On March 23, 2010, the Patient Protection and Affordable Care Act was signed into law bringing with it changes designed to help make Medicare and Medicaid more efficient, incentivize insurers and providers to provide high quality care, and provide affordable healthcare insurance for all. As part of the Act, the Innovation Center was established at the Centers for Medicare & Medicaid Services (CMS). The Innovation Center “fosters health care transformation by finding new ways to pay for and deliver care that improve care and health while lowering costs.” One of these innovative projects has focused on the coordination of care for those people who receive both Medicare and Medicaid benefits known as dual eligibles.
Before I continue, let me explain the difference between Medicare and Medicaid:
- Medicare is a federally funded healthcare insurance program for those 65 and over, or those who are disabled. You are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States.
- Medicaid (Medi-Cal in the state of California) is a joint federal-state program that provides health coverage or nursing home coverage to certain categories of people with low-income/low-assets including children, pregnant women, parents of eligible children, people with disabilities and elderly needing nursing home care. Medicaid is managed by at the state level.
Those who qualify as dual-eligibles fall into all age categories—a young person with a severe disability may be receiving Social Security Disability benefits (that includes Medicare) as well as Medicaid coverage because they fall into the income/asset guidelines. A senior who is receiving Medicare due to their age, may also be receiving Medicaid because they too fall into the income/asset guidelines. No matter what age, the vast majority of those receiving both Medicare and Medicaid suffer from multiple chronic diseases and conditions that result in considerably higher use of healthcare resources and facilities.
Medicare and Medicaid were not designed to work together leading to significant fragmentation of services. Under the current system, these people must navigate a complex and confusing array of requirements, benefits, and agencies in order to receive the care that they need. Two separate agencies, payment systems, and often two different sets of health care providers. Lack of coordination, unnecessary hospitalizations and emergency room visits are frequent—and costly to the patient as well as both Medicare and Medicaid.
In the face of this, the Innovative Center proposed a project that would coordinate the care of these patients under one umbrella. The result is that California’s Medicaid program, Medi-Cal, and the federal Medicare program are partnering to launch a three-year demonstration project, beginning in 2013, that will promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both of the public health insurance programs.
The project aims to create a seamless service delivery experience for dual eligible beneficiaries—one health card, one set of providers, one set of requirements with the ultimate goals of improved care quality, better health and a more efficient delivery system.
The demonstration project will include 8 California counties, including San Diego County, and is slated to begin in March and June of 2013—less than a year away.
What will it mean for those dual eligible beneficiaries who participate in the project?
In the counties where the coordinated project is implemented, dual eligible beneficiaries will enroll in a managed care health plan. This health plan will become responsible for providing beneficiaries seamless access to all needed services, including medical care, behavioral health care and long-term services and supports (LTSS). Beneficiaries will have a single health plan membership and a care team to help them coordinate services. The health plans will be responsible for enhancing home and community-based services that help beneficiaries maintain their independence and live in home and community-based settings for as long as possible.
The project emphasizes continuity of care so beneficiaries don’t experience interruptions in their needed services. Newly enrolled beneficiaries would be able to maintain relationships with their out-of-network Medicare providers for up to six months upon enrollment and out-of-network Medi-Cal providers for up to twelve months.
Four health plans have been chosen to provide coordinated services under San Diego’s project called the Long Term Care Integration Project: Care 1st, Community Health Group, Health Net of California, and Molina Healthcare of California. A beneficiary will enroll in one of the plans and it is the job of the plan to provide that beneficiary with coordinated and comprehensive services, including long-term services and supports that help beneficiaries remain in their homes. The big questions come in as to how, exactly, will they do this?
Typically, a health plan will pay for services through an approved service provider, and typically these are medical or medically-related services such as home health care services (nurse, physical therapist, aide) or durable medical equipment such as a wheelchair, bed, or walker. They do not however, manage or pay for a host of other community-based services such as Meals-on-Wheels, transportation, and social activities that are an essential component of helping a senior age in place.
With the health plans now mandated to provide these services, it is unclear what the impact will be on community-based organizations. Will the health plans decide to develop these services in-house? Will they subcontract services out to various organizations? If they subcontract the services, who will they contract with? None of these questions have been answered as of yet. There is no doubt, however, that if this demonstration project results in positive outcomes—reduced cost, greater efficiency, and better care that there will be profound changes in the way that community-based service organizations, such as Meals-on-Wheels, will operate.
What will the picture look like? We don’t know. We are however, preparing to take on the challenges that these changes may bring. Along with other community-based senior services organizations in San Diego County, we formed the San Diego Senior Alliance. We are working together to create the structures and capability to continue to provide true community-based services for San Diego Seniors, services that are based on an intimate and local understanding of seniors in our area.
We are committed to supporting the independence and well-being of seniors so that they may age in place with dignity.