CMS and at least 20 states are moving hell-bent-for-leather toward enrolling as many as 3 million of the 9 million Dual Eligibles into health plans in the next two years, creating one of the biggest opportunities for payers in history. Now a rising chorus including the Medicare Payment Advisory Commission, the American Medical Association, some policy analysts and now at least one key Senator are urging CMS to hit the brakes. I tend to think the movement of duals into plans is like the movement of water: it can be slowed but not stopped.
Most agree that something has to change for the 9 million Americans who receive both Medicare and Medicaid. Duals typically have multiple chronic conditions, much higher prevalence of mental and behavioral health problems, polypharmacy issues, and much higher rates of institutionalization. They represent about 15% of Medicaid enrollees but account for almost 70% of program costs. Duals are the most vulnerable patients in the entire US health system, and they need the best of what health plans have to offer: better coordination, access to broader networks of providers, and better deployment of home and community-based services. 15 states are working with CMS on a pilot program to transition these folks to health plans in the next couple years, and at least another half-dozen states are moving forward on the same timetable but without CMS assistance.
But resistance to the effort is escalating:
- MedPAC recently raised a number of concerns over the size, scope and rapid pace of the program. “If all the state proposals are approved, then roughly 3 million dual eligible beneficiaries will be enrolled,” MedPAC Chairman Glenn Hackbarth stated in an 11-page letter to CMS. “This would mean that approximately 40 percent of all full-benefit duals will be enrolled in the demonstration.”
- Provider and advocacy groups warn that the size of the pilot programs under consideration represent the equivalent of a waiver or Medicaid program change. Last month, the AMA called for a delay of the program to give providers and patients more time to understand how it would run. Among the AMA concerns were disruption of established doctor-patient relationships, auto-enrollment of duals, and that pilots don’t slash physician fees.
- Sen. Jay Rockefeller (D-W.Va.), who helped shape the effort in the Affordable Care Act (ACA), has called for its immediate suspension. In a letter released late last week, Rockefeller torched the pilot, asserting its design is more about savings for states and less about improving care. Rockefeller created the CMS Federal Coordinated Health Care Office in the ACA — so this episode is a bit like Daddy taking his son to the woodshed.
I tend to think these concerns will result in CMS raising the bar on states and other stakeholders – there will be plenty of strings attached to these pilots, especially for the plans – but they won’t stop the movement of duals into health plans. The state fiscal crisis is so severe that Governors and Legislatures need these initiatives to move forward just to balance their budgets — duals are the #1 or #2 item in every state budget now. And the Feds are eager to help states with the right approach, especially in light of the drama on Medicaid expansion arising from the recent Supreme Court decision. So it may get noisy around the duals’ transition to health plans, but it won’t get slower.