments would be contingent on saving money, and would be funded in part by withholding a portion of the quarterly care coordination fees.

Committee members took issue with the idea of withholding care coordination funds Thursday.

Mag Morelli, president of LeadingAge Connecticut, which represents nonprofit providers of services for the aging, said paying for care coordination is at the heart of the program, so withholding a portion of those funds would send the wrong message.

It would also make it harder to entice providers to participate in the initiative, said Matthew Katz, executive vice president of the Connecticut State Medical Society.

Some committee members also took issue with the idea of basing performance payments on saving money. Toubman said it could give providers incentives to save money by doing things like recommending fewer hours of home care or physical therapy, which wouldn’t likely land patients in the emergency room or hospital but could diminish their quality of life.

“We’re picking the sickest population to impose this troubling financial risk on, and that is a very troubling idea,” he said.

Mark Schaefer, DSS’ director of medical care administration, said it hasn’t been determined whether getting performance payments would be based on meeting targets for care quality and patient experience, or whether providers would also have to meet savings goals.

“Part of what we’re trying to achieve here is a sustainable system, and to do so in a way that benefits clients but also works for the state and federal government,” he said.

Not everyone on the committee opposed rewarding providers for achieving savings. Morelli said her organization thinks it’s possible to both spend money more efficiently and improve health outcomes because the care provided to dual eligibles now is not coordinated and often wasteful. And she argued that if two health neighborhoods improve quality but only one achieves savings and the other spends more, the one that saved might expect to be better rewarded.

Ultimately the committee recommended a compromise: In the first year, performance payments would be based only on quality measures. After that, health neighborhoods that achieve quality targets but don’t meet savings goals could still receive the additional payments, but those that save money would get more.

Amdur said she’s not convinced the savings will be significant at first. “We have a lot of unmet need,” she said. “There has to be a lot of services put into place for people who aren’t now getting them.”

But it could reduce the growth in health care spending in the long run, she said, and could produce significant changes.

“For the population that I know the best, which is people with serious mental illnesses, this would be huge if we could actually pull it off,” Amdur said.