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Dual Demonstrations: Challenges and Promise

The Centers for Medicare and Medicaid Services (CMS) is banking a lot on the Medicare-Medicaid Plan pilots, also known as dual demonstrations, to improve quality and lower acute and long-term care costs in both the Medicare and Medicaid programs. In addition, CMS is now looking closely at the alleged discrimination against quality attainment and appropriate risk adjustment revenue in the Special Needs Plan (SNP) program within Medicare Advantage and for those dually eligible in general.

But the dual demonstration programs are taking a few hits of late in the states that have rolled them out. In some states, advocates for the elderly have successfully forestalled mandatory auto-assignment into the programs. In others, so-called opt outs are compromising plans’ ability to balance out selection in the program. In still others, prominent players are exiting, complaining that the risk borne by plans simply does not show up in overall rate setting.

A new survey from California, home to one of the largest dual eligible demonstration projects known as MediConnect (now in the second year of its initial three years), shows some of the challenges and promise. California’s Medicaid agency reports that about half of all those eligible have opted out of the program. About 117,000 of the 500,000 dual eligible beneficiaries eligible for MediConnect are currently enrolled in the program. According to a just-released Field Research Corporation survey funded by the Scan Foundation, here are the leading reasons for beneficiaries opting out:

  • “I was satisfied with my current health care services and didn’t want to make any changes” (84%)
  • “I didn’t want to risk losing my doctor” (71%). About 30 percent ended up with a different Primary Care Physician.

On a positive note, the program does seem to be making in-roads with members. About 80 percent of members surveyed say they can get their questions answered about their health needs and that they know how to manage their health conditions. In addition, over 70 percent are very or somewhat satisfied with each of six aspects of health services that were measured in the survey. Finally, less than 10 percent have decided to leave the program once enrolled.

There is no question that a properly run managed care program can be a blessing to those with multiple co-morbidities and socio-economic barriers to health care. The alternative oftentimes is languishing in two very complex and antiquated systems that lack care coordination and critical specialty providers.

Finding ways to bridge the divide between the perceptions of these managed care programs and the solutions they bring compared to the traditional fee-for-service (FFS) systems is a struggle. Doing so is imperative as premiums in these programs are based on a healthy balance of lower and higher risk individuals.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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