California finds the road to reform is rocky for vulnerable ‘dual eligible’ patients
More than 9 million health care consumers in the United States are eligible for both Medicare and Medicaid. This group, often referred to as “dual eligibles” or “duals,” includes both low-income seniors with multiple chronic conditions and young people with significant disabilities. Duals are among the poorest and sickest of health care consumers and account for a disproportionate share of health care utilization and spending.
The Affordable Care Act of 2010 established the Center for Medicare and Medicaid Innovation (CMMI), which was charged with testing new ways of paying for and delivering care to those who receive both Medicare and Medicaid benefits. Currently, there are 1.5 million duals in 12 states who are eligible to enroll in CMMI demonstration projects, and more than 450,000 reside in California.
In 2014, California launched a three-year demonstration program for duals called Cal MediConnect, a managed care plan in which participating health plans are responsible for the delivery and coordination of all medical, behavioral health, and other long-term services and benefits. The managed care health plans are paid a monthly fee per enrollee in exchange for providing a package of Medicare and Medi-Cal (i.e., California’s Medicaid program) services.
Most would agree with the goals of MediConnect: to better coordinate benefits and services, improve the quality of care, and reduce overall costs. Historically, the delivery of care to this patient population with complex needs has been disjointed, with little or no communication between providers. This often results in duplication or gaps in patient services. The integration of behavioral health, support services and medical care under MediConnect represents a major shift in the practice and delivery of health care, so this is a brave new world for providers and consumers alike.
Yet the rollout of MediConnect has been a rocky road, beset by repeated delays and pushback from patients and providers.
Yet the rollout of MediConnect has been a rocky road, beset by repeated delays and pushback from patients and providers. Eight of California’s 58 counties were initially selected to take part in Cal MediConnect when enrollment began in April of 2014. California adopted a “passive enrollment” process, meaning that those eligible have to actively “opt out” if they wish to retain their current fee-for-service Medicare providers. Some of the delays in implementation have been due to stakeholder concerns and “pushback” as they advocate for this vulnerable population, to protect them from any adverse consequences. Other delays have been related to the finalization of three-way agreements between the federal government, the state, and participating health plans. Still other delays have been due to the lack of readiness of participating health plans or counties. Indeed, one of the initial counties selected for the demonstration (Alameda) dropped out of the demonstration several months ago, citing financial concerns. And more than one of the selected managed care health plans (for example, CalOptima in Orange County) could not enroll patients in the new program until they proved they had met federal quality standards.
Effective communication about Cal MediConnect has been a challenge from day one. It is a complex program that involves several decisions for consumers. Even individuals who are healthy might find the process daunting, let alone those who are managing multiple chronic conditions and disabilities and are highly dependent on the health care system. The process was further complicated by the fact that many of the program’s details were still changing or being finalized as it was being launched.
Fourteen months after the first of seven counties launched MediConnect, enrollment data reported by the state suggests that the program is falling far below expectations. As of June 1, 2015, a total of 122,846 duals have enrolled in MediConnect. Opt-out rates are higher than anticipated and a significant proportion of consumers newly enrolled in MediConnect are canceling within the first month or two. In the six counties with active enrollment, only one-third of those eligible have enrolled in MediConnect. The remaining two-thirds have either opted out from day one (44 percent) or cancelled their enrollment (23 percent) within the first few months.
In response to these low enrollment numbers, the state is working hard to improve its messaging to ensure that consumers fully understand the program’s potential benefits. And because those who opt out of Medicare benefits are still required to receive their MediCal benefits through a managed care plan, many of the plans are now turning their attention to directly marketing the program to this group of consumers.
While the state and the health plans try to “recapture” dual eligibles who have opted out, it is important to pay attention to what is actually happening — both to those who have opted out and to those who have transitioned to MediConnect. For the former, there does not appear to be a plan to ensure the coordination or quality of their care, and they may even face added barriers to getting the care they need. For example, confusion reigns as many Medicare providers wrongly believe that they need to contract with the Medi-Cal managed care plan in order to be paid for Medicare cost sharing, a payment that was previously issued by the state. As a result, some Medicare providers are turning away consumers who are now enrolled (by mandate) in the Medi-Cal plan, or they are trying to bill the consumer for the cost sharing, a practice which is illegal under both federal and state law.
And for consumers who have transitioned to Cal MediConnect, the jury is still out. It remains to be seen whether their care will now be effectively coordinated, how “team-based” care will be put into practice, and whether consumers will truly be in the driver’s seat when it comes to planning their own care. The evaluation of the Cal MediConnect program is underway and the results will determine whether the program is implemented statewide. What we learn about the outcomes experienced by this especially vulnerable population through this three-year project will have implications for other broad efforts to improve the coordination and delivery of care that are moving forward across the nation.
Kathryn G. Kietzman is a health researcher at the UCLA Center for Health Policy Research.
[Photo by Sjoerd Lammers via Flickr.]