We've been talking about the continued focus on Medicare and Medicaid, which is intensifying as Election Day nears and voters' decisions will play a key role in the future of these programs. We must develop policies that will preserve these valuable programs for future generations without leaving today's elderly and disabled population behind -- all while minimizing negative impacts on the nation's budget. It's a complex, multi-faceted problem. Or is it?
Why do we need an integrated care model?
Robert Master takes an in-depth look at the Massachusetts Commonwealth Care Alliance as a framework for integrated care for dual eligibles (those eligible for both Medicare and Medicaid) on the Health Affairs Blog. The success of this program makes it a viable solution for the Medicare-Medicaid puzzle, if it's scalable.
According to Master, the goal is "to promote appropriate medical care as an alternative to hospital care and independent living as an alternative to institutional care," which would lower healthcare costs. But what ends up happening is repeat hospitalizations -- many of them avoidable. Emergency room visits drive up the cost of healthcare and the financial burden on the Medicare and Medicaid systems.
Here's the shocking part: Less than one percent of dual eligibles are actually enrolled in an integrated healthcare delivery program that could lower healthcare costs and improve patient outcomes. It's a subset of about 20 percent of dual eligibles (1.8 million people) who account for 60 percent of total expenses and 72 percent of Medicaid expenses.
The Affordable Care Act (ACA) created the Medicare and Medicaid Coordinating Office (MMCO) as a part of the Centers for Medicare and Medicaid Services (CMS). MMCO is focused on testing integrated financing options as well as integrated care delivery, working towards a solution.
The Massachusetts solution
Massachusetts takes a different approach with the Commonwealth Care Alliance (CCA), a fully integrated care delivery program for dual eligibles. The population served includes about 4,400 low-income seniors and 650 younger recipients. About $225 million in Medicaid and Medicare premiums finance this program, providing full and complete care to the target population with these funds.
The Senior Care Options Program, part of the ACA, includes 28 primary care practices within eight hospital systems throughout the state. Homebound patients are cared for by teams of nurse practitioners, social workers and nurses -- 80 teams in total, while the 650 younger patients are also cared for by interdisciplinary teams.
Standout features of the program:
- Thorough home visits replace the standard, 20-minute physician office visit.
- Each patient receives an individualized care plan.
- Medical equipment needs and mental and behavioral health needs are addressed as needed.
- Emergency services are provided via nurse practitioner home visits.
- Clinical care is available to patients 24-7 in any setting.
- Hospital admissions and days were 56% of risk-adjusted Medicare dual-eligible FFS experience from 2009-2011.
- 2010 30-day hospital readmission rate of 4% compared to 13% (median Medicare Advantage rate).
- Permanent nursing home placement rate of just 34% in nursing home eligible population of that of Nursing Home Certifiable population in FFS care.
- Annual average total medical expense increase far below the overall Medicare trend.
It's simple: We know what works. The same approaches and strategies have been proven effective in improving outcomes and lowering costs over and over again. But when we think about scaling such programs, the cost of implementation becomes a barrier.
How do we scale the necessary integrated care approach? And will it produce the results we're looking for over the long term if we're able to do so? Share your thoughts with us in the comments.