Improving care and lowering costs for beneficiaries eligible for both Medicare and Medicaid is the holy grail of the government and health plans alike. Two health plans, CareSource and L.A. Care, are participating in a pilot to see if that goal can be achieved.
The two are among demonstration plans contracted with the Centers for Medicare & Medicaid Services and states to test if aligning financial incentives can help propel patient-centered care. It aims to improve outcomes and contain costs by using managed fee-for-service and capitated models and by coordinating care for these beneficiaries, many of whom have a number of complex and chronic medical and non-medical needs that impact each other.
"It's about person-centered care in a way that does not exist today in the fee-for-service system," said Melanie Bella, director of CMS' Medicare-Medicaid Coordination Office, at a recent conference sponsored by America's Health Insurance Plans in Washington, D.C.
CareSource, a managed Medicaid plan in Dayton, Ohio, will offer a duals plan in partnership with Humana in three of the state's seven regions (Cleveland, Akron and Youngstown). Voluntary enrollment starts in March 2014 but then moves to automatic enrollment, said Janet Grant, CareSource executive vice president of external affairs and corporate compliance officer.
The health plan expects to have all regions of the state live by July 2014, she said at the AHIP conference. Dual eligibles will be able to opt out as in all of the states on the Medicare side, but Ohio has received a waiver to require participation on the Medicaid side.
CareSource's strategy will use quality metrics as a tool to help narrow its network to the highest-quality providers, said Grant, and will develop interdisciplinary care teams by integrating the community health and social services that serve dual eligibles.
For instance, CareSource will draw on the large home- and community-based system of services for seniors that Ohio's agencies on aging have long had in place. And, for the first time, health plans in the state are contracting directly with community mental health centers and integrating mental and physical health.
"We have built fairly sophisticated systems along with those relationships in order to have data sharing and developed methods for integrating historical data so that they will have a good idea when patients come in whom they have been seeing and the services that they have received right at the first contact that our care management team makes," Grant said.
Like CareSource, L.A. Care's strategy also involves building interdisciplinary care teams and sharing data.
"We are convinced that if we can gather all the information, it will feed into the proper risk stratification, health risk assessment process and care plan development," said Bruce Pollack, senior director for the project management office at L.A. Care Health Plan.
While L.A. Care has access to historical Medicare and Medicaid claims on their members, the health plan needs to develop access to various assessments conducted by community-based adult service centers, multi-purpose senior programs and in-home support services, all of which are housed in numerous different systems and files, Pollack said.
"All the data is going to feed into one big pot and help us by connecting members with their services, transitions of care, continuity of care concerns and the risk assessment," Pollack said. "When we get the data, we can set up the right programs and care plans and connect all the members of the team, and that will get us off to a good start."