The Centers for Medicare & Medicaid Services has made better management of dual-eligibles – people who qualify for both Medicare and Medicaid – a key target in efforts to reduce healthcare spending. While
CMS has provided grants to some states to study the problem, a Massachusetts program called Senior Care Options (SCOs) has been tackling the issue since 2004.
Richard Burke, president of senior care services at the Fallon Community Health Plan, recently spoke with HFN about their efforts and the effectiveness of SCOs.
What are Senior Care Options and when were they created?
The central feature of the Senior Care Options program is a highly coordinated model of care where the individual has all of their medical and social needs coordinated through us. The program coordinates with Medicare and, by doing so, it allows these eligible individuals to access all of their Medicare and Medicaid benefits from one source. One of the goals of the program is to keep people out of a long-term care facilities. So what we do is bring services at the appropriate time and in some sense generously so people are well served and receive the care they need.
This like a patient-centered medical home model?
Yes, it is very much in the same vein.
Is this contracted with the state as a managed care program?
Yes, it is a managed care program. We have a contract with the state where we are paid a monthly rate by the state depending on the category the individual falls into. While the details of the payment are different from a Medicare Advantage payment, in essence it is the same thing –a monthly bundled payment. We are responsible in exchange for that payment to arrange for and pay for Medicare and Medicaid benefits and even beyond Medicare and Medicaid. We have the flexibility to go beyond Medicare and Medicaid (coverage) if those services are going to contribute to the goals of the program.
Where are the savings to Medicare and Medicaid in an SCO?
If you think about just the reduced reliance on nursing homes as a result of these programs, and avoiding the high cost of a nursing home placement there is a savings there. A study a couple of years ago by JEN Associates found SCOs reduced nursing home admissions and decreased acute care hospital days. We also can see lower prescription drug costs associated with these programs.
What kind of commitment is needed from states to make a program like this work?
At the highest level it is a commitment at the public policy level, that coordinated care models like Senior Care Options can produce better quality at a lower cost for a population that is traditionally one of the most costly to serve. Then you need to put the infrastructure in place. There is clearly a lot of work associated with that at the state level in terms of developing contracts the regulatory infrastructure and determining the rates. Rates are a very big part of this – determining the appropriate rates that will be paid for Medicaid eligible individuals who enroll.
The SCO program is voluntary. Why not make it mandatory?
I think this is an issue that has been and will continue to be debated. Choice is something that is very important to people, especially when it is something as personal as healthcare. Yet, at the same time, we know these models of care work and we know there are very high levels of member and patient satisfaction with these programs. When people enroll in these programs they are delighted with what they have to offer and the attention they receive and the care they are able to access. I think states should try to lead people toward these programs while also needing to reserve the right to opt out if it is something someone just doesn’t want to have.