The Centers for Medicare & Medicaid Services (CMS) is trying to control ballooning Medicare costs by improving the management of care for people who are eligible for both Medicare and for Medicaid.
Medicare serves the elderly and people with disabilities. Medicaid covers the poor.
Many of the 9 million "dual eligibles" are the kinds of elderly people who could not or would not buy private long-term care insurance (LTCI) and now have to rely on the kindness of Uncle Sam and state governments to pay for their LTC services.
About 16% of Medicare enrollees and 15% of Medicaid enrollees are dual eligibles. They account for 27% of Medicare program spending and 39% iof Medicaid spending, according to Sen. Herb Kohl, D-Wis., the chairman of the Senate Special Committee on Aging.
But Dr. Robert Berenson, an internist who's now working as a health policy specialist at the Urban Institute, Washington, argued at a hearing that Kohl organized on dual eligibles that CMS and others may be overselling the benefits of a care coordination program now in the works, and that officials should consider reducing the size of the program.
Berenson acknowledged that the current payment system works poorly and that government agencies should be experimenting with ways to improve it.
"There have been some notable successes of state‐supported programs for disabled and for duals," Berenson said, according to a written version of his remarks.
But Berenson argued that CMS should resist the urge to put 2 million dual eligibles in new coordinated managed care plans in just a few years, as it currently hopes to do.
"As we have learned repeatedly in Medicare demonstrations the challenges of scaling and generalizing from successful local initiatives is daunting," Berenson said. "Anecdotes of successful program initiatives, often resulting from unique leadership and culture, while pointing to a direction for additional progress, should be viewed skeptically, especially when marketers start promoting a '$300 billion dollar opportunity' for the managed care industry."
Even plans that have done a good job managing the needs of ordinary Medicaid enrollees might not have the staff and other resources to handle large numbers of dual eligibles wiho have severe, complicated health problems, such as dementia, Berenson said.
Some care coordination proposals "seem to be based on 'rosy scenarios,' such as the broad availability and success of patient‐centered medical homes," Berenson said.
Patient-centered medical homes -- primary care offices that make aggressive efforts to manage patients' care and offer patients wellness and condition management programs -- could help, but no one knows how well they'll really handle ordinary patients, let alone dual eligibles, Berenson said.
Another problem is that it's hard to get data that can be used the judge the performance of the existing dual eligible care coordination programs, Berenson said.
Once CMS and the states have 2 million dual eligibles in care coordination programs, "would a future CMS administrator actually then get on the phone to the involved governors and tell them to shut down their programs and return to the status quo ante, once again dislocating beneficiaries, while disturbing state budgets?" Berenson asked. "It won’t happen, at least not in my thinking."
- An agent who wants to explain to clients why voluntarily depending on Medicaid to take of any future long-term care (LTC) needs might be unwise should just e-mail them a link to Berenson's written remarks.
- It might be good members of the LTCI community with a deep interest in the well being of LTCI claimants to wonder how the coordination programs might affect LTCI claimants who are eligible for Medicare but not for Medicaid. Will coordination lead to more crowding in LTC programs, or more pressure for LTC programs to shift costs to private-pay patients? Will the programs lead to hospitals changing their approach to care in ways that will increase or decrease patients' need for LTC services?
- It also might be good to think about how all of this might affect participants in Long-Term Care Partnership programs, who are coordinating Medicaid nursing home benefits with private LTCI benefits. Is there any way to increase the likelihood that they well end up in good coordination programs that maintain or improve the quality of care if they do end up qualifying for Medicaid?