The 10 million individuals dually eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees) often receive fragmented, uncoordinated care. Nationally, health plans are taking on a key role in providing more integrated care for Medicare-Medicaid enrollees through Dual Eligible Special Needs Plans and the recently extended federal financial alignment demonstrations. Currently, more than two million Medicare-Medicaid enrollees receive integrated care in these programs, including more than 370,000 individuals in capitated financial alignment demonstrations. While the structures of health plans’ arrangements with federal and state purchasers may differ, their early experiences in providing integrated care — and their priority issues — are quite similar and offer important lessons for other plans and state partners.

With support from The Commonwealth Fund, the Center for Health Care Strategies is working with a group of plans committed to integrating care for this population — CareSource (Ohio); Commonwealth Care Alliance (Massachusetts); Health Plan of San Mateo (California); Independent Care Health Plan (iCare) (Wisconsin); UCare (Minnesota); and VNSNY CHOICE (New York) — as well as Together4Health (a coordinated care entity in Illinois) to enhance integrated models for Medicare and Medicaid enrollees. Five priority areas have emerged during the two years that these organizations have collaborated under the PRIDE (Promoting Integrated Care for Dual Eligibles initiative:

1. Contacting Hard-to-Locate Members

Health plans must locate members before being able to address their health care and social service needs. However, incorrect or missing contact information and/or unstable housing often make them difficult to locate. PRIDE plans are employing a variety of creative and practical strategies to find hard-to-locate individuals. Commonwealth Care Alliance targets phone calls to enrollees during the first 10 days of the month — before the minutes on commonly used pre-paid cell phones are likely to run out. iCare established electronic flags in its care management system so that when hard-to-locate members make any contact with the plan, they can be directly connected to their care manager.

2. Building Relationships with Members

Establishing trusting relationships between care managers and members is a crucial first step for developing person-centered care plans. It often takes multiple meetings with an individual, particularly someone who has been passively enrolled, to establish trust before performing an assessment and completing a care plan. It is important to connect with members at their own pace and resolve their most pressing needs before trying to complete a full assessment. For example, a CareSource Ohio care manager contacted a new member, who was initially unwilling to engage, and learned that his most pressing need was for a pair of shoes. Before broaching the subject of an assessment, the care manager brought a pair of new shoes for him, thereby building trust and showing him that she was willing to listen and help. He agreed to an assessment soon thereafter.

3. Enhancing Electronic Care Management Systems

Increasingly, health plans are eschewing paper-based processes in favor of customized electronic care management systems. PRIDE plans are in the process of implementing new electronic care management or electronic health record systems to deliver more timely care and social support services. Many plans are looking for ways to broaden the scope and reach of these new systems, both by widening access to the records to more people involved in a member’s care within HIPAA parameters (e.g., social service providers or family members) and by expanding what information is captured in the records (e.g., social determinants of health). CareSource Ohio developed a new cloud-based electronic care management system for its MyCare Ohio program that provides access to all of its participating providers and delegated care management entities. Members can also access their own portal to input information and communicate with their care managers.

4. Refining the Star Rating System for Medicare-Medicaid Enrollees

Medicare-Medicaid enrollees are among the sickest and highest-cost individuals in each program. There is considerable discussion about how much harder it is for Dual Eligible Special Needs Plans to achieve similar scores on the Medicare Advantage Star Rating system as plans that do not primarily serve dually eligible individuals. The implications for Medicare Advantage plans that receive lower Star Ratings include: future contract terminations; lower quality bonus payments; and, for Medicare-Medicaid Plans, the potential to lose passive enrollment of individuals into financial alignment demonstrations. In short, the implications of lower Star Ratings are a significant concern for plans serving predominately Medicare-Medicaid enrollees.

5. Advancing Value-Based Purchasing

Efforts to use performance incentives to encourage providers to deliver value over volume are just starting to emerge for long-term services and supports providers in integrated care networks. UCare has worked with providers under value-based arrangements for many years in Minnesota and has found that performance incentives have heightened provider willingness to engage in: quality initiatives (e.g., diabetes screenings); discussions about preventing unnecessary emergency visits, admissions, and readmissions; and efforts to improve medication adherence. The use of value-based purchasing can also help shift the focus toward prevention and wellness. iCare provides nursing facilities in its network with brief quality reports for each of its members, highlighting readmission rates and other metrics to help direct targeted interventions.

Moving Forward

Over the next two years, the number of people in the financial alignment demonstrations is expected to grow. And far more people will continue to receive services through other models of integrated care, primarily Dual Eligible Special Needs Plans, with substantial growth in enrollment expected among these organizations as well. With this growth, the salience of these five priorities for managed care organizations will increase commensurately.

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