Archive for the ‘Dual Eligibles’ Category

Better Care, Lower Costs: New Models of Care for Duals

Friday, April 13th, 2012

Recently, the Kaiser Family Foundation released helpful new data on the role Medicare and Medicaid programs play for dually eligible beneficiaries. As a group, these 9 million low-income seniors and people with disabilities tend to have higher rates of chronic disease and make greater use of hospitals, emergency rooms and nursing facilities. As a result, they make up a disproportionate share of spending in in both programs.


As the pressure to curb health care costs increases, states are moving full steam ahead with a new set of CMS-sponsored initiatives aimed at integrating care for dual eligibles. In fact, with its submission to CMS last week, Ohio is the second state to make a formal proposal for a demonstration project (Massachusetts was the first). While the goals of the overall program are laudable – better care at lower cost – consumer advocates must be aware of the risks and work to make sure the new programs maintain or improve beneficiaries’ access to high-quality, comprehensive care and services.

Community Catalyst has written an issue brief aimed at helping advocates shape the design and implementation of these new programs. The brief focuses on ten priorities:

  1. Enrollment
  2. Provider Networks
  3. Long-Term Services and Supports
  4. Coordination
  5. Benefits
  6. Consumer Engagement
  7. Beneficiary Protections
  8. Financing and Payment
  9. Quality Measurements
  10. Cultural Competency

With consumer advocacy on these priority areas, we believe there is a better chance of making real improvements in the health and well-being of high-risk seniors and people with disabilities. At the same time, if done well, these programs may lead to savings that can curb the growth in state and federal health care spending, thereby avoiding harmful cuts to these critical programs. The bottom line? Duals demonstration projects will only achieve their promise if advocates are meaningfully involved, voice their concerns and propose real solutions that work for real people.

– Leena Sharma, State Advocacy Manager, Integrated Care Advocacy Project

 

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For Seniors the Affordable Care Act is the Gift that Keeps on Giving

Monday, March 19th, 2012

This week marks the two year anniversary of the Affordable Care Act. And, while we will devote plenty of space this week to highlighting the many successes of the ACA, we could think of no better place to begin than with the law’s benefits for seniors. Under the ACA, older adults have already seen concrete new benefits such as:

  • • Decreased drug prices: In 2010, the ACA provided a $250 rebate check to seniors who hit the “donut hole” coverage gap, and last year, began offering a 50 percent discount on covered brand-name drugs in the donut hole. New data released over the weekend shows that more than 5.1 million seniors and people with disabilities on Medicare saved more than $3.2 billion on prescription drugs because of these provisions. This means real money back in the pockets of the people who need it most. And the savings will only continue. Under the law, this year, Medicare beneficiaries will receive a 50 percent discount from manufacturers on covered brand-name drugs and a 14 percent savings on generic drugs in the donut hole. These discounts will increase over time until the donut hole is completely closed in 2020.
  • • Increased access to preventive services: In 2011, seniors started receiving a slew of new benefits aimed at keeping them healthy without breaking the bank. The law ended cost-sharing for wellness visits, flu vaccines and certain preventive services recommended by the US Preventive Services Task Force. The free annual wellness visit also includes a new health risk assessment intended to spot chronic diseases and urgent health needs.

These are all tangible benefits that seniors are already enjoying. However, there many lesser-known ACA provisions that hold the promise of improving the health and well-being of the frailest seniors while also reducing the cost of that care. The law created two new offices at CMS – the Center for Medicare and Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office (MMCO) – charged with finding ways to improve care and lower costs within the public programs. These offices have been hard at work developing new programs aimed at finding cost-effective methods of better coordinating care, keeping people from being unnecessarily hospitalized or placed in a nursing home, and promoting overall good health. Two of the latest programs are especially worth mention:

  • • Duals Demonstration Projects: More than nine million Americans have both Medicare and Medicaid coverage. These so-called “dual eligibles” include more than five million low-income seniors who tend to have a higher incidence of chronic conditions, poor care coordination and – as a result – higher rates of preventable (and expensive) hospital admissions and readmissions. Together, CMMI and MMCO have provided planning grants and new financing opportunities to help states design new programs aimed at improving care and lowering costs by better integrating Medicare and Medicaid services. Consumer advocates in many of these states are actively involved in helping to shape these programs so that they fulfill their promise.
  • • Nursing home readmission initiative: Just last week, the MMCO announced a new program aimed at keeping long-term nursing home residents from bouncing back and forth to the hospital. These admissions are disruptive and disorienting, especially for frail elders who are vulnerable to the risks of hospital-acquired complications and other transition-related complications such as medication errors. They’re also expensive. This new program will wisely test whether providing enhanced on-site services and supports can support the goal of reducing avoidable hospital admissions.

These are but two of the many smart programs the ACA has created to improve the lives of older adults and their family members. We look forward to the continued rollout of these kinds of innovations and urge advocates to get involved at the local, state and federal levels in shaping them so they best suit the needs of those they intend to benefit. Happy anniversary, ACA!

– Renée Markus Hodin, Director, Integrated Care Advocacy Project

 

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Doing Dual Eligibility Right

Thursday, March 8th, 2012

Last week our old friend Laurie Martinelli (former Executive Director of Health Law Advocates) penned an op-ed in the Boston Globe nicely summing up both the opportunities and risks of new initiatives aimed at integrating care for dually eligible beneficiaries. Laurie, now at NAMI Massachusetts, writes on behalf of the nearly 70,000 Bay State dual eligibles with behavioral health problems. In her piece, she points to some of the promising elements of the Massachusetts proposal such as new access to community based alternatives to hospitalization and a single appeals and grievance process. But, she also notes where there is room for improvement: clarifying whether a behavioral health specialist can qualify as a “patient-centered medical home,” expanding transportation services and ensuring adequate provider rates.

At bottom, Laurie’s message echoes what we at CC have been saying all along: the need is great, the opportunity is before us, but the details matter. And, as Laurie concludes, “if it’s worth doing, it’s worth doing right.”

 

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Guest Blog: Home Care Workers Need Your Support

Tuesday, February 28th, 2012

On December 15, 2011, President Obama announced that the Department of Labor planned to amend the Fair Labor Standards Act (FLSA) to guarantee minimum wage and overtime protections for 2.5 million home care workers. Since 1974, when Congress amended the FLSA to include domestic workers, home care aides have been subject to the “companionship exemption,” which equated their employment with that of teenage babysitters and denied them the same basic labor protections as other American workers.

Home care workers—90 percent of whom are female, and half of whom are people of color—are the foundation of our system of long-term services and supports. They provide assistance with dressing, bathing, toileting, mobility, and meals for millions of elders and people with disabilities. In some cases, they also provide medical-related assistance, helping to manage medication, taking vital signs, assisting with exercise programs.

Our families rely on home care aides to ensure that our loved ones can remain as independent as possible. That’s why home care is one of our nation’s fastest-growing occupations. With 10,000 baby boomers turning 65 every day, the number of Americans who need assistance is growing rapidly. Within the next decade, the workforce is expected to grow by an additional 800,000 workers.

The outsize demand for home care aides, however, doesn’t guarantee that there will be compassionate, skilled workers to take these jobs in the future. Home care may be one of America’s largest and fastest-growing occupations—but it also among the most poorly paid and supported. Wages average $9.40 per hour, but more than half of workers are part time employees. As a result, annual wages average about $16,600.

These wages reflect the severe undervaluing of the skills and dedication of our home care workforce. These workers play a vital role in our health care system—often reducing overall costs by noticing changes in a client’s appetite, mental clarity, or strength and communicating these changes to a family member or medical professional. With their daily visits to client’s homes, home care workers are the eyes and ears of the health care team.

Yet, for nearly 40 years, as home care has grown into an $84 billion industry, these workers have been denied the most basic labor protections under the FLSA. Home care agencies have used the “companionship exemption,” which was intended to apply to a neighbor who came to sit with grandma for a few hours, to lower labor costs across the board. Confirming this attitude, in a recent article in USA Today, the government relations director for the National Private Duty Association, the industry’s for-profit trade association, said of home care workers, “For them, this isn’t really a job, it’s a lifestyle.”

Tell that to the 2 million women trying to feed their children on poverty-level wages. Though most workers earn above minimum wage, many are not paid for travelling time between clients or for the cost of gas (now nearly $4/gallon). Only fifteen states have wage and hour protections that guarantee time and a half for overtime for home care aides. As a result, at the end of the day, home care workers have so little income that nearly half live in households that rely on public benefits such as Medicaid and food stamps.

The proposed change to the Fair Labor Standards Act, which would narrow the companionship exemption to workers hired by individual households to provide companionship (not personal care), is long overdue. As our nation ages, we need to strengthen and stabilize the home care workforce. Better wages will reduce turnover, which is notoriously high and disruptive to quality care. Moreover, basic labor protections are sign of respect—an acknowledgement that our nation’s 2.5 million home care workers have a true vocation that we value as a society.

The Department of Labor’s proposed rule to provide home care workers minimum wage and overtime protections is open to public comment through March 12. Please add your voice in support of home care workers by visiting www.companionshipexemption.com. Easy instructions and sample comments are available at the website.

– Karen Kahn, director of communication, PHI
– Carol Regan,  director of government affairs, PHI

PHI is a national nonprofit dedicated to transforming eldercare and disability services to ensure dignity, respect, and independence for all who receive care and all who provide it.

 

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CMS Releases Guidance on Payment Model to Improve Care for Dual Eligibles

Wednesday, February 22nd, 2012

The issue of improving care for people who are eligible for both Medicaid and Medicare (“dual eligible”) continued to pick up steam with the recent release of a new federal guidance related to payment models. While advocates will not be formally commenting on this new guidance, it is imperative that they keep a close eye on what the guidance says and how this will impact which health plans will be chosen to oversee the care of the dual eligible population.

As readers may recall, the Affordable Care Act created two new offices within CMS to promote long-term systemic improvements for dual eligibles. The Center for Medicare and Medicaid Innovation (Innovation Center) was established to rapidly test, evaluate and replicate innovative models of care. The Medicare- Medicaid Coordination Office (“MMCO”) was created to promote policies and assist states in better integrating care specifically for dual eligibles. As a result, 15 states have planning grants to develop models of care for dual eligibles. In July 2011 MMCO announced a demonstration program to test two new payment models – the “capitated” and “managed fee-for-service” approach – designed to help states improve quality and share in the lower costs that result from better coordination of dual eligibles’ care.

The guidance released last month by the MMCO is directed at health plans or other qualified entities interested in pursuing the capitated financial model. Under this model, CMS, the state, and health plans or qualified entities would enter into a three-way contract, where the participating plans would receive a prospective blended payment to provide comprehensive seamless, coverage to dual eligibles.

Why Focus on the Dually Eligible?
The dual eligible populations (approximately 9 million) are a lot more vulnerable and typically have poorer health status and a greater need for more high-cost services such as inpatient and outpatient hospital, emergency room, and skilled nursing care. Navigating the Medicare and Medicaid programs, which have different sets of rules and requirements, is an added burden for beneficiaries and results in care that is often fragmented and uncoordinated.

Given the uncertainty of today’s political environment, state advocates need to be actively engaged in the decision-making process of any duals-related initiative. Advocates need to keep a close eye on decisions made about: enrollment, provider networks, appeals processes, marketing including how beneficiaries receive information, quality measures, financing, and consumer protections. Without an active voice, we are leaving the decisions to insurers and big providers who do not necessarily have consumers’ best interest in mind. It is important that all states be involved – not just the 15 states who received planning grants or those states that have sent in a letter of intent.

What does this new guidance mean for our work?
The new guidance on pursuing the capitated approach addresses important issues such as payment principles, standards in programmatic areas, key dates, and network adequacy. For each issue, there is a role consumer advocates can play to ensure that the proposed demonstrations keep consumer interests at the forefront. In a previous blog, we shared with you disability-oriented advocacy principles, to help shape the design of the demonstrations. Advocates should use them as guide as well as this fact sheet that highlights the role consumer advocates should play.

The efforts to improve care for the dual eligible population are commendable. However as CMS and states move forward on their aggressive timetable, advocates must ensure that only proposals that maintain or improve beneficiaries’ access to high-quality, comprehensive services make it to the finish line.

 – Leena Sharma, Field  Coordinator
Integrated Care Advocacy Project 

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The New Boom in Managed Care: Long-term Services and Supports

Monday, February 13th, 2012

A new report from AARP captures the changes coming for people who depend on Medicaid for services that help them live with chronic illnesses and disabilities. The number of states that actively manage long-term services and supports in Medicaid will nearly double by 2013, from 12 to 23, with many states folding in services previously only offered through special arrangements with the federal government, called waivers. Long-term services and supports include everything from nursing home care to community-based supports such as help with chores, personal care, transportation, and maintaining a home.

Will this mean more seniors and people with disabilities get the services they need to live in the community and better coordination of those services with medical care? Or will it destroy the fragile network of supports and community-based organizations that millions of often vulnerable people rely on for their everyday needs?

AARP is sponsoring a webinar tomorrow on their report, which is the latest of a string of papers on the transformation of Medicaid-supported long-term services and supports.

The reason for this boom in managed care is no surprise if you look at the numbers: More than one-third of Medicaid spending is for long-term supports and services. But only 6 percent of that is delivered through capitated managed care where plans are paid a fixed sum to provide services. Demand is rising for these services as the population ages, and the lingering recession makes more people eligible for Medicaid to pay for them. Facing fiscal crises, more states are turning to managed care – and making participation mandatory – in the hope of controlling spending. States are also looking to shift more long-term care from nursing homes into the community, largely in response to consumer demand. And the federal government is offering incentives and flexibility to states that make one or both of these moves.

But only a dozen states and relatively few managed care companies have experience with Medicaid managed long-term services and supports. There is little evidence on whether managing long-term services improves outcomes or cuts costs, which may in part be because many of the states are managing these services in a vacuum, separate from medical services, according to a report last fall from the Kaiser Family Foundation. Adding to the challenge, AARP reports that many states have gutted their staffs who work on aging and disability issues.

Meanwhile, the biggest users of these services in Medicaid are low-income seniors and people with severe disabilities who also qualify for Medicare, often referred to as “dual eligibles.” Making things even more complicated, three-quarters of the states are pursuing separate, but related initiatives to integrate all care for these folks, from hospital and doctor’s visits to long-term services, and many plan to actively manage that care.

If there ever was a time for consumer watchdogs to start barking, this is it.

Getting it right will take time, but states are rushing forward. Making it robust will require trained home care workers, but there is a shortage. Making it responsive to consumer needs will take listening to consumers and leaning on the community-based agencies that know this stuff cold, but the for-profit national companies are moving in.

Advocates would do well to focus on these 10 questions:

  1. Are consumers, and consumer advocates, actively involved in planning the changes?
  2. Will services be patient-centered and consumer-directed whenever possible?
  3. Will consumers have as much choice as possible – of participating, of plans, of providers?
  4. Will a full range of services be available, without bias toward nursing home care, and without medicalizing what are primarily social services?
  5. Will long-term services and supports be integrated with medical and behavioral health services, with the right services offered in the right setting at the right time?
  6. Will community-based organizations, such as Independent Living Centers, Recovery Learning Communities, Aging Services Agencies, and Aging and Disability Resource Centers have the opportunity to be providers, or even managed care organizations?
  7. Will there be a single point of entry for consumers to obtain long-term services and supports?
  8. Will there be continuity of care for consumers with long-standing relationships with specific providers?
  9. Is the emphasis on improving quality of care as strong as the emphasis on cutting costs?
  10. Will the state exercise strong oversight over managed care plans?

There are some small programs across the country that can serve as examples, as well as aspects of state managed LTSS plans that are particularly responsive to consumers or creative in serving their needs effectively and efficiently. Some are described in the Kaiser report, some in a State Long-Term Services and Supports Scorecard published by AARP last September, and some in a “Roadmap” put out by the Center for Health Care Strategies in 2010. Watch for additional resources on best practices from Community Catalyst in the coming months as well.

– Alice Dembner, project director

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The Shape of Coordinated Care: Advocates Pave the Way

Thursday, February 9th, 2012

In a big win for consumers that could set another model for the nation, advocates in Massachusetts have convinced state officials to significantly improve a plan that will coordinate care for 100,000 people age 18 to 64 with disabilities who are eligible for both Medicaid and Medicare. The Massachusetts plan for people known as “dual eligibles” is the first from the 15 states that received federal planning grants for this purpose. Massachusetts officials previewed revisions to the plan this week, ahead of a second draft expected soon.

Advocates for people with disabilities had pressed the state to give unique attention to long-term services and supports that help people live better and more independent lives. The first draft included a broad range of expanded benefits, including home care, respite care, peer support and home modifications. At a public meeting this week, the state said the second draft will adopt advocates’ suggestions for an independent coordinator of long-term services who will be part of the team that is at the center of coordinating better care for enrollees. As appropriate, that team will include the member, primary care providers, behavioral health specialists, social workers, a primary care coordinator, family members and advocates. The team will create a comprehensive, individualized care plan.

The long-term services and supports coordinator will assess the member’s needs, including those that improve quality of life, and help set up the appropriate package of services. The coordinators will be hired from community-based organizations with experience serving dual eligibles but which are not also service providers. Organizations expected to supply the long-term care coordinators include Independent Living Centers, Aging Services Access Points, Aging and Disability Resource Centers, and Recovery Learning Communities providing peer support to people recovering from mental illness and substance use disorders.

At public hearings, consumers with disabilities packed the room to make poignant pitches for these changes and to share inspiring stories of how robust long-term services, integrally connected with responsive medical and behavioral health care, are helping them live fulfilling lives and contribute robustly to the community.

Also in response to concerns from Disability Advocates Advancing Our Healthcare Rights, the ad hoc consumer coalition, the state is considering an oversight committee to ensure compliance with the Americans with Disabilities Act. Advocates are still pressing for an independent community-based organization to provide that oversight role.

There are still some concerns with the overall proposal, including the plan to automatically enroll everyone eligible unless they explicitly opt out; how much the managed care plan will disrupt existing relationships between patients and providers; the extent of consumer control of care choices; and whether long-term services and supports will be cut if push comes to shove. Fortunately, advocates are continuing to raise their voices and state officials have pledged to continue to meet regularly with all stakeholders, including consumer advocates, to improve the plan. The federal government will also have a say, once the state officially submits its proposal – expected in the next few weeks. From there, it will be a sprint to the finish, since the state hopes to begin enrolling people in the new plan next January. To do that, it must get federal approval, put out bids, select organizations to manage the plan and educate members.

If that isn’t enough pressure, all parties are well aware that Massachusetts is once again being watched by folks across the nation.

– Alice Dembner, project director

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