The Promise of Integrated Care for Dual Eligibles

September 5, 2013 § Leave a comment

By Bob Master, Chief Executive Officer of Commonwealth Care Alliance

Massachusetts is once again at the forefront of a healthcare revolution. This fall, healthcare organizations and leaders at the state level will launch One Care, an innovative program created by the Affordable Care Act (ACA) that aims to change the system of care for dual eligible beneficiaries. “Duals,” as they’re often referred to, are low-income seniors and younger persons with disabilities who are enrolled in both the Medicaid and Medicare. According to the Centers for Medicare and Medicaid Services, they make up just 15 percent of Medicaid enrollment, but they represent nearly 40 percent of annual Medicaid spending, and 21 percent of Medicare enrollees represent 36 percent of Medicare expenditures.

Nearly 40 years ago, Congress expanded Medicare eligibility to non-elderly individuals with disabilities; legislators simultaneously expanded the scope of Medicaid’s community-based, long-term care benefits to make Medicaid our nation’s preeminent disability and long term care insurer. The goal then, as now, was to promote appropriate medical care as an alternative to hospital care, and independent living as an alternative to institutional care.

Yet today, less than one percent of dual beneficiaries are enrolled in integrated medical and long-term care delivery models designed to meet their needs. As a consequence, too many individuals with disabilities have their goals of independence and autonomy subverted because of functional decline that is mostly preventable. Far too many frail elders and younger individuals with disabilities are routinely hospitalized because of a failure to effectively intervene to address a predictable and treatable array of complications of their underlying chronic illnesses.

Far too many frail elders are permanently placed in nursing facilities when lower-cost community living options are available and achievable. Far too many individuals with serious mental illness die prematurely — at the average age of 53, mostly due to cardiac and metabolic causes that we know how to treat. And far too many dollars are wasted because of four decades of missed opportunities to intervene on this set of circumstances.

Commonwealth Care Alliance oversees the care of about 5,000 low-income seniors and about 650 younger individuals in Massachusetts. We work to build integrated, interdisciplinary clinical teams of physicians, specialists, nurse practitioners, nurses and social workers with the ability to deliver and coordinate care in the home, replacing the ineffective physician office visits. Clinical care is available 24-hours a day, seven days a week, in all settings at all times so members don’t have to go at it alone in an intimidating inaccessible health care system.

This model of integrated care has proven to be effective at increasing the quality of care for this population while controlling the costs associated with dual eligibles. Commonwealth Care Alliance received a 30-day hospital readmission rate of 4 percent from NCQA in 2010 while the median Medicare Advantage program rate was 13 percent. CMS Quality Star Ratings awarded CCA with 4.5 Stars 2010 through 2012, ranking in the 90th percentile of all Medicare Advantage Plans and in the 99th percentile of all Medicare Advantage Special Needs Plans.

We know what works for dual eligibles. The challenge now is to scale what we know works as rapidly as possible with all the necessary safeguards in place. Massachusetts will be the first out of the gate to take on the challenge of demonstrating effective care delivery transformation with effective safeguards.

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