McKesson Pays $190mil for Claims of Defrauding the Medicaid Reimbursement Program

McKesson, the largest US drug distributor, agreed to pay more than $190 million to resolve claims that it caused the U.S. to overpay for prescription drugs. As Bloomberg News reports, a New Jersey lawsuit claimed McKesson defrauded the Medicaid Program by falsely reporting inflated prices of drugs, which in turn caused the federal government to set higher reimbursement rates. Under the agreement, state governments can separately negotiate with McKesson, meaning more fines could be on the way.

This story isn’t new. Every year companies are fined millions of dollars for a variety of offenses, both large and small. At the 17th annual Medicaid Drug Rebate Program Summit, September 10-12, in Chicago, we do everything possible to give you the information you need to avoid audits and be compliant, to ensure the next story in the news cycle isn’t about your company’s million dollar fine. We have more CMS, OPA, OIG, and DoJ officials, as well as industry legal heads to explain who is getting caught, why, and how to avoid those actionable behaviors.

Register today to attend the nation’s longest running and most respected event in the MDRP space!

What should be the considerations for health plans in the Medicaid Space?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

In this final installment, he answers the question:
If our health plan audience is looking ahead in the Medicaid space, what would you say to these plan executives who will be at our Conference in May? Are there any key planning considerations that you’d like to share with them?

Nathan: That’s a great question. There a couple of things. First of all, we’ve got to remember that these programs are going to be state-by-state. Last year, 2011, the Coordination Office awarded 15 states $1 million a piece to design person-centered approaches to coordinated care across primary, acute and behavioral health and long-term supports and services for duals. And what that means is that state-by-state you see different approaches. What I meant by the laboratory here. In Colorado, the proposal is to enroll duals into what’s called an ‘Accountable Care Collaborative’, which is sort of a hybrid medical home and ACO, which is a familiar term to our listeners I would imagine. And it would include involuntary enrollment of both Medicare Fee-for-Service and MA enrollees. 

It’s different elsewhere. New York is considering a range of options. State management of delivery and financing of a combined benefit package, managed long-term care, SNPs. In Oklahoma they are considering ACOs or state-operated network, an expansion of the PACE program. Tennessee is going to do it through TennCare and expand managed care services to include Medicare Parts A and B. So, the first thing these folks need to do is bring their head of Regulatory Affairs with them to the Conference. It’s worth paying for the extra seat. They are going to get so much knowledge that they can apply to their home situation, but recognizing that the home situation is going to be unique to that state. And that’s where it begins.

The other considerations, at least where the duals are concerned, would be as follows: One is that the model of care or the service model with which you approach these beneficiaries needs to be different. In case management (traditionally in managed care), you would have a case manager assigned to that very small proportion of beneficiaries (2-5% depending on the plan and the way they approach it) to be that advocate within the plan and that navigator to help the beneficiary navigate the system. Keep in mind that dual eligibles see an average of 10-12 different physicians, 30-40 office visits a year. It’s an extraordinary volume of clinical information to coordinate. Imagine being that beneficiary. Imagine when, as inevitably happens, a couple of those doctors tell you to do different things, things that contradict each other. How do you resolve that? Many of the beneficiaries don’t. So, it’s critical that traditionally you would have a case manager watching out for those beneficiaries. They weren’t necessarily duals. They were just your most vulnerable beneficiaries. We would make the argument that you need to take almost a case management approach and apply it to customer service where the duals are concerned. We actually recommended for many of our plan clients it’s a good fit for them in serving their Medicare Advantage population more generally. It is certainly true in the duals. The challenge, of course,is that, as we’ve stated, these can be very hard beneficiaries to get in touch with. Where do you send the mail to a transient beneficiary? As I said earlier, sometimes the cell phone is the best way to get in touch with them. Maybe you should offer a cell phone as part of your plan to all of your beneficiaries. Plans need to think outside of the box here and get involved in a different way in their beneficiaries life if they have any hope of succeeding here.
The first consideration is: “What’s going on in my state?” The second consideration is: “What kind of a service model can I offer my beneficiaries that can distinguish my plan and do so, of course, in a completely compliant way to attract beneficiaries (because you are going to voluntarily enroll into my plan in some cases or make me attractive to the state to be a qualified provider).” And how do I get on top of some of these difficult service issues?

The next two things are absolute must dos. The first is to take a look at how your provider network is contracted, both the rates and the incentives, the information that you share with the network, how you share it to them, and your use of field agents (are you sending in long faxes to these offices? Well, they are getting used to line bird cages; they aren’t getting read). Are you having face-to-face interaction with the big players in your provider network and compelling them and giving them better information with which to make better clinical decisions because ultimately they are the one in contact with the beneficiary, not us the payer? We can only give them information for them to make better decisions. We can’t force them to do anything. No bonus scheme in the world is going to do that.

The last consideration is really a financial one that ties back to care, which is risk adjustment. As I’ve said a number of times, these beneficiaries are terribly expensive. They are expensive because they are sick. In that they are sick they need our support, but we can’t do this purely out of the goodness of our heart without getting revenues to pay for all that care. Risk adjustment is the way the plans get the revenues to care for those beneficiaries.Your non risk-adjusted average beneficiary premium is around $800-$850 pmpm.. It’s a big range nationally, about $350 range between a high and a low. But, let’s say it’s 800 bucks. These beneficiaries can be as high as $3000 per member per month. But, if you don’t accurately report that risk score, how much money are you going to get? Well, in this example, you’ll get $800 or $850. So, you’ve got to risk adjustment right to get the payment right or else you’ll never fund those benefits that the beneficiaries are entitled to.

So, those are really the four considerations: what’s your state’s local market condition, what is your service model, what can you offer these beneficiaries that’s unique, risk adjustment. And then think about your provider network very carefully. You’re probably going to have to re-contract portions of it to make this all work.

Look Who’s Attending the Medicaid Managed Care Congress 2012

With the ACA appearing in the news almost daily, you need to know what your company needs to do now so you can take advantage of new opportunities, such as Medicaid expansion and health insurance exchanges. There is a lot at stake and the timelines are tight. We invite you to join us at the 20th Annual Medicaid Managed Care Congress, taking place on April 30 – May 2 in Baltimore.

Don’t let your company fall behind. Join top executives from the following companies to achieve better quality and better care at lower costs. More people are registered to attend than ever before, so space is limited. Make sure you reserve your spot today!

2012 Attending Companies:

3Cinteractive * Access2Care * Aegis Sciences Corporation * Aetna Medicaid * Altegra Health * Amerigroup * AmeriHealth Mercy * Amgen * Arbor Healthcare * Association for Community Affiliated Plans * Assurance Wireless * AstraZeneca Pharmaceuticals * Bayer Healthcare Pharmaceuticals * Bio-Reference Laboratories Inc * BioRx * Blue Cross Blue Shield Northern Plains Alliance * Blue Cross Blue Shield of Tennessee * BMC Healthnet Plan * Boehringer Ingelheim * CalOptima * Cardon Outreach * Care Systems Design LLC * CareCall Inc * CareSource * CenCorp Health + Solutions * Cenpatico Behavioral Health * Central California Alliance for Health * Children's Hospital and Health System * CMS * Community Health Choice Inc * Comprehensive Behavioral Care * Connolly Healthcare * Cook Childrens Health Plan * Covidien * DC Health Care Finance * DentaQuest * DMoller Associates * DST Output * Excellus BlueCross & BlueShield * Express Scripts Inc * Fallon Community Health Plan * Forest Laboratories Inc * Geisinger Health Systems * Genentech Incorporated * Georgia Department of Community Health * Gilead Sciences Inc * Gorman Health Group * Government of the District of Columbia * Health First Health Plans * Health Management Associates * Health Partners * Health Services for Children With Special Needs Inc * HealthHelp * HealthPlus of Michigan * HealthPort * HealthSpring * Hemophilia of Georgia * Horizon NJ Health * HSMA * Hudson Health Plan * Humana Inc * InstaMed * ISG * Johns Hopkins Healthcare Inc * Krames A MultiMedia Company * Lilly USA LLC * Loving Care Agency * LVHN * MDwise Inc * Medicaid Health Plans of America * Medimpact * MedSolutions * Merck & Company Inc * Michigan Department Community Health * Molina * Monroe Plan for Medical Care * Montgomery County Government * Mostly Medicaid * Myers and Stauffer LC * National PACE Association * Navitus Health Solutions * NC Divison of Medical Assistance * Neighborhood Health Plan of Rhode Island * Network Health * Newkirk Products Inc * Novo Nordisk * Nurtur * OCCMHA * OptiCare Managed Vision * Optimetra Inc * OptumHealth * OptumInsight Life Sciences *Pfizer * Physicians Pharmaceutical Corp * Piurek & Associates * Plasma Protein Therapeutics Associates * Prestige Health Choice * Prolacta Bioscience * Purdue Pharma Minnesota * QualityMetric Inc * RI Department of Human Services * Sanofi Aventis * Schaller Anderson Inc * Senior Link * South Florida Community Care Network * Sprint * State of Maryland * State of Michigan * State of Mississippi * State of New Jersey * State of New York * State of New Hampshire * State of North Carolina * State of Pennsylvania * State of Texas * Sunovion Pharmaceuticals * SXC Health Solutions * Teva Pharmaceuticals * UCB Managed Markets * UnitedHealthCare Community Plan * US Government Accountability Office * Utah Department of Health * Varis * Vertex Pharmaceuticals Inc * Visiting Nurse Service of New York * VITAS Healthcare Corporation * VNSNY CHOICE Health Plans * Walgreens * Wellpoint * ZOLL LifeVest *

Also, as a reader of this blog, you can receive 25% off the standard registration rate with Priority Code XP1726BLOG. For more information on the Medicaid Managed Care Congress and to register, visit our webpage.

Why is it critical to identify the needs of duals now?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

Today he answers the question:
It’s clear that dual eligibles initiatives bring a new level of complexity to the government programs marketplace. From your perspective, what makes now such a critical time for these issues? Looking ahead, what impact do you think the Medicaid expansion that you’ve talked about will have on health plans?

Well, now is the time partially because of demographics. We talked about the boomers aging. Keep in mind when the economy hit the skids as it has since the crash in 2008. You’ve got a lot of new beneficiaries that might not think of themselves as being Medicaid eligible but who may be finding under the provisions of health reform that they are. They never expected to be in this place. Nevertheless, they are. So, you’ve got the demographic reality of the boomers aging in. 

Keep in mind, we’re going from 45 million Medicare beneficiaries to 80 million beneficiaries in a blink of an eye. That’s profound. We’ve seen what has happened in Japan and other industrialized nations who have been a little out in front of us in terms of that boom. It puts enormous strains on the economy and, no doubt, our listeners are aware of the challenges that it puts the federal and the state treasuries through with the entitlement programs. 

And that’s worth mentioning for a second. There is a lot of reform talk here in Washington about the entitlement programs. Everyone knows that earmarks don’t actually increase spending. Actually, not everyone knows that. Earmarks don’t actually increase spending. There are designations within budget priorities that have already been made. There is really not a lot of foreign aid. When people look for things to cut, it always comes back to the entitlement programs. That means social security, Medicare and Medicaid. Well, two thirds of that Medicaid spending has been on everything but these types of beneficiaries. We are not about to cut spending to moms and kids. Frankly on a Medicaid standpoint, probably not going to cut funding to seniors, either. Typically not a good idea to do in an election year. Wouldn’t you know it, it always seems to be an election year (especially these days). 

So, you’ve got this demographic issue that’s staring us down in the face. Then you’ve got health reform essentially saying: ‘You know what? We’re going to increase eligibility for this program, not decrease it because it’s the way we’re going to try to get the lower, lower middle class (which some call the working poor) with some coverage here, particularly as so many more of themare finding themselves in a position of need that they maybe didn’t expect to be five years ago.’ They weren’t going to be living high on the hog in retirement, but they had savings. Well, those savings are wiped out now. If they had a little 401K, it’s probably hurting. Most Americans don’t have the benefit of those retirement vehicles.

So, you’ve got a number of forces here conspiring to make us confront this issue. The issue we’re confronting is how we finance care for everyone in a way that doesn’t bankrupt either the federal government or the traditional provider of coverage, which is the employer. Something that is lost in this debate too often is that the cost of care increases as the rate of medical inflation increases. All the payers are in the same boat. Whether it’s Medicare or the employer Boeing, they are paying more and more money every year to provide coverage for those people. Whether it’s the State of California or Medicare Fee-for-Service. We are all in the same boat as payers here. So, while in the short term it’s pretty incredible to think about adding 30 million more people into managed care through the exchanges and millions more through these dual eligibles programs (just a million more this year alone), we’re going to find ourselves in a position where we’ve got a significantly larger amount of people with coverage in this country and we will be forced by the cost of that coverage to reform how we purchase services. Coverage will be something different. Benefits will look something different. We are ending up with this patchwork of coverage here and we are going to be compelled to fix the way that we finance underneath that coverage. There’s no way we can continue on the path we’re on and just add more people to the federal government’s tab. And that’s really what’s happening here. 

So, the challenge with the duals, again, everything that’s hard about health care, even harder and with even higher stakes because these are beneficiaries who are tremendously vulnerable. A $2 co-pay or a $5 co-pay is out of reach to these beneficiaries, which is why they receive such heavy subsidies now. They are on the most fixed incomes. They sometimes lack family or community support. We know sociologically speaking how isolating it is to be elderly in this country. So, we need to be cognizant that as we do this reform, we have to hold the beneficiaries harmless. We have to protect them from feeling what is, quite frankly, a great deal of volatility in the structure and the financing of care. They should never feel it. They should never feel the difference. They should instead feel higher levels of service. Our work on the dual eligibles through the Special Needs Program tells us that it is absolutely possible.

It may sound like an impossible issue when you begin to describe the demographic factors and the challenge in providing a good model of care and the challenge of finance, but it can work. There are plans out there that are doing exceptional work in this space. But, every single one of them has something in common, which is that they knew they had to approach their business fundamentally different in order to make this dual eligibles program work. My counsel to the listeners of this podcast is that it is absolutely worth going into this program and serving this population. In fact, it’s a strategic imperative for most plans. But, you’ve got to go in with eyes wide open, as I said earlier, or you will find yourself upside down from a financial standpoint very, very quickly. Again, these members are $30,000 a year or more to care for. Think about that number. It’s extraordinary. It’s as high as an entry-level salary into this economy; $30,000 a year to care for these beneficiaries under the current system. That payment from the federal government is risk adjusted and plans have shown that they are incredibly unsophisticated over the years in managing that risk adjustment score. So, they’ve got to get that right or they will be in a world of hurt a couple of years into the benefit when they start seeing some volume of members being attracted to the plan.

The other interesting thing where at least the Dual Eligibles SNPs are concerned is that they are voluntary enrollments traditionally into these programs and under some of the projects that are being contemplated by CMS now, there may be the auto-assignment of beneficiaries into qualifying plans in those states on a state-by-state basis. Plans obviously will be applying to be qualified here. It’s not going to be random. But, it will be a specific number of plans and they will get these beneficiaries auto-assigned, just as they did with Part D. And that voluntary assignment is, again, a movement of an entire industry towards a retail sales model that is, frankly, alien to most health plans who are operating in this space today. But, one place where they’ve had significant experience in the retail model is Medicare Advantage. So, very interesting times for our payers. Extraordinary opportunities to improve care for these beneficiaries.

Healthcare Reform and how dual eligibles are impacted

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

Today he answers the question:
We hear a lot these days about health care reform. In what ways has health care reform impacted the duals population?

Nathan: That’s a great question. We talked a little bit about the expansion of eligibility. That’s probably the single biggest immediate change in this program. We also see a number of Dual Eligibles Coordination Demonstration Programs. For those who may not be familiar, Demonstration Programs are designed and initiated by CMS itself. Take us back to high school Civics class for a second here. When a law gets passed by the legislature, by our Congress, it then gets handed to the executive branch to execute. In this case it gets handed to CMS. We all know that moment when that law passes (Obama Care, as some people call it), it gets passed and it gets handed to the agency and then they write regulations. You could take a 1,000-page law and turn it into hundreds of thousands of pages of regulations, rules and guidance as it actually gets implemented.

But, CMS also has the authority to conduct experiments. They are given a rather broad purview in doing this. Some of these are called ‘demonstrations’ where they also do them under a different designation called an ‘authority’. There are some technical details between

the two. But in this case, they have a number of Dual Eligibles Coordination Demonstration projects that they run out of the MMCO, which is that Medicare/Medicaid Coordination Office that I mentioned before. They’ve got CMS sponsored Medicare/Medicaid integration waivers in the states of Massachusetts and Minnesota and Wisconsin. They’ve got 29 states that our audience is probably aware of that operate what are called: ‘PACE programs’, which is an older program. The program of All-Inclusive Care for the Elderly. Those provide a full range of medical and long-term services for duals over 65 who qualify for nursing home care. The most vulnerable of the vulnerable. And they get a capitated payment to cover Medicare and Medicaid services at those pay sites.

And then we also see Dual Eligibles enrolling in Medicare Advantage plans through that program I mentioned a moment ago called: ‘The Special Needs Plan Program’. They are allowed to have different benefit sets that are tailored around the needs of this population.There were major changes that came though. The most important change (other than the eligibility requirements changing) really was that creation of this Office to handle integration because what they are doing is creating a structure and a mechanism for continued experimentation around these programs.

At the risk of getting political about any of this, one thing that we see is that although the government is marching into the health care sector with an energy it never has seen before (remember 2012 is the first year that government spending is going to exceed private spending in the health care space), it’s sort of a milestone. That typically doesn’t retrench; it doesn’t typically go in the other direction. But, far from a one-size-fits-all approach to this, they are giving a wide range of latitude to the states to waiver out of certain programs, to waiver out of certain requirements. They are creating an Office that’s really dedicated to experimentation. I can’t remember the Supreme Court Justice who called the states the ‘laboratory for democracy’. Well, to some extent the CMS is using the states as a laboratory for creating best practices around care.
We are moving, one way or another, into something like government-financed care for all US citizens, but it’s not single payer. It’s going to be a patchwork. Now, that might sound like a pejorative term, so a better term might be a ‘sewn together system of best practices that are locally tailored’. They are not imposing one coordination-of- care system on the nation. They are allowing for many, many different types of systems to be created here. I think that CMS (although I certainly can’t speak for them) would acknowledge that they are making this kind of experiment.

So, it is a time of great experimentation. It’s a time of great opportunity for payers that have experience with either the Medicare or Medicaid population. They just need to go in eyes wide open to this program because the needs of this beneficiary population are just so different than your average Medicare beneficiary or the moms and kids of so many that our Medicaid providers currently care for.

Why are the dual beneficiaries unique to healthcare coverage?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

Today he answers the question:
You mentioned this special population of beneficiaries that are both Medicare and Medicaid programs and have a great deal of impact on today’s healthcare system. What makes this member population so unique?

Nathan's Answer:

Well, there are a number of things. First of all, there is a direct correlation between income and health status in this country. It’s an issue of profound moral importance, I think, when we’re talking about health care. We can’t lose that dimension. The further down you are on the socioeconomic ladder, typically the more ill you are. Remember, of course, the important thing (and our audience surely knows this) is that the driver of costs in our health care system isn’t so much the funding of acute episodes of care (although it is important), but it is the management of chronic illness over a long horizon. By the time a Dual enters into the system and becomes Medicare eligible and, in some cases has perhaps not had Medicaid coverage over their life because they’ve had a lower middle class income and they haven’t qualified for their Medicaid benefit, they may not also have had consistent health coverage. So, by the time they come into the system they often have multiple chronic illnesses or co-morbidities that have a very complicated clinical interaction. 

You remember back a moment ago to your first question. Everything we know about the health care system is compounded with the duals. So, one of these is the duals who receive fragmented care because they’ve got multiple complex conditions. They can have clinical recommendations or pharmacy therapies that are at a cross purpose. So, it is a challenging population to manage because of the way they enter into the system. But, there are other challenges, as well. 

It seems like we see every extreme when you’re talking about the duals. In our practice at GHG, we work with quite a few Dual Eligible Special Needs Plans, which is a designation created by CMS. In the previous major health reform in the MMA, it grew out of a pilot that was created there. The Special Needs Plans that we work with, you see populations that are either virtually housebound, often in neighborhoods that don’t have a grocery store. The food comes from a corner bodega or they have, on the other extreme, extremely transient lifestyles. The most consistent thing about these beneficiaries is a cell phone, if they have one. 

So, they are incredibly difficult beneficiaries to manage from a model-of-care standpoint. They are in many cases (but certainly not always) at the lower end of the educational scale. So, communicating with them can be difficult. You think about what it’s like to come out of a hospital stay and have complicated discharge instructions. We know that hospitals and clinics are struggling to really get on top of the importance of discharge planning. We know it, but we don’t do a terribly good job of it. So, again, all of those things are compounded when you’re talking about serving this population. 

Whether it’s a plan or a state, historically as you’re trying to reach out to these folks you’ve got to do so in ways that can be profoundly different from how you manage the rest of your population. The average Medicare plan that got into a dual SNP was accustomed to a certain model of care for caring for these beneficiaries and it doesn’t quite apply or it certainly needs to be changed for the duals. They require from a regulatory standpoint, an independent model of care from the plan. 

And then your average Medicaid provider or payer, rather, is accustomed to perhaps moms and kids, blind and disabled, different populations. So, plans need to come into managing the duals with an expectation that everything from the operational model to

Who are the dual eligables for Medicaid?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

Today he answers the question:
To start off our conversation with the upcoming Medicaid Managed Care Congress in mind, when we talk about dual eligibles and the Medicaid’s programs role for the low-income Medicare beneficiaries, who are we talking about here? Who are the duals?

Nathan's Answer:

Right. It’s an important question, especially these days. The duals are low-income individuals who are entitled to benefits from both Medicare and Medicaid. There are roughly 9 million elderly and disabled duals in the system. These are the most vulnerable patients in the healthcare system. They are also among the most expensive patients in the system. To an average managed care plan they will generate almost $3000 per member per month in costs. That translates to a little more than $300 billion in annual health care spending.

The challenge here is that the Medicare program, which is financed and administered by the Federal government and the Medicaid program which, as our audience knows, is partially financed by the Feds but managed by the states, are generally not coordinated. There has been a fragmentation of care with respect to the Duals which really is an amplification of everything we see in the system. Anything we know about a beneficiary--whether they are a healthy 35 year-old commercial beneficiary or a 70 year-old Medicare beneficiary--everything we know that’s wrong with the system is doubled in the case of the Duals. They experience the fragmentation of the system more acutely. They suffer from the lack of coordination because their needs are greater and the lack of financial integration between Medicare and Medicaid is only the tip of the iceberg. More importantly with Duals, as for everybody, the much bigger deal is the lack of clinical integration. What we are seeing in the policy landscape is tinkering with the finances in order to get clinical things aligned and tinkering with the way we do clinical alignment and integrated care in trying to influence the way the program is financed. So, everything we know about the health care system really comes home to roost with the Duals. 

CMS, the agency that has oversight of the Medicare and Medicaid programs, the federal level has known this for some time. So, in 2010 they actually created a new Medicare-Medicaid Coordination Office. That Office is dedicated to trying to coordinate not just the finances, but the clinical infrastructure and the data flow and what have you around the Dual Eligibles. So, they’ve set a goal of enrolling one million Duals in coordinated care programs by the end of this year, 2012. That came out of a result of what was in the ACA. 

The Health Reform Act, which is now nearly two years old (hard to believe; it passed on March 23, 2010) is known in some quarters as ‘Obama Care’. From a policy standpoint, though, it is known as the ‘Affordable Care Act’. The ACA mandated better coordination and established a structure to accomplish that mandate. The other thing that the ACA did, though, which is of great importance to our audience is that it expanded the eligibility criteria for Medicaid. That meant that more beneficiaries were eligible for Medicaid and, therefore, more beneficiaries became duals. 

So, you have this double whammy demographically, one of which is just the overall aging of the population, right? You’ve got the Medicare beneficiaries increasing by 30,000 Baby Boomers a month to become Medicare eligible. It’s a big, big number. But now you’ve also got expanded eligibility on the Medicaid side. So, those two things have created an environment where the number of Duals is just absolutely exploding. 

Now, of those Duals about three quarters of them are what are known as ‘full benefit duals’ who qualify for full Medicaid benefits in addition to Medicare. And then the remaining quarter are partial duals. Partial duals qualify to have Medicaid subsidize their Medicare Part B premiums and the cost sharing, but they don’t receive the full spectrum of Medicaid benefits. 

Getting back to your question of who they are, there is a broad range of duals state by state. Eleven states have 25% or more of the Medicare beneficiaries also receiving Medicaid benefits. And these are highly populated states – California, New York, Massachusetts (a very sophisticated state from the standpoint of clinical infrastructure and, of course, a state that already has a mandate for coverage) and Wisconsin. The actual state with the highest proportion of duals (and this surprises many people) is Maine. And then you’ve got the deep South states of Louisiana, Mississippi, Alabama, Tennessee and then up into Kentucky. Very high proportions of duals. That’s over 25% of Medicare beneficiaries. 

The lowest state, by the way, is Montana. And you look out to those mountain states (Colorado, Utah, Wyoming, and Nevada). These are all states of generally low proportions of dual eligibles.So, it’s a national issue. The states are going to deal with this in different ways. CMS has shown itself open to experimentation on a number of different levels.

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And 2012 has proved to be a pivotal year for government rebates with the release of the long-awaited AMP Proposed Rule. Industry experts will be on hand to interpret these rules and discuss proposals for operationalization.

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MMCC Session Spotlight: CMS Joins MMCC!

In today's session spotlights, we look at the newly confirmed sessions in which the CMS will be joining the Medicaid Manged Care Congress.  Steve Larson will be on hand to look at the current state of healthcare reform and how the CMS is working with the upcoming transitions.  Patrick Conway will also be on hand to look at what strategies are in place in order to serve the Medicaid population with a higher quality of care.

For more information on these presentations and the Medicaid Managed Care Congress, download the brochure here.  MMCC will take place April 30-May 2, 2012.  As a reader of this blog, when you register today and mention code XP1726BLOG, you'll receive 25% off the standard rate.

Featured Session: Health Care Reform: A Federal Perspective
Featured Speaker: Steve Larsen, Deputy Administrator & Director of the Center for Consumer Information and Insurance Oversight (CCIIO), CMS
About the Session: The Center for Consumer Information and Insurance Oversight (CCIIO) is charged with implementing the private market provisions of the Affordable Care Act. During this keynote address, Steve will focus on areas of the ACA of interest to Medicaid managed care.

• • Learn what CCIIO is doing to help states and plans prepare for health insurance exchange implementation
• • Understand some of the implications of Medicaid Expansion
• • Discuss insurance market reforms

Featured Session: CMS’ Strategies to Increase Quality
Featured Speaker: Patrick H. Conway, M.D., MSc, Chief Medical Officer, CMS; Director, Office of Clinical Standards and Quality
About the session: At CMS, the Office of Clinical Standards and Quality identifies best practices and techniques to improve quality, then implement them across all states.

• • Learn about the demonstration projects the Office of Clinical Standards and Quality supports
• • Hear the best practices they have currently identified

Have Lunch with your State Medicaid Representative at the Medicaid Managed Care Congress!

The 20th Annual Medicaid Managed Care Congress is just around the corner, taking place April 30-May 2, and you’re invited to an exclusive luncheon discussion with a State Representative. This is your opportunity to ask state government officials questions and converse with other attendees about Medicaid Expansion, Health Insurance Exchanges, and Dual Eligibles. Don’t miss this amazing opportunity to speak with key stakeholders and walk away with exclusive information about your state.

To reserve your seat at the table, please use the specific state Priority Codes when registering:

Lunch on Tuesday, May 1:

• - Michael Norton, Senior Program Manager, Massachusetts Health Connector
• ◈Register with Priority Code BLOGMA
• - Deborah Florio, Administrator, Center for Child & Family Health, Rhode Island Department of Human Services
• ◈ Register with Priority Code BLOGRI
• - Joe Vesowate, Deputy Director, Managed Care Operations for Medicaid and CHIP Texas Department of Health & Human Services
• ◈ Register with Priority Code BLOGTX
• - Amy Allen, Healthcare Reform Planning Director, Department of Community Health, Michigan
• ◈ Register with Priority Code BLOGMI

Lunch on Wednesday, May 2:

• - Valerie Harr, Director, Division of Medical Assistance & Health Services, State of New Jersey.
• ◈ Register with Priority Code BLOGNJ

For more information on The Medicaid Manged Care Congress, including the complete program, visit the webpage to download the brochure.

Also, don’t forget as a reader of this blog, you can receive 25% off the standard registration rate with the above Priority Codes. For more information on the Medicaid Managed Care Congress and to register to have lunch with your Medicaid Representative, visit our webpage.  If you have any questions about the event, feel free to email Jennifer Pereira.

Download the New 2012 Medicaid Drug Rebate Program (MDRP) Summit Brochure

2012 is a pivotal year for government rebate executives.

First and foremost, compliance is king, and with pharmaceutical manufacturers continuing to see fines in the hundreds of millions of dollars, you want face-to-face interaction with the government watchdogs who will direct you towards improved compliance initiatives.

With the January release of the long-awaited AMP Proposed rule, you have had several months to interpret what the rule could mean, and now you must begin to develop internal strategies to implement those pieces that make it to the Final Rule in 2013.

No other event has these government and industry leaders at a time you need them most.

Download the 2012 Medicaid Drug Rebate Program Summit Agenda and join the one event where you will navigate regulatory hurdles, maximize limited resources and limit company liability and risk with the most current government updates and industry practices.

At MDRP 2012:

Access to more CMS, OPA, DOJ and VA officials who provide regulatory updates to clear up uncertainty and ensure compliance

More states confirmed than ever before, providing insight into state operations and enabling dispute resolution

Over 45 branded and generic manufacturer executives share best practices to inform successful rebate operations

Access to more leading industry expert opinions sharing information that would otherwise cost thousands in fees

Don’t miss out on the leading Medicaid Drug Rebate Program event of the year!


To register today, please visit the www.medicaiddrugrebates.com, call (888)670-8200, or email register@iirusa.com.  


The 17th Annual Summit on the Medicaid Drug Rebate Program is taking place September 10-12, 2012 in Chicago, Illinois.  As a valued reader of the Health Care Insights - From Policy to Practice blog, you can use priority code XP1758BLOG to receive 25% off of the standard and onsite rate!  


* Group Discounts Available:
Send your entire team to MDRP 12! For information on group discounts, please contact Millison Thenor at (646) 616-7625.