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A Health Law Program States Actually Like? Yes, in the Case of Duals Demo

By John Reichard, CQ HealthBeat Editor

April 19, 2012 -- The deep disdain expressed by many state officials for "Obamacare" doesn't extend to everything in the health care law—witness their response to a program to test the widespread use of managed care for the so-called dual-eligible population.
Melanie Bella, the head of a new office created by the law (PL 111-148, PL 111-152) to improve care for people eligible for both Medicare and Medicaid, said that 28 states want to take part in the managed care demonstration. It's expected to start in January and enroll up to two million duals.

In response to questioning during a meeting of a Medicaid advisory group, Bella said that the program has not drawn partisan fire. She added that in her testimony at two congressional hearings and in meetings with Hill staff, the demonstration, called the "financial alignment program," has not sparked opposition. Hill staffers "have a lot of questions, but there is no opposition to doing this," she said.
With the U.S. Supreme Court weighing a decision that might strike down the entire law, such apparently broad-based support could help ensure that the duals program continues, no matter how the justices rule.

Better care for the duals excites both those are most concerned with controlling spending and those who want to improve the quality of their care.

It's the sickest, frailest populations in Medicare and Medicaid that accounts for a disproportionately large chunk of spending—old people in nursing homes with multiple chronic conditions, and younger disabled people who have severe illnesses or are developmentally disabled, for example.

Many providers and multiple tests and medications are involved in delivering their care. But there is no one quarterbacking their treatment. That leads to medication errors and preventable trips to the hospital, poor preventive care, duplication of services or omission of treatments. These are all things that drive up costs or threaten patient well-being.

Most of the states that plan to participate in the demonstration intend to automatically enroll duals in managed care plans as part of a broad, dramatic push to better coordinate their treatment. While that would fulfill the goal of policy makers who have urged such a step for two decades, it arouses great anxiety about whether such new arrangements will, in practice, actually be a good match for the particular needs of the dual population.

Bella said that CMS has "every intention" of seeing states do what is known in the field as "intelligent assignment." In other words, an individual dual-eligible would not simply be assigned at random to a plan but an assessment would be made of whether it has the providers and medications that the dual needs.

Members of the advisory group Bella spoke to, the Medicaid and CHIP Payment and Access Commission (MACPAC), praised the demonstration program but wanted to be sure that the automatic enrollment process doesn't harm people who are very vulnerable and that intelligent assignment actually occurs. Commissioner Andrea Cohen suggested that Bella be more "proactive" in making sure states do the kind of enrollment that best protects the duals. Bella said that guidance documents issued by her office, which is known as Medicare-Medicaid Coordination Office, have language about ensuring continuity of care. "Your point's well taken," Bella added.

Bella also assured commissioners that "we really are testing the passive enrollment" and will take a hard look at things like "opt-out rates"—the percentage of people who decide they don't want to stick with the plan to which they are assigned.

Commissioner Robin Smith, the adoptive parent of special needs children covered by Medicaid, underscored the stakes involved for the duals who will be enrolled in the project. "Their care is going to dictate the type of life they have," Smith said. "The team that's dealing with them has to be really good."

Smith then singled out Bella for praise, and other commissioners similarly lauded her efforts, her office, and its programs. Many Medicaid analysts and state officials want to see all three continue at CMS long after the fate of the health law is resolved. Executive Director Matt Salo of the National Association of Medicaid Directors (NAMD) said "there's no question" no matter how the ruling on the law comes out "there is strong bipartisan support for the office of the duals." Added Andrea Maresca, the director of federal policy at NAMD, "I think HHS would work very hard to figure out how to make it work under existing authority."

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