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Doing dual eligibility right

Posted by Marjorie Pritchard  March 2, 2012 02:26 PM

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By Laurie Martinelli

There are approximately 105,000 people between the ages of 21 and 64 enrolled in both Medicare and Medicaid here in Massachusetts. These individuals, known as “dual eligibles,” represent some of the toughest cases in health care.

The question now before the state is how best to provide care for this unusually vulnerable population.

Dual eligibles represent some of the most expensive patients in the health-care system. And it’s not merely the high cost that causes trouble -- the crisscrossed payment systems create bureaucratic overlap that results in mismanaged treatments and administrative waste, as well as endless headaches for patients and families who must navigate a maze of competing health systems.

Differing eligibility rules force beneficiaries to construct treatment regimes in fragments, and make it difficult, if not impossible, to coordinate care between the two systems. The lack of coordination can mean that patients don’t have access to the care they need. Limits on access to behavioral health services are particularly problematic -- especially given that two thirds of the state’s dual eligibles have some sort of behavioral diagnosis.

But thanks to the Affordable Care Act – the federal health-care reform law that passed in 2010 – 15 states have an opportunity to test out reforms designed to streamline the system, giving patients the choice of services and ease of access they need.

Massachusetts is one of the states planning a demonstration project to combine the funding streams for dual eligibles in hopes of reducing friction between the programs and improve care. The state’s proposal to integrate care between systems is a good start toward necessary reforms. In particular, it will give dual eligibles access to managed care programs – such as PACT teams (Programs for Assertive Community Treatment), partial hospitalization, and intensive outpatient treatment.

But reorganizing the care of such a vulnerable and complex population is no easy task, and the details matter. Coordination efforts must be carried out with patient interests in mind, and a focus on expanding access and choice while minimizing disruptions to their health services.

One of the ideas in the integration proposal is to create what’s called a “Patient Centered Health Home.” Health Homes would create a team of specialists to provide primary care to a population with special needs – such as individuals with mental illness -- to ensure better coordination between multiple providers. But for the two thirds of under-65 dual eligibles in Massachusetts who have behavioral health problems, the current proposal leaves a critical question unanswered. Can these new “Health Homes” be housed or led by a behavioral health specialist? Mental health has been the poor step child of physical health for far too long. “Patient Centered Health Home” is a chance for behavioral health to be the primary focus.

Transportation is a major issue for many dual eligibles with mental illness as well. Any attempt to coordinate care must consider a patient’s transportation needs as part of their overall health plan: Without it, these individuals are effectively blocked from visiting health providers -- making other efforts to expand access futile.

Nor can these reforms be used as an excuse to skimp on provider reimbursements. Lower reimbursement for health services rates inevitably affect access, as health providers leave the program when rates drop too low. Current Medicaid rates for inpatient hospital stays are lower than Medicare reimbursement rates. NAMI knows this all too well as inpatient psychiatric beds have dried up across the state. Many people, including the state’s Attorney General have noted that the reimbursement rates for psychiatric services are already woefully inadequate.

Ultimately, the goal must be to ensure the equality, stability and continuity of care: Dual eligibles should not be forced to disenroll from their current prescription drug plans. Every effort must be made to avoid allowing budget-stressed state programs to cut prescription drug benefits. And those with low incomes should be treated the same as other Medicare enrollees.

Many of the proposal’s suggested policies already offer obvious benefits. Reforming the confusing appeal process for dual eligibles, for example, is certainly worthwhile. A single appeal and grievance process, rather than a fractured system without jurisdiction over all of a patient’s treatments, should help ensure that beneficiaries are protected and can take full advantage of their rights.

In other words, there’s much that’s worthwhile in the proposal already. But there’s also much that could be improved. The Bay State's proposed dual eligible integration demonstration is off to a good start -- but if it’s worth doing, it’s worth doing right.

Laurie Martinelli is executive director of the National Alliance on Mental Illness of Massachusetts.

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