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A proven way to care for the poor and sick

Posted by Marjorie Pritchard  November 22, 2011 04:01 PM

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By John Baackes

If life is not hard enough for them already, the state's poorest, sickest residents enter a bureaucratic maze when they need health care, having to navigate between the federal Medicare program and the state-run Medicaid program known as MassHealth. Often, they slip through the cracks and end up with worse health issues that are more expensive to treat.

The Patrick administration has embarked on an initiative that would better meet the needs of this vulnerable population, reduce government health care costs, and provide a roadmap to a higher-quality, more cost-effective health care system for all. The would provide one-stop, all-inclusive health care to adults ages 21 to 64 who are eligible for both Medicare and Medicaid.

Entities chosen on a competitive basis by the state would receive a set amount in combined Medicare and Medicaid payments to provide coordinated, seamless care to each "dual eligible.''

State and federal officials should embrace and promote this approach - and they can feel comfortable doing so - because it has already worked in Massachusetts with "dual eligibles" 65 and older. Using a similar approach, the Senior Care Options (SCO) program has already achieved the new initiative's goals of better care, lower costs, and happier members.

This model of comprehensive services, coordinated care and accountable providers should also serve as a positive bellwether for initiatives being pursued by state and federal government for the health care system as a whole, including patient-centered medical homes and accountable care organizations. If the model can work for the dual eligible population, it will certainly work for the general population.

Dual eligibles, who are the least equipped to navigate the health care system, have its most complex issues. Massachusetts has nearly 250,000 dual eligibles, half of which are under 65 years old. Of that under-65 group, more than 75 percent have a chronic medical condition such as asthma or heart disease, and 64 percent have been diagnosed with a mental health or substance abuse issue. As a result, dual eligibles make up less than 20 percent of the state's Medicaid enrollment but more than 40 percent of the Medicaid budget.

SCOs have succeeded in caring for a similarly challenged population. More than 60 percent of our members do not speak English and 13 percent are illiterate. Most have at least one chronic disease. The average number of prescriptions is five.

The keys to the success of SCOs are the one-stop shopping they provide and their team approach to providing care. Each member has a nurse care manager who is the main contact and chief advocate in arranging the right combination of services. Each member also has an individual care plan, a primary care physician, and a geriatric social worker. A nurse is available for consultation 24/7.

Use of community-based services such as personal care and homemaker services support members at home and are integral to preventing declines in health status and nursing home placement.

SCOs are also allowed a degree of creativity to match their all-inclusive responsibility. For example, they can pay for rides to medical appointments and provide non-traditional programs like Tai Chi fall-prevention classes.

According to a study commissioned by MassHealth, SCOs have reduced nursing home admissions for long-term custodial care by almost half. That's a savings of $35 million a year. Just as important, SCO members are satisfied with the program. A University of Massachusetts Medical School survey of SCO members found that they "were quite happy with the program, the services they received, and the personnel who provided them." They especially liked the free prescriptions and the support given to family caregivers.

The new initiative for dual eligibles under 65 should follow the SCO model closely. The rest of health care should follow both. They are our best hope for an affordable, high-quality health care system.

John Baackes is the president of Senior Whole Health, the state's largest SCO.

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