In early 2020, states and their federal and health plan partners were well-positioned to advance the significant progress in Medicare-Medicaid integration achieved in recent years. COVID-19, however, has stalled some efforts, shifting state attention to critical pandemic response. Yet those populations most vulnerable to the virus — older individuals with multiple chronic conditions or functional limitations, people with disabilities, and residents of nursing facilities — are largely dually eligible. For these individuals the need for coordination across physical and behavioral health care, access to long-term services and supports, and programs that address social support needs is more critical now than ever.

The COVID-19 crisis shines a light on existing gaps in care, system fragmentation, and lack of coordination between Medicare and Medicaid. In doing so, it is highlighting both opportunities for states to better serve dually eligible populations as well as new resources that states will require to be ready to act to respond to these opportunities, rebuild systems, and improve integrated care. To explore the current and future landscape for integrating Medicaid and Medicare services, CHCS recently spoke with Melanie Bella, MBA, chief of new business and policy at Cityblock Health, current chair of the Medicaid and CHIP Payment and Access Commission (MACPAC), and formerly, the founding director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services and senior vice president at CHCS.

Q: Dually eligible individuals have long been among the most high-need populations in either Medicare or Medicaid. How are they faring in the COVID-19 crisis?

It’s a time to reflect on the system inequities and fragmentation that dually eligible individuals face every day as they try to access the care and services they need.

A: Right now there’s a focus on coordinating services for high-risk individuals to meet their health and social needs and help them remain at home safely to reduce their risk of contracting COVID-19. States, health plans, and providers have been challenged to put that coordination in place quickly. However, for dually eligible populations, that lack of coordination is the norm. This crisis really highlights the difficulties that dually eligible individuals face in trying to get care on a regular basis. While it’s important right now to address the immediate needs of all high-risk populations — duals as well as other individuals — it’s also a time to reflect on the system inequities and fragmentation that dually eligible individuals face every day as they try to access the care and services they need.

The groups at highest risk for complications and death from COVID-19 are those that are typically comprised of dually eligible individuals: people with multiple chronic conditions and/or disabilities, and frail, older adults — especially those living in nursing facilities. Although it’s critical to keep high-risk people at home, it’s also important to remember that staying home may prevent them from filling prescriptions or having access to food. They may be skipping appointments with their providers or avoiding the emergency department when they truly need it. This means that their chronic conditions may go untreated and worsen. Unless they have a very well-informed caregiver and/or are enrolled in an integrated program with someone checking in regularly to understand their needs and ensure they are getting met, they will face considerable difficulty with obtaining needed services.

Q: Is COVID-19 exacerbating gaps in the system of care for dually eligible individuals? How do integrated care models address those issues?

As we move past the initial crisis, states should consider how this crisis has reinforced the need for integrated programs and appropriately leverage that to get back on the path toward more value-based arrangements.

A: COVID-19 is certainly shining a light on system gaps, including the lack of infrastructure to provide safe in-home care, coordinated transitions of care, food and housing security. It also highlights ineffective coordination between physical and behavioral health care. Integrated care models were built to address these gaps. Yet, unfortunately, only about 10 percent of dually eligible individuals are enrolled in an integrated care program.

Integrated models have really advanced in the last 10 years, particularly the Medicare-Medicaid Plans (MMPs) operating under demonstrations in the Financial Alignment Initiative, Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), and Programs of All-Inclusive Care for the Elderly (PACE). The model that a state uses is not as important as long as it contains three key elements: (1) person-centeredness to best understand and address each individual’s needs; (2) capitated payments that cover the full range of medical and non-medical services and offer both financial and care delivery flexibility for plans and providers to meet person-centered care goals; and (3) aligned incentives across Medicare and Medicaid.

Models with these elements give plans and providers the flexibility to quickly address an individual’s changing needs while still requiring accountability and reducing the potential for cost-shifting. States have been moving away from payment methodologies that reward volume over value. Although COVID-19 may have interrupted that journey, as we move past the initial crisis, states should consider how this crisis has reinforced the need for integrated programs and appropriately leverage that to get back on the path toward more value-based arrangements.

Q: What promising practices have come out of the COVID-19 response? Can these approaches and new federal flexibilities be used going forward to support dually eligible individuals?

A: This answer is evolving but some of the most beneficial flexibilities and state and health plan activities I’ve seen thus far are:

  • Telehealth for both medical and LTSS needs when community-based needs can be addressed remotely;
  • Expanded use of home-based team care, including new roles and resources for community health, family caregivers and other workers to better support beneficiaries and engage in new key activities such as contract tracing; and
  • Greater flexibility to address social needs through Medicare or Medicaid. In particular, some states have taken advantage of flexibilities under 1915(c) Appendix K to increase access services such as home delivered meals and increased non-emergency medical transportation.

Another key area that is gaining attention, but requires significant new effort, is improving transitions of care from institutional settings to the home, understanding that many people will need access to team-based care or post-acute level of care in the home.

There are policy considerations around making new flexibilities permanent. States would want to figure how to incorporate new services in payment rates, while ensuring actuarial soundness. States, plans, and providers would have to work more collaboratively. More providers would need to take on risk and participate in team-based, multidisciplinary arrangements. We would have to ensure that incentives were aligned for states to invest in LTSS and community-based care, as the return from state investments in home-based care typically accrue to Medicare first. Discussions about shared savings flexibilities could be meaningful right now.

Q: How can states regain their momentum toward integrated care? Are there new opportunities for states that were not thinking about Medicare-Medicaid integration?

A: COVID-19 is precipitating very rapid change, and as states respond and seek to address the many challenges facing vulnerable beneficiaries, integration opportunities may rise to the forefront. States may want to consider re-focusing efforts on making system changes that increase coordination and alignment. The Medicare-Medicaid Coordination Office has re-opened the Financial Alignment Initiative and will consider partnering with new states for demonstrations. States can also propose completely new state-specific demonstrations that are responsive to elevated care coordination or service delivery gaps. Efforts may also be based on Dual Eligible Special Needs Plans already operating in a state. They could be incremental in focusing on only one region or subpopulation or potentially build on an existing delivery system or payment reform effort.

Q: What can states and their federal partners do now to prepare to support dually eligible populations moving forward?

Increasing transparency around provider payments may help prevent a potential system inequity whereby providers serving the most at-risk beneficiaries are not getting the supports they need.

A: This crisis is prompting all of us to think about how we can do things differently. At a more granular level, there are three priorities for states that come to mind.

Bolster state capacity. We need to provide supports that help states build capacity to advance integrated models. This is important whether states are focused on either incremental or broad-based program changes to how care is delivered for this population. This is a place where federal funding to support states through enhanced FMAP or, even better, through grants that can provide direct funding for specific activities. Now is the time to give states resources; otherwise this population will continue to be left behind.

Assess whether relief payments are reaching safety net providers. I am grateful for the speed at which Congress and CMS have been moving supports out the door, but there is a lack of transparency for states to assess whether the needs of safety net providers are being addressed. There should be a concerted effort to support Medicaid providers that are doing the really hard work and who are crossing both acute and non-acute settings to provide in-home care to people with complex chronic conditions and other limitations. Increasing transparency around provider payments may help prevent a potential system inequity whereby providers serving the most at-risk beneficiaries (e.g., Medicaid in-home supportive providers, community medicine providers, etc.) are not getting the supports they need.

Continue program monitoring. Many service requirements are now more flexible or are being waived to avoid infection. However, it’s still very important for states and CMS to ensure overall care model requirements for health plans serving dually eligible beneficiaries are being met related to outreach, assessments, and care management. While some processes might necessarily look different, such as telephonic care management instead of in-person, paying attention to individuals’ increased risks and whether or not needs are being addressed is critical. Likewise, many providers are receiving retainer payments to keep their doors open, but these payments should be coupled with a focus on monitoring to ensure that providers are maintaining interaction with beneficiaries and addressing their needs.

Q: Do you have any closing thoughts on how COVID-19 could create opportunities for innovation for the dually eligible population?

Integrated models are better able to deliver the right care, at the right time in the right setting in a person-centered way.

A: As we come out of this crisis, there will likely be a desire to do many things differently. At the same time, there will be an increased and significant strain on state budgets and capacity, and we will need new ways to cost-effectively serve complex, low-income populations. A lot of resistance to integration has been from those who want to keep the system status quo. But from experience, we know that non-integrated arrangements don’t work well. Integrated models are better able to deliver the right care, at the right time in the right setting in a person-centered way. There may be push-back from some providers, but — done right — integrated care could help them come out of this in a better position than before.  As states rebuild their delivery systems, they will need to be ready to redeploy programs for dually eligible individuals and it is important for them to have the resources, analytics and leadership support to do so.  This is the time to support and facilitate successful state and health plan factors that result in person-centered, integrated, team-based care, and to replicate these models elsewhere. In this unprecedented moment, we will want to put everything on the table to come out of this stronger for dually eligible and other populations with complex needs.

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Glenn Lippman, MD DLFAPA

Excellent presentation of necessary concepts. I would like to see a further discussion around how the systems of care can be assisted in “catching up” with missed appointments, cancer screenings, vaccinations, etc. There is going to be a period of time when the current system of healthcare is going to need to “reopen” and create increased accessibility to people who have been delaying their healthcare due to COVID….any ideas ?

Alexandra Kruse, CHCS

This is a great point and one we will be sure to explore. We will likely see a need for increased accessibility coupled with innovation that offers new or alternative care settings that encourage beneficiary/patient engagement and ensure safety for all involved. Communication strategies will be key as well to raise awareness of any expanded or altered ways to safely access care. We’d welcome more discussion and ideas!

Pam Parker

Terrific advice and wise perspective, thanks so much to Melanie and CHCS for sharing this!