See What’s New at MMCC 2015

The Medicaid Managed Care Congress is in its 23rd year, and there is a reason why we have been around so long—we consistently provide the newest and freshest insights on the topics that matter most to you and your business. For the 2015 event taking place on May 20-22 in Baltimore.

Here is a sneak peek of what’s new:

8+ New Health Plan Case Studies
Evaluate opportunities to grow membership, increase quality and decrease costs by learning from victories (and lessons learned) from speakers who haven’t presented in the past, including representation from Humana, Community Health Choice, Molina Healthcare executives on a national and regional level, plus many more.

Dual Eligibles Summit
It’s not just a few sessions anymore; we now have an entire day focused on increasing revenue by successfully navigating the very complex but extremely lucrative duals market.

A 360º view
The popular Medicaid Managed Care 101 pre-conference summit has been reformatted to give you multiple perspectives on the areas that have the highest impact on your bottom line. A unique 360º view from health plans, government officials, solution providers and other perspectives for a well-rounded understanding of the topics that will grow your skill set, such as ACA implementation, improving quality, the long-term industry outlook and more.

Customize your Agenda (coming soon!)
Create a personal agenda to select which sessions will increase your ROI the most. Prepare your networking strategy in advance to optimize your time at the event and coordinate attendance with colleagues to ensure you get maximum expertise. Stay tuned as we will make this feature available in the coming weeks!

Download the preliminary agenda for more details.

Register now and save $400! Use code XU2026BLOG - Register here.

The Medicare Trajectory: Take the Healthcare Quiz

By Nalini K Pande, JD

Want to reduce the nation’s spending on healthcare?  How about your own healthcare spending? This quiz could help do just that.  “How” you ask?  It’s quite simple.  When we think about Medicare spending, we don’t often think about kids, young adults or even adults under 65.  But, we should.  The major driver of Medicare costs is spending on chronic disease.  How do we reduce this spending?  We get people like you and me to take care of their health, focus on prevention, and become an active player in the health system before we become Medicare-eligible.  In doing so, you could end up saving money.  And, we also engage those already on Medicare to better manage their care.  Certainly, this is easier said than done.  

Why is America so alienated from their own health care? Could it be that the health system has become so complex that you would have to be a health care expert to figure out what’s going on?  And, who has the time?  This holiday season as you dine with your loved ones and catch up on some good books, you might consider sharing this fun Healthcare Quiz.  This “take” on the 12 days of Christmas will teach you everything you need to know - well, at least 12 important health topics. 

Quiz Directions: Read the Healthcare Quiz and see how many of these terms you know.  Use the red short answer key to see what these terms mean.  You get 1 point for each numbered phrase/term you know for a total of 12 points. Want to earn extra points?  Then, read the “Detailed Answers” section below to learn why these 12 issues are critical to the health policy landscape and earn extra points.

Detailed Answers
(Give yourself an extra point for every detailed answer you know)

12 States Expanding: The Supreme Court has indicated that states can determine whether they will expand Medicaid to cover some of the uninsured under the Affordable Care Act.  Thus far, 28 states and DC have expanded Medicaid.  You get a bonus point if you know whether your state has expanded.  Click the link to see if you are right.

11 Measures Measuring: Health quality measurement is critical to improving the quality of health care services and identifying areas in need of improvement. Measures also inform consumers.  Check out the following consumer health quality sites: for hospitals (Hospital Compare), health plans (HEDIS), and doctors (HealthGrades), as well as an overview of all consumer sites.  Measures can be controversial given operational challenges, and concerns that incorrect inferences have been made from measures. All of this leads many to question how useful some measures are for determining true health quality. Now that I have you completely confused, let’s move on to the Exchanges.

10 Exchanges enrolling:  Also known as Health Insurance Marketplaces, the Exchanges are where both individuals and small businesses can go to shop for health insurance coverage.  Federal subsidies (premium tax credits) are available to consumers if they meet certain incomes requirements. Some states established their own Exchanges. Other states relied on the federal government to do so.  Open enrollment for 2015 coverage started Nov 15 2014 and ends Feb 15, 2015.

9 Duals pending: Dual eligibles are given this name because they are covered under both the Medicare and Medicaid programs.  They are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Currently, 9 states are in the process of implementing a capitated (managed care) model with goals of improving quality and cutting costs for duals.  What’s pending is the evaluation.  It has yet to be seen how successful these initiatives will be.  Additional states are implementing other models as well.  What’s important is that HHS is focusing on ways to address this vulnerable and high-cost population that maintains strong quality standards while also reducing costs. 

8 Curves a bending: Bending the cost curve in the policy arena really means reducing costs over time.  If someone is acting like a know-it-all about some policy, just throw out the phrase, “but will it bend the cost curve?” and watch them quickly back away.  You get a bonus point if you use this phrase at work or with friends today.

7 COBRAs extending: The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions require group health plans to continue your employer health coverage (18 months) if you have a qualifying event such as being laid off.  However, you will now pay 100% of the premium costs (not just a portion).  If you’re feeling really adventurous, you can also investigate whether the Exchanges give a better deal given their subsidies or check out your local health plan’s website (except in DC and VT) and shop around accordingly.

6 Health apps trending: Health apps are specialized programs/software often used on mobile devices that focus on health, nutrition or exercise programs.  What’s exciting is that a new app focusing on managing chronic conditions is out.  No longer do the healthy get to have all the apps.  Venture capitalists have been challenged to do more in the chronic condition app arena and it will be interesting to see this field develop further.  You get a bonus point if you have a health app on your mobile device and you use it.

5 Bundled payments!!! Bundled payments is a new payment model that transforms multiple claims into a single payment for one “episode” of care based on predetermined lump sum amount. Why is this important?  This new payment model may lead to higher quality and more coordinated care at a lower cost.  It essentially incentivizes providers to coordinate care and prevent costly and avoidable hospital readmissions. The jury is out as to whether this model will be a strong cost-saver. What is most critical is the cost transparency that the new reform represents.

4 EHRs: Electronic Health Records (EHRs) are seen as the wave of the future (and are currently being used in some health systems). EHRs allow doctors and hospitals to access your medical history, lab tests, allergies, immunizations, and radiology images all in one digital format.  EHRs improve quality, efficiency and care coordination across your care while reducing waste such as duplicative tests.  However, adoption has been slow, and transitioning from paper to digital has been challenging. Further, not everyone believes it is improving efficiency given additional burdens and high costs.  Addressing privacy and security issues are critical for successful implementation.  You get a bonus point if you already have access to your health records online (and another bonus point if you actually use it!)

3 Co-pays: A copay is a fixed amount that you pay when you visit the doctor’s office or when you buy prescription drugs. Why is it important?  As you probably have seen recently, your premium (how much you pay monthly for your health insurance), co-insurance (a percentage you pay of your medical bill) and your deductible (how much you must pay before your insurance will kick in) has been increasing over the years.  How can you effectively select a plan that will best meet your budgetary needs?  Hint: The lowest premium plans aren’t always the best.  They can have high deductibles and out-of-pocket maximums that might make a different plan a more financially appropriate choice.

2 ACOs:  An Accountable Care Organization (ACO) is a group of coordinated providers (doctors, hospitals) in which provider reimbursements are linked to improving quality and reducing costs for a  population of patients. Doctors get more money if their patients stay healthy and if they save money.  (This is unlike previous systems, where doctors are incentivized to reduce costs without always focusing on improving quality). ACOs are seen as cutting edge.  Whether they are the “next big thing” has yet to be seen.  Pioneer ACOs have seen some real success.

And a PCP in a Pear Tree! No, this is not the drug, PCP, but rather what we call in the health field, a Primary Care Provider.  Why is your PCP important?  Having a PCP leads to better health outcomes and reduced costs (through lower hospitalizations), including improved prevention and better coordination of care for those with chronic diseases. You get a bonus point if you have a PCP. 


What’s your Number? How many did you get right? 
• You get 1 point for each numbered phrase/term you knew based on the red answer key for a total of 12 points
• You get an extra point for every detailed answer you knew based on the detailed answers section above for a total of 12 additional points.  
• You get additional bonus points as indicated above for a total of 6 bonus points.

28+: Congratulations! You are a Health Guru. We need more experts like you!

21-27: Great job! You are a Health Professor.  Everyone in the office comes to you for help with their health questions.  Keep up the great work!

11-20: Nice work!  You are a Health Enthusiast. You are on your way to becoming an active player in the health system.  Keep learning and sharing what you know with others!

1-10: Hang in there!  You are a Health Rookie. Healthcare is a very complex topic. It's hard to understand health reform, health delivery system changes and payment reform when the existing system is so confusing. Keep learning!



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  She previously taught a graduate health quality course at Georgetown University as an Adjunct Professor.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
Follow @nalinipande

Dual Eligibles and HIT: Managing Not Just Measuring

By Nalini K Pande, JD

Why is HIT Important to Duals?

There’s an old saying in the health care quality world: “We cannot improve what we don’t measure.”   And, of course, the follow-up to that is: “how can we measure without good data?” Health Information Technology (HIT) is at the heart of one the most exciting aspects of health reform.  HIT systems are designed to collect and display data related to the delivery and care of patients.  

Dual eligibles are covered under both the Medicare and Medicaid programs and are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Given this, it is essential that HIT systems, including Electronic Health Records (EHRs),  are designed to supply actionable data for the measurement of dual eligibles and ultimately, to improve the care of this unique population and reduce costs.

Where Are We Now?

The future of the nation’s health measurement and  HIT agenda is at a cross-roads.  We are still in the process of changing old systems to move us into the health electronic age.  We are also in the process of developing and endorsing measures specific to the duals population.  As we do so, there are several key issues that we must focus on to improve the care of the dual eligibles population.  One issue that stands out above the rest is how to better manage this unique population, not just measure them.  It is not enough to just collect the data.   Rather, it is what we do with this data and the measurement findings that will ultimately lead to improvements in health outcomes and care delivery for dual eligibles. HIT can capture data that is critical in improving care coordination, care transitions and disease management for dual eligibles.  We must use this information to analyze clinical trends and better engage dual eligibles as well as help providers in clinical decision support.

It’s no surprise that in the world of health apps and iphones, we turn to HIT to revolutionize our health care systems and improve outcomes.  However, HIT alone is not the Holy Grail we seek.   Rather, HIT is only a tool to get us the data we need to measure and improve our patient outcomes, our clinical care, and our delivery systems.  The story cannot end with more measures and data.  Otherwise, we will simply collect a lot of good information without much action.  We must re-tool our delivery systems and health care culture so we can act on the data we capture such as changing patient care plans and engaging patients differently.  Essentially, we must focus on moving from health measurement to health management and outcome improvement.   This will take a stronger focus on analyzing the data, and measurement findings, using predictive modeling, and taking a more proactive rather than reactive approach.  Many Accountable Care Organizations and other health entities have embraced this new approach but it is far from the norm.  Can we afford to shift from measurement to management?  Many fear the cost of HIT alone is too great.   However, with duals costing Medicare and Medicaid $250 billion, can we really afford not to?



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including health information technology, accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

Dual Eligibles and ACOs: A Blueprint for Success

By: Nalini K Pande, JD

Background:  Why Duals Need Stronger Focus and Attention

You may notice that when we talk about health reform, most health policy experts tend to bring the conversation back to the dual eligibles.  These beneficiaries are covered under both the Medicare and Medicaid programs and are generally sicker and costlier than Medicare and Medicaid beneficiaries as a whole.  Thus, it is no surprise that duals have been the focus of those trying to bend the cost curve.


ACOs May Be Uniquely Situated to Address Key Duals Issues

How do we improve the care of these beneficiaries while also working to reduce costs?  Accountable Care Organizations (ACOs) that take on dual eligibles, are uniquely positioned to provide effective solutions. An ACO is a group of coordinated providers in which provider reimbursements are linked to quality metrics and reductions in the total cost of care for an assigned population of patients. Given their emphasis on patient-centered, integrated care and coordinated Medicare and Medicaid benefits and funding streams, ACOs could facilitate greater quality improvements and reduce cost-shifting between programs as well as overall costs. Yet, the fundamental question still remains:  What is the blueprint for success?

Two core frameworks will need to be developed as part of a blueprint for success:
   • ROI Framework
   • Measurement Plan

Certainly additional key components will be necessary.  However, two critical components of the blueprint for ACO success are ROI (return-on-investment) and Measurement frameworks. First and foremost, a successful ROI framework is needed to ensure financial viability of the ACO structure: (e.g, hospitalization costs must be significantly reduced to pay for increased expenses in care coordination, care transitions, and care management). 

Second, a measurement framework will be needed to test improvements in quality.  Key measures should include patient-reported outcome measures, beneficiary experience, care coordination measures, utilization and cost measures, etc.

As part of this blueprint, the ACO must consider the barriers and challenges to changing the current system. How can the ACO overcome these barriers?  This will depend on whether the ACO can achieve a true culture change at three levels:

• • at the governing level with a stronger focus on clear and attainable management goals and benchmarks with diverse stakeholder input
• • at the clinical level with team-oriented care in order to improve care coordination and
• • at the community level with a focus on population health and collaboration with community organizations.

Can ACOs that take on duals bend the cost curve and improve quality? This has yet to be seen.  Setting ACOs up with a blueprint for success may be just what the doctor ordered.

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

The Medicare Congress Brochure is Now Available | Register Now to Save $600

The 12th Annual Medicare Congress was designed with you and your team in mind—covering Medicare and Dual Eligibles from A-Z. Make sure you join us this February 3-5 in New Orleans!


Let us help you navigate through the evolving landscape so you can increase reimbursement with stronger Star ratings, build relationships with provider networks to improve quality of care, meet the clinical needs of dual eligibles to attract and retain new members— and much more!

What’s new at Medicare Congress 2015:
• C-Level Sound Off
• Patient Advocacy Group Panel
• Think Tank Roundtable Luncheon
• Town Hall Round-up
• And more!

Download the 2015 Brochure Here.

Register now and SAVE $500 but use the code XP2007BLOG and take an extra $100 off – total savings of $600! Register here.

PLUS! Dual Forum and Stars University are back by popular demand. Click here to learn more.

Free Webinar | Better Quality and Cost for People Eligible for Both Medicare and Medicaid

More than 10 million Americans qualify for Medicare and are eligible for some level of Medicaid benefits. They receive health care in often fragmented settings from two distinct programs. This webinar will provide insight on ways to effectively provide care for the dually eligible population and work with the state to help control costs, along with specific examples of what WellPoint is doing on a state level to address the dually eligible population and share success stories from Amerigroup Tennessee.

In this upcoming webinar, Dr. William Wood, Chief Medical Officer of Behavioral Health for Amerigroup Tennessee, will provide insight into managing dual eligibles as a preview to his participation at Medicaid Managed Care Congress 2014. Dr. Wood's professional experience includes more than 25 years in behavioral health care and executive-level medical management. At Amerigroup Tennessee, Dr. Wood is responsible for overseeing and directing the behavioral health programs to meet the contractual requirements and expectations of TennCare of Tennessee, the state's Medicaid managed care program.

Webinar Highlights:

• How to coordinate long-term services with Medicare services for dual eligible members
• How the Long-Term Supports and Services (LTSS) CHOICES program facilitates coordinated care in Tennessee
• The need for integration of physical health and behavioral health in a dual eligible population, including barriers and solutions
• How dual integration is key to LTSS development
• Key savings drivers for the State

Date: 3/28/2014 Time: 2:00-3:00 EST
Speaker: Dr. William Wood
Priority Code: 1926WEBHCI

Register today!

To learn more about IIR’s 22nd Annual Medicaid Managed Care Event, download our brochure.

Register with code XP1926BLOG and save 15% off of the standard rate. If you have any questions or need any further information, feel free to email kdevery@iirusa.com or visit the webpage. We look forward to seeing you next May 19-21 in Baltimore!

Cheers,
The Medicaid Managed Care Congress

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Which Medicare topic areas are most important to you?

Over the past couple weeks, I've had research calls with dozens of your peers: some of which have attended the Medicare Congress, some who have spoken at the Medicare Congress, and some who didn't know what the Medicare Congress was until I told them about it. As always, some are feeling positive about the industry, some are feeling not-so-positive, and EVERYONE had insight into what matters most in the Medicare industry.

One of my favorite parts of being a conference producer is getting to translate all of this feedback into a tangible program that attracts high level, provocative speakers, which in turn attracts a larger audience. I’m just starting to put together a loose agenda, and although I'm not quite ready to show all of my cards, I can tell you that we’re planning on adding a few full day summits to the mix, in order to provide you with deeper insight into the areas that matter most (and are the most lucrative).

We'd love to hear from you! Which topic areas would you like us to cover for next year's event?

Are you ready for the D.U.A.L.S. Forum?

Join us this week, April 4-5 at the Marriott Inner Harbor at Camden Yards to hear all of the necessary strategies and tactics to increase care coordination and decrease costs.As your partner in dissecting and understanding healthcare and all that it encompasses, we are pleased to provide you with a forum to learn industry insights from health plans making waves in the dual eligibles space.

By attending, you will:

• DEFINE opportunities, including financial incentives, created by serving dual eligibles.
• UNDERSTAND duals' needs in order to determine how you would have to extend your network and change your benefits to best address their needs.
• ALIGN programming by partnering with (or purchasing) a health plan that compliments your plan.
• LEVERAGE existing resources to reduce administrative costs.
• SUCCEED in providing quality, cost efficient care to dual eligibles.

To find out more about the 2013 program, download the agenda. Onsite registration will be open both days of the event. If you have any questions about the agenda or event, please contact Kate Devery at kdevery@iirusa.com or visit our webpage.

We look forward to seeing you in Baltimore!

Best,

Medicaid & Medicare Marketing & Enrollment Congress

The D.U.A.L.S. Homepage
The D.U.A.L.S. Twitter: https://twitter.com/healthcarebiz
The D.U.A.L.S. Blog: http://healthcareinsights.blogspot.com/

Only 2 Weeks Left to Register — Save Your Seat Today

The DUALS Forum is just over two weeks away! Join us to hear all of the necessary strategies and tactics to increase care coordination and decrease costs.

By attending, you will:

• DEFINE opportunities, including financial incentives, created by serving dual eligibles.

• UNDERSTAND duals' needs in order to determine how you would have to extend your network and change your benefits to best address their needs.

• ALIGN programming by partnering with (or purchasing) a health plan that compliments your plan.

• LEVERAGE existing resources to reduce administrative costs.

• SUCCEED in providing quality, cost efficient care to dual eligibles.

Join the growing list of attendees already confirmed to participate in Baltimore on April 4–5:

Altegra Health | American Institutes for Research | Amerigroup | Blue Cross Blue Shield | BMC Healthnet Plan | Brockton Hospital | CareMore | CareSource | Catamaran | Commonwealth Care Alliance | Commonwealth Medicine | Fallon Total Care | Firstsource Solutions | Gateway Health Plan | Glenridge Healthcare Solutions | Gorman Health Group | Group Health Cooperative of Eau Claire | Health Management Associates | Health Partners | Health Policy Matters | HealthSpring | Homefirst Elderplan | KnowledgeBase Marketing | L.A. Care Health Plan | Marwood Group | Montefiore Medical Center/CMO | NARBHA | Optima Health Plan | Public Consulting Group | SCAN Health Plan | Seniorlink | United Healthcare | WellPoint |

There's still time to register!  As a reader of the D.U.A.L.S. blog, you get a 15% discount off the standard rate when using code XP1804LINK to register. To find out more about the 2013 program, download the brochure. If you have any questions about the agenda or event, please contact Kate Devery at kdevery@iirusa.com or visit our webpage.

We look forward to seeing you in Baltimore!

Best,
The D.U.A.L.S. Forum Team

The D.U.A.L.S. Homepage
The D.U.A.L.S. Twitter

Does the dual eligibles population make financial sense for your plan?

The dual eligibles population comprises 24% of Medicare enrollees, but accounts for almost 35% percent of Medicare expenditures. With healthcare expenditures increasing at an alarming pace across the board, managing the care (and finances) for serving duals is now more important than ever.

At the Annual Medicare Congress, taking place on February 11 – 13 in Phoenix, you’ll hear best practices to determine if providing coverage for dual eligibles makes sense for your health plan. Panelists will share their insight on evaluating the financials of providing care to duals, predicting utilization patterns and how to overcome marketing barriers.

Evaluate if Dual Eligibles Make Financial Sense for Your Plan Tuesday, February 12, 2013 at 11:45am:

• - John Gorman, Founder and Chairman, Gorman Health Group
• - Rhys W. Jones, MPH, Vice President, Medicare Policy and Market Development, Specialty Products Group, Amerigroup Corporation 
• - Jeff Flick,National Vice President, Government Programs, HealthCare Partners 
• - Austin Ifedirah, Vice President of Medicare

To view the 2013 program, download the agenda.

As a reader of the Medicare Congress blog, you get a 15% discount off the standard rate when you register to join us and when using code XP1807BLOG. If you have any questions about the agenda or event, please contact Kate Devery at  or visit our webpage here.

Have a safe and happy Thanksgiving!
The Medicare Congress Team

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.

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.