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Automatic Enrollment of 'Duals' in Managed Care Plans Stirs Anxiety at MedPAC

By John Reichard, CQ HealthBeat Editor

April 5, 2012 -- Members of the Medicare Payment Advisory Commission (MedPAC) recently expressed concern about automatically enrolling "dual eligibles"—some of the sickest Medicare enrollees—in managed care plans as part of a series of health law demonstration programs to be launched next year.

MedPAC Chairman Glenn Hackbarth said the programs could entail moving people into care delivery arrangements that may or may not be a good match for a dual given such a patient's particular medical needs.

The duals are a population that is eligible for both Medicare and Medicaid. They may see a large number of doctors given their complex medical needs, and often there is little or no oversight of their treatment. They include people 65 or older with incomes so low they qualify for Medicaid. In many instances they are nursing home residents who have exhausted their assets, have many chronic medical conditions, and are physically frail. They may also be cognitively impaired.

About one third of the 10 million duals are below age 65 and disabled. They qualified for Medicare by virtue of having been disabled for two years. In many cases they are developmentally disabled.

Both Democrats and Republicans favor trying new arrangements for delivering health care services to the duals because they account for a disproportionately large amount of health care spending.

But getting the details right about how to better coordinate the care of duals is a major challenge and commissioners had many questions about how the demonstration programs would work. Since those details are the subject of negotiations between the Centers for Medicare and Medicaid Services (CMS) and the states, there are few answers right now. MedPAC is likely to summarize its concerns in the form of a comment letter to CMS officials at some point down the road.

Commissioner Raymond C. Castellanos said it seems unfair to automatically enroll a dual in a plan. "Perhaps we should be talking to {patient advocacy groups} more about this," he said. "I think you raise a good issue," replied Christine Aguiar, a MedPAC staffer who gave a briefing on the CMS demonstration programs.

MedPAC Executive Director Mark Miller helped frame the issue by noting that duals whose care has been delivered mostly under the Medicaid program have often struggled over a period of years to line up the appropriate providers. Access in Medicaid is a challenge because many doctors do not participate.

If duals are switched to a plan under the demos that requires them to go to different providers, their care might be disrupted, he suggested. They may then want to go back to their old providers.

CMS says the demos will enroll up to two million of the nation's 10 million duals. Twelve states have said they will conduct demonstration programs to better coordinate care of the duals.

Aguiar said that the states involved plan to enroll most if not all of their duals population. In California, for example, 700,000 duals will take part.

It's also likely that most of the states will automatically enroll duals in a plan in the demo without giving them a choice ahead of time. They will be able to opt out, however.

That sparked another concern on the part of the commissioners. Opt out to what? If a plan was a poor fit, would there be other options that were preferable? "People can opt out but they have to have something to opt into," said Castellanos. "Where the hell are they going to go?" Hackbarth said that if enrollment is going to be automatic there needs to be a way to properly match duals to the plan appropriate to their needs.

The commission also discussed the particular package of benefits in the demos. CMS officials are aiming for flexibility in that regard, the better to attract states to participate. But benefits could be too lean, commissioners fretted.

Uneasiness about the demonstration programs dominated the early part of last week's discussion but then the tide turned, with a number of commissioners emphasizing the importance of moving ahead with the programs. "The status quo is not adequate," one commissioner said, stressing the need to control the huge costs of treating duals.

Improved coordination of care could be a big improvement for duals, added another commissioner, Katherine Baicker. "This could very well be making everybody better off."

It's likely to take weeks and months for CMS officials to iron out the details of the program. It's being closely watched by industry and patient groups because of the large amount of money involved and the vulnerability of the population that will be enrolled. The duals discussion was one of the most heavily attended sessions ever at MedPAC.

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