A Pathway to Full Integration of Care for Medicare-Medicaid Beneficiaries
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Video Transcript
00;00;02;18 [Tom Daschle]: Good morning as a cofounder of the Bipartisan Policy Center and co-chair with the BPCs health program. Let me welcome you to today's webcast today. We're releasing recommendations to better alignment and integration between Medicare and Medicaid for the more than 12 million people who are eligible for both programs. About 60% of Medicare Medicaid beneficiaries also referred to as dual eligible individuals are age 65 and
00;00;37;23 older and 40% are under age 65. They are more likely than the average Medicare beneficiary to have physical or cognitive impairment. And they have more chronic conditions. Medicare spending for this vulnerable population is more than double that of their Medicare only counterparts in 2018 annual Medicare per capita spending for a dual eligible individual was
00;01;06;14 over $18,000 compared to less than $9,000 for Medicare only beneficiaries while cost is not the driving concern behind these recommendations. We believe that over time, the integration of services will result in lower spending by reducing hospital admissions and readmissions and emergency
00;01;31;06 department visits and post acute care in the short term. However integration will require significant upfront investment Congress and the department of health and human services have taken actions to integrate Medicare and Medicaid. My colleague Gail Lewinski will speak to those efforts and to the challenges, but progress has been slow for a number of reasons, include conflicting regulatory requirements and bifurcated state, and federal administration of the Medicare and Medicaid
00;02;07;03 programs, lack of resources, technical assistance, and incentives for state action, the varying situations and needs of dual eligible beneficiaries BPCs recommendation seek to address these challenges by setting up a policy framework that guarantees every Medicare, Medicaid beneficiary has access to a fully integrated care option recommendations fall into four broad
00;02;36;26 categories, removing regulatory barriers to full integration of care. Second, providing resources to incentivize state led integration, third, creating a federal fallback program to offer integrated care models in state that choose not to integrate care and for to improve beneficiary's experience and the delivery of care.
00;03;03;14 [Tom Daschle]: I'd like to highlight two of these areas, state incentives to integrate care and improving Medicare and Medicaid beneficiaries experience. First, it is critical to recognize that state Medicaid programs are under extreme stress as a result of COVID-19. They face increases in the number of Medicaid eligible individuals. As people lose their jobs and lose access to employer sponsored coverage States are seeing reductions in state revenue resulting from the economic downturn. At
00;03;37;25 the same time, we must keep in mind that dual eligible individuals are the most vulnerable to this pandemic. We are hearing news reports of significant infection rates and loss of life in our nations. Nursing homes States face significant challenges in keeping this population safe in nursing homes and in keeping them safe at home and in the community integration of Medicare and Medicaid, if done well, there's an opportunity
00;04;06;01 to improve quality of care and the availability of home and community based care. Our report recommends providing upfront investments and technical assistance to States to help provide a need a regulatory framework to move forward and a guarantee of a share of any savings that result from integration. Second, we must assure that beneficiaries in their families have the information and time needed to understand both the benefits and
00;04;38;05 trade offs of integrated care models. To address this. We recommend strong collaboration between CMS and the administration on community living to develop model outreach and enrollment programs. In addition, we believe that increased resources are necessary for the state health insurance assistance program, but those investments we're comfortable recommending a
00;05;04;12 continuation of the existing policy that permits auto-enrollment of Medicare, Medicaid beneficiaries into integrated care models with the ability to opt out at any time.
00;05;18;03 [Tom Daschle]: Let me now recognize Gail Wilensky for her initial remarks. Gail,.
00;05;24;07 [Speaker 2]: Thank you very much, Senator Daschle since the mid 1980s, federal and state policy makers have been working to better integrate care for Medicare and Medicaid beneficiaries, 1986, the department of health and human services approved waivers for the San Francisco based online program in 1997, Congress authorized the program of all-inclusive care known for the elderly known as pace building on the
00;05;56;10 unlock model. In 2003, Congress provided a temporary authorization of Medicare advantage, special needs plans in 2010 Congress directed HHS to create the Medicare and Medicaid coordination office. And over the last decade, we've seen the expansion of integration through demonstrations and food through the use of fully integrated dual special needs plans in 2018. After 15 years of
00;06;28;21 temporary authorizations Congress permanently authorized the program known as de snips. The special needs programs as noted by Senator Daschle integrating these programs is not easy for this population. Medicare covers most medical services, prescription drugs and supplies and short term stays in nursing homes, but only after a hospitalization, Medicaid covers
00;06;57;28 Medicare premiums and glass sharing some medical services in surprise that Medicare doesn't cover long term skilled nursing here and home and community based services. For those who need ongoing help with basic day to day activities such as bathing dressing and meal preparation, where States have implemented the Medicaid managed care, Medicare and Medicaid beneficiaries can be enrolled in one or more Medicaid managed care plans
00;07;27;29 for different types of services, including medical care, behavioral health, long term care, or dental services.
00;07;36;29 [Speaker 2]: They've cut these carve-outs of benefits, limit care integration of financing and services. 23 years after the first demonstrations, fewer than 10% of dual eligible individuals are enrolled in early integrated plans. Remember, these are the individuals who are most in need of gear. The vast majority of Medicare and Medicaid beneficiaries and their families need to navigate two separate programs with different
00;08;10;14 eligibility criteria, different benefits, different participating providers and different procedures for filing grievances and appeals. In addition to the recommendations already outlined, there are two others that I would like to highlight. The first is program alignment. Our report recommends giving broad authority to the secretary of HHS to align conflicting program
00;08;37;24 requirements. As long as the authority does not result in a loss of eligibility access to care or beneficiary due process rights, CMS needs the authority to align program requirements to make the care seamless to beneficiaries. As part of the financial alignment demonstrations under authority provided by the centers for Medicare and Medicaid, innovation, CMS and States were able to work together to develop joint state and federal oversight of care,
00;09;11;16 health plans and providers. They were able to develop a single enrollment date, enrollment process marketing and member materials. However, this cannot be done outside of the demonstrations also recommends that Congress director, secretary stakeholders, to develop a common standard in areas such as network adequacy. The second area I'd like to talk about is the
00;09;39;25 requirement to integrate care with federal callback program. These recommendations outlined a regulatory framework for three integration models. States could use one or more of these models to integrate care. They include improved fully integrated dual special needs plans, pace, and a more flexible managed fee for service model. Based on Washington state's program. Finally, the recommendations include an alternative to the
00;10;12;12 existing Medicaid structure to enforce state requirements today.
00;10;17;11 [Speaker 2]: Failure to comply with the federal requirement, jeopardizes state access to all federal Medicaid funds. Instead these recommendations provide for a federal fall back program, similar to the ACA regulatory structure for private insurance. Under the fallback, the secretary of HHS would have the authority to contract with plans to offer integrated care in States that choose not to comply. This would be financed through existing federal and state Medicaid dollars. Similar to the
00;10;51;12 recruitment mechanism, employed Medicare part D while the report provides a framework for a federal fall back program, many questions remain unanswered and the concept will require additional work. I now like to recognize Arielle Mir with Arnold ventures.
00;11;13;22 [Arielle Mir]: Thank you so much. And thank you all for coming together today. I am Arielle Mir, and I'm the vice president for our complex care program in the healthcare team at Arnold Ventures. Many of you may be familiar with Arnold ventures and our approach to philanthropy, but our investments in this space are relatively new. I take just a moment to share a little bit about our mission and why we care deeply about using policy to mend the broken system affecting the vast majority of people who
00;11;46;27 are eligible for both Medicare and Medicaid is health work is motivated by a deep concern about the affordability of healthcare in this country for individuals, for governments and for our employers. One focus of our work on the health team is the high prices we pay. You may be familiar with abs work to lower drug prices and address surprise billing, but we are also
00;12;15;22 drawn to populations and services that represent disproportionate shares of spending and where outcomes are poor.
00;12;24;16 [Arielle Mir]: A prime example of that as the fragmented and uncoordinated systems of coverage and care for people that are dually eligible for Medicare and Medicaid and changing this broken system means changing policy, policy development. Like the report that we're going to discuss today is one leg of the stool that AV is helping to build. As we work toward change, these ideas and frameworks give the Hill and the executive branch, a running start on reform. The second leg of that stool
00;13;00;04 is research AV is an evidence driven organization, and we believe that policy must be informed by high quality data on what works, what doesn't for whom and as best can be as can be determined. What is driving outcomes? The third leg is technical assistance to States. Senator Daschle mentioned system reform is hard, and we cannot ignore that in this moment, especially
00;13;29;23 with States facing lumen budget deficits. It's critically important to support States in the efforts to transform and to learn from those experiences. AV began our complex care strategy investment just over a year ago. And despite the powerful and clear work that many people on this very webinar have done for decades around the dual eligible population, it was rare to see this issue in the headlines, as you
00;13;58;23 all know, since that time the world has turned upside down. And now the problems that you all have long documented and warned us are overflowing in our newsfeeds. The latest data is sobering. Dual eligibles are four times as likely to be infected with COVID as Medicare only beneficiaries. And this is a statistic that reflects unacceptable racial and economic health inequities. This report released by BPC today emerges at a critical
00;14;31;07 moment. It reminds us that not only do we need to address the crisis of the hour, we must also address those long standing system failures, impacting people who are dually eligible failures that will not be remedied with, uh, with a COVID vaccine or treatment. We are so grateful to
00;14;53;03 [Arielle Mir]: BPCs work on this project and to their partnership. We still value the clarity and urgency. They bring to elevating policy proposals to break through the polarized and LA often log down legislature, Glen pragmatic bipartisan policy is essential. So thank you again to Katherine, to the staff, to the BPC advisors and to all the panelists for participating today. We so appreciate it.
00;15;23;05 [Tom Daschle]: Yeah. Well, thank you very much for that wonderful statement. And we're very deeply grateful to Arnold venture support and partnership in this critically important project and, and our report. And we're grateful for your participation. And especially today, it's now my pleasure to turn the program over to Katherine Hayes. And I, let me so and so doing just, uh, once again, thank the BPC staff and Katherine, and, uh, the leadership provided, uh, ad BPC on this extraordinarily important project.
00;15;57;07 A lot of people went into enormous work and effort to get us to this point. This was not easy. It never is, but Katherine and her team Rose at once again to the occasion. And for that, I know I speak for everyone and expressing our gratitude. Katherine,
00;16;13;19 [Katherine Hayes]: Thank you, Senator Daschle. And I'd also like to thank Gall Wilensky. Both of you have been so good in your support of staff work here, and we really do believe that your voice is amplified, the messages and the work that we're doing here today. And again also thank you to Arnold ventures, um, Arielle and Amy have both been wonderful to work with and we've really appreciated their help and their guidance. Um, I wanted to just speak very briefly to the process that we use to come up
00;16;43;21 with these recommendations. For those of you who are not familiar with the Bipartisan Policy Center, we've been working on this project for the last year, but BPCs leaders and staff have been engaged in this issue in the issue of better integrating care for dual eligibles. For more than five years, we have worked with a broad range of stakeholders across that time period with state and federal policy makers, with consumers, with provider
00;17;13;22 organizations, with plans, health plans, um, offering both, um, healthcare and long term services and supports and without their experts, we will be moving forward with this effort in the coming year, we will be looking at better ways to align program requirements in Medicare and Medicaid.
00;17;36;05 [Katherine Hayes]: For example, um, Medicare and Medicaid have very different network adequacy requirements. And that would be one, one of the issues that we'd really like to dig into at the same time, we recognize that the federal fallback program is really just a, and it needs a lot of work to flesh it out in those areas where States choose not to move forward. In closing, I'd like to thank, um, folks on our staff, Lisa Harootunian, Eleni Salyers, and Kevin Wu for the long hours that they put into
00;18;07;11 this project and their patients. And with that, I'd like to turn things over to Sheila Burke, who is a senior fellow at BPC, and will be moderating our panel.
00;18;18;01 [Sheila Burke]: Thank you, Katherine. Uh, and let me begin as Katherine did with a series of thank you's one, thanks to Arnold for their continuing support in this area, as in many others, which is critical to our work, uh, and their commitment to these issues, the issues around drug pricing and others, uh, have really made an enormous difference. Uh, my thanks as well to the staff, uh, led by Katherine who have in fact put in extraordinary numbers of hours, uh, in looking at this issue and, uh,
00;18;50;16 combining, uh, from a variety of sources information that allowed us as a team, uh, essentially to assist in evaluating how things have progressed and where we need to make additional investments. Uh, and of course, uh, my continue, thanks to Senator Daschle, uh, one for having the gun, uh, the Bipartisan Policy Center, which has contributed in so many ways to many of the issues that confront us in terms of healthcare.
00;19;17;17 [Sheila Burke]: Uh, I hope that we have achieved the result that he and Senator Baker and Senator Dole and Senator Mitchell had in mind when they created the Bipartisan Policy Center, uh, and really finding a balance among issues and among physicians to come up with reasonable solutions that can be considered. And I think in fact, they have done that over time. Uh, I am, uh, as Katherine suggested going to lead a conversation among a group of experts who have an assistance to us during the course of our work, as
00;19;47;26 Katherine pointed out, uh, we've had a number of people assist us in a variety of ways in participation in a round table discussions, in reviewing materials, in providing evidence based on the role experience in terms of what has occurred, uh, as we have, uh, provided, I think evidence in the report, there were a great many interested parties, uh, not surprisingly in this issue, which has been with us for a very long period of time. Uh, it is a complicated set of questions, uh, therefore the results. And I
00;20;20;18 think the recommendations reflect those complications. Uh, it is a set of relationships that are enormously important in achieving, uh, our goal in terms of integration. Um, and we hope of course, to better serve the population, the 12 million, uh, that are essentially at risk and dependent upon the combination of the Medicare and Medicaid programs to assist them. Uh, they of course, were at the top of our list in terms how we focused our
00;20;49;28 efforts and focus our recommendations, but so were the participants in this program, specifically the federal government and the state government who are critical to really making these programs work, uh, and finding a way to work with one another. Uh, it's been described that if you've seen one Medicaid program, you have in fact seen one Medicaid program. And so the added complexity of managing a federal relationship with essentially a variety of challenges on the Medicaid side, uh, have made the result a
00;21;22;04 complicated one and made the challenge, uh, not surprisingly an enormous one.
00;21;27;20 [Sheila Burke]: Um, we have four individuals with us today who have essentially, uh, contributed to our deliberations who have participated in those, uh, working group discussions and reviewing materials and recommendations and have provided extraordinarily thoughtful commentary throughout our, uh, our work over a period of time with our leaders in terms of the policy group at BPC, along with the staff, uh, Jean Accius, Tom Englehardt and Jack Rollins, Lois Simon um, are going to be with us.
00;22;00;04 I'd like to give a brief introduction of each of them will then engage in a conversation. I'll ask them some questions and then hopefully they'll talk with one another as well in terms of how we came to the resolutions. We came to a, and then we will leave ample time for discussions from each of you. So if you're on Google or whatever system you're on, please feel free to contribute questions, uh, that I will oppose to the discussion group, uh, and have them, uh, give us opportunity to hear from them on those
00;22;31;08 questions. Uh, I'm going to begin with an introduction of Jean Accius and as the senior vice president at AARP, their thought leadership, um, he is a variety of board and advisory experiences, including the justice and aging, the American society on aging, been involved in leadership in Maryland. Uh, the editorial advisory committee for Generations, which is the journal for American society on aging. Uh, Jean has extraordinary experience and has
00;22;59;06 added much to our conversation, particularly focused on the recipients on people that benefit from these programs, uh, and essentially are challenged. If in fact, we can't find a better way, uh, to coordinate them going forward. Uh, Tim Englehardt, Tim has been a participant for a long period of time with us in our many deliberations with respect to Medicare and Medicaid. He is the director of the CMS Medicare-Medicaid Coordination
00;23;26;27 Office, which was established under the affordable care act.
00;23;30;23 [Sheila Burke]: Uh, Tim has a remarkable range of experience in looking at these questions and looking at questions of implementation and the challenges of implementation and coordination, and has a firsthand experience as to the demonstrations what's worked and what hasn't so will depend and have dependent on Tim to assist us in thinking about this from the perspective of the federal government, Jack Rollins, uh, is with us as well, who is the Program Director for Federal Policy, for the National
00;24;01;02 Association of Medicaid Directors. Uh, again, an enormously important participant in this process in helping us understand how the Medicaid programs work. One of the things I'll want Jack to talk about is that if you've seen one, you've seen one, and that is the enormous variation among the programs and the barriers they face and the unique set of challenges, each of them confronts and trying to stand up any kind of integration. So we'll count on Jack to help us think about that. And then finally, a
00;24;31;13 Lois Simon. Lois is the Executive Vice President of Senior Link. Uh, Lois has a long history of being involved in, uh, senior projects and national caregiving for the elderly. She was the cofounder and former president of the Commonwealth care Alliance, uh, and has a great deal of experience, particularly with respect to Massachusetts and other areas, uh, with respect to how one sets up programs to service this unique population. Uh, so again, all four of them have a great deal of knowledge and experience.
00;25;03;08 Uh, and each of them has a different perspective that will help us focus on these issues. I'm going to begin with Jean, uh, and Jean has thought about the consumer focus. And one of the challenges that Gail pointed out was the very low rate of engagement on the part of the duals, uh, 12 million duals, a very small percentage of them participate in these fully integrated plans.
00;25;27;02 [Sheila Burke]: And one of the questions is what is the information that is needed for individuals to make these decisions to essentially choose how best to identify and participate in a plan? Uh, in many cases we're dealing with the population, uh, that are elderly, that are infirmed that have limited access to this information. Uh, and I'm hoping that, uh, Jean could talk with us about what kind of education, uh, what kinds of engagement activities, uh, would assist in essentially increasing the number of people participating in these programs where they're available
00;26;00;21 keen over to you. I should say, I apologize. I've asked each of our speakers to give just a couple of minutes, uh, at the outset about their impressions of what's most important in the report. Uh, and so I'll, I'll ask Jean to do that as well as to engage us on, uh, on that first question, Jean.
00;26;19;25 [Jean Accius]: Well, Sheila, first of all, thank you so much. And I also want to start off by thanking, uh, the bipartisan Senator for just a amazing report and just the continued leadership to find solutions in order for us to really move in a direction that will benefit, um, millions of consumers in this case, uh, the 12.2 million, uh, beneficiaries who are dually eligible, I'd like to kind of pick up where Ariel off. Cause I thought that was such a very powerful, uh, statement, uh, and some thoughts, particularly around policy and the importance of driving policy
00;26;53;13 to change systems in order to impact lives, I think is critically important. Uh, given the fact that duals are a high need high cost population, and we've heard about their demographic profiles in the course of our conversation today, uh, that is fair to say that, uh, of the 12.2 million duels, uh, is fair to say that all of them have similar to all of us that's on this webinar.
00;27;16;06 [Jean Accius]: And those who are actually, uh, participating in this conversation have some things in common. And what that is, is the fact that we really want to live a life of dignity, of purpose and independence, uh, that we really want to live a life where we are in the driver's seat and we're empowered to make informed decisions. And I think it's fair to say that is something, a key principle and key attribute, particularly for a conference call, I'll call you and them. But the population, uh, with
00;27;46;06 that I think is critically important. And as we've outlined in the bi-partisan, uh, report, uh, today, the central focus is really thinking about how best to support, empower and equip the duly eligible population and their family members as appropriate, uh, in helping to navigate some of the system challenges that has long existed, even pre COVID. I think it's fair to say as even her from one of the data points that COVID-19 has exacerbated many of the systems failures that has long existed. And now we have an opportunity as a country to really think about what are
00;28;19;04 those meaningful and innovative solutions to really start to address this keeping in mind that the duals in their families should be at the center of those transformations, uh, in light of your question, with respect to, uh, education and outreach, uh, Sheila, I think it's critically important, particularly in an environment where there's passive enrollment, that consumers have enough information to make informed decisions, especially as their needs change over time. I want to give Tim and his team a tremendous
00;28;49;13 amount of, uh, credit, uh, for the work that they've been doing over the years to really take into account. What are some of the lessons we're learning from those of the demonstration projects and how do we take those lessons and really start to do the program improvements that is needed. And what we've learned is the fact that relatively speaking, that consumers who have participated in the demos are generally satisfied.
00;29;11;10 [Jean Accius]: Uh, but, uh, there are opportunities to continue to improve, uh, whether that is informing them of, um, their choices, whether it is ensuring that they understand the trade offs, uh, whether it is ensuring that they understand the provider network, particularly as needs might change is going to be critically important. Uh, over the course of the demonstrations, we've seen, uh, tremendous opportunities where, uh, integration has yielded some promising results, uh, both in terms of
00;29;41;11 ensuring that consumers are not as confused in terms of navigating their care, that they are empowered in some very meaningful ways. Uh, but we also learned that sometimes too much information might be overwhelming and that if we're not providing clear information, communicating information to those who most likely need it, uh, then, uh, we still have some opportunities, uh, ahead of us. One of the things that I though was very, uh, insightful, uh, from, uh, some of the focus groups that were done,
00;30;12;21 particularly with the dual demonstrations, uh, when you heard from some of the beneficiaries was the fact that, uh, they all in many cases talked about the need to get clearer, uh, concise, uh, information that would really benefit them and make an informed decision. So really thinking about what are those consumer tools that can help people make informed decisions is going to be critically important. The other aspect of this too, is understanding, uh, the need to provide, uh, multilingual, uh, information, uh, and a lot of States are doing that. I
00;30;43;07 think one of the challenges, the fact that some dos may not even know that they can ask for that information in a different language. So how do we start to do that? Uh, so those are some of the things that we can talk about, but I did want to emphasize that we are at a inflection point, uh, and that, uh, this inflection point allows us to really think about what are the systems we need to have in place to really accelerate and ensure that it's very consumer centric and consumer driven. Uh, and that is something that I think we can all agree that we want for ourselves, as well
00;31;14;02 as when you talk to duels, that's something that they are looking for.
00;31;19;18 [Sheila Burke]: Thanks so much, Jean. Um, one of the things I'd like to come back to one, we've all sort of had a first round, um, is to talk with you a little bit about, um, the language issue that you mentioned and how one gets information made available. And also the extent to which the state health insurance assistance programs play a role in whether they can be part of the solution in terms of providing the information. So I'd like to come back to that in a moment if we could. Uh, but I want to turn to Tim next, if I might, uh, Tim one for some opening comments, uh, and then, uh,
00;31;54;01 I do want, um, if possible, I mean, noted, uh, by Jean where the questions about the successes and what we've learned from the demonstrations, uh, and what you think is most important, but also I'd like Tim, uh, during the course of our conversation this morning, uh, to ask you to sort of reflect on what the implications are and the challenges that the COVID-19, uh, uh, pandemic has really presented to what is already, I mean, as Gail pointed
00;32;21;11 out, as other pointed out an extraordinary impact on this population, uh, but Tim, let me turn it over to you for some initial comments. And then, uh, let's talk a little bit about what we know successes and failures in the demos.
00;32;34;08 [Tim Engelhardt]: I know much of the work on this report predated pandemic, but it's still instructive to start there that going
00;32;42;05 [Tim Engelhardt]: With Ariel said earlier, Julie eligible beneficiaries are four times more likely to have a confirmed case goal, but also four times more likely to be hospitalized with a case of COVID-19. And, um, and there are multiple steps we need to take to control that right begins with reducing transmission and work around infection control, especially in nursing facilities, dialysis clinics work around testing, um, and eventual vaccination are big parts of that, but there are other important aspects to many of which resonates from the BPC report. One would
00;33;16;13 be ensuring access to treatment that means access to COVID treatment if needed, but also means ensuring access to home McKeon based supports that help someone stay independent in their own homes instead of in a nursing facility. And so much of integrated care work is about promoting that access as States and CMS has done remarkable work to try to preserve that access in this particular time of crisis. And then, and then the COVID has exposed the how important it is for us to
00;33;48;26 reduce comorbidities that we know to be associated with poor outcomes highlighted in the pandemic. But this is longstanding disparities work that, um, that, you know, has to be a point of focus for this agency and for our state partners, frankly, long after we have an effective vaccine for the coronavirus underlying disparities in diabetes and hypertension,
00;34;15;08 disparities, and access to preventive services. And others are in many ways defining challenge for us for many years to come. And I think highlighting the ways in which integrated care can help address those challenges is, is an important part of this report.
00;34;36;05 [Sheila Burke]: Thanks, Tim, um, if you'd reflect for just a moment, um, enormously important points, particularly as we look forward in terms of the continuing challenges, uh, and unique challenges as population space, but from your sense of the demonstrations to date, I mean, Jean's raised a number of issues and concerns regarding the ability of individuals to make decisions, the information that they're provided. Um, have we found particular elements of success, uh, things that we ought to be sure are
00;35;09;00 part of whatever it is we do going forward based on those demonstrations.
00;35;14;15 [Tim Engelhardt]: Y ah, I think we have, I mean, the most important success today is for beneficiaries in their families. So, um, Jean mentioned beneficiaries of reporting your high levels of satisfaction with their health plan with their overall healthcare and these different demonstration approaches, um, published analysis on those models has found significant reductions in hospitalizations, in skilled nursing facility admissions, even in the very early years of the different demonstration and our own analysis of hedis measures. So it's really remarkable improvement over time. So that's number one, but the second important success is, is
00;35;49;22 structural, right? Um, it was, it was well and accurately stated that a relatively small around 10% of dually eligible beneficiaries in any kind of integrated care, but that's a, that's about a million people now. And about half of that are in the current, um, demonstration programs under the financial alignment initiative and getting there require the development of a lot of new capacity.
00;36;13;28 [Tim Engelhardt]: So compared to a decade ago, there's vastly more capacity and expertise among our state Medicaid agencies. Um, we in the States have much better mechanisms for listening to the people that we serve. Um, and CMS itself is kind of normalized. Some things that felt a little bit radical, um, five or 10 years ago. We also have a new and expanding crew of innovators out there. You'll hear from both Simon and her experience soon, but, um, inland empire health plan and community health
00;36;46;17 group in California, uh, upper peninsula health plan in Michigan neighborhood, Atlanta, Rhode Island. You just add all of these relatively newly to the ranks of the highest performing organizations and serving dually eligible beneficiaries right up there with the early adopters and Massachusetts and Minnesota and Wisconsin and elsewhere. So to me, a lot of the capacity development work will, um, will benefit the people we serve for a long time after, even after a particular demonstration period is, uh,
00;37;18;14 I think Jean references really well so that, um, we can and need to do better at communicating with beneficiaries. And I think that starts with information about their options, but it also extends to engagement in the healthcare system with ours, the loss of us, um, approach care, coordination, and managed care, and a kind of naive sense that if we just
00;37;44;15 like offer this additional support, people will take it. And in fact, engagement with beneficiaries is something that you have to earn it. You don't just give it, and that takes time and skill and effort by the thousands of people on the front lines of care coordination through these endeavors.
00;38;05;00 [Sheila Burke]: Thanks, Tim. Um, I do want to come back when we have a moment, um, and talk about networks, um, and some of the challenges of establishing those networks, we've had some experience under the ACA in terms of the network requirements. Um, there are particular challenges. I mean, you think about behavioral health and other elements that, um, historically we've not been as good at in terms of determining the adequacy of the networks and how we think about that. Uh, so I'd like to, uh, come back to that in a moment, uh, once we've, uh, again, gone through, uh,
00;38;37;06 Jack Rollins, um, Jack some opening comments and, um, I'm particularly interested in having Jack talk about some of the unique differences between States, uh, and some of the challenges that, uh, individual state Medicaid departments have and participating. Uh, and again, um, once we've gone through this round, I'm also interested in having each of our panelists feel free to engage on any of these issues. Cause I know Tim has some thoughts as well about, uh, the, the difficulties or the challenges of diff
00;39;09;09 different Medicaid agencies and, uh, dealing with their capacity. So Jack, let me turn it over to you for some opening comments and some thoughts on the so unique nature of each state Medicaid agency,
00;39;21;21 [Jack Rollins]: Right? Thank you, Sheila. And thank you to the Bipartisan Policy Center for, for us an excellent report that so neatly encapsulates a variety of issues that we've been talking about for, for years and for the opportunity to just share some of the state perspectives on these issues. Um, and AMD has been working on duals integration for a number of years and something that I've met, many of our members have prioritized. Um, so as I noted that the policy recommendations in this report capture a variety of issues across the really the full spectrum of integration work. Uh, but I think one of the most valuable things here and
00;39;53;09 something that has done such a good job articulating already. So I don't want to belabor the points that he's already made is the, the focus on the individual as a kind of the locus of decision making and where we're focusing our efforts here.
00;40;05;29 [Jack Rollins]: Uh, I think it's a principle that we all agree on as we consider the various systems level changes that need to happen to promote widespread integration. It's going to be critical, uh, to continually bring those changes back down to the person level and understand their impacts on the individuals that are being served so that we're not engaging in an exercise to make things more administratively simple for States and the federal government and neglecting the, the actual impacts on, on actual members of these programs. That said, even with this framework in place, uh, integration is very detailed and slow going work.
00;40;39;16 And in the world, the state Medicaid programs and the public servants that administer those programs, the experience of integration both to date and going forward is going to be very, very different from state to state. Um, it's a little, I know it's cliché to say this, and Sheila's already said it in her opening remarks, but it's very much true that when you see one Medicaid agency or one Medicaid program, you have only seen one program. And I think that's definitely the case. We're talking about the duly eligible population, and as we've already heard, and as the report has
00;41;08;26 plenty of evidence to support duals are not a monolithic population. Uh, they may, they come, they arrive at the status of a dually eligible beneficiary through a variety of pathways. And so, um, on some of the shorthand that policymakers may have employed to date about thinking about duals is not necessarily giving us the most accurate picture. So it's duals, aren't, aren't only individuals who agent and Medicare and are low income. There are many who arrived the pathway disability and are under 65.
00;41;38;23 And those needs are going to look different from dual setup that are, that have, that are aged and have more physical impairments. So when we think about the service categories, the duals are using on the Medicaid side, and we're not just talking about some, some acute care services that are more primarily the Medicare responsibility, but we're talking about behavioral health services.
00;41;56;03 [Jack Rollins]: We're talking about long term services and supports home and community based services. The types of services where Medicare's footprint is relatively minimal and Medicaid is really at the forefront, but it's also an area where in many States the operational responsibilities may be divided across various entities within state government. Not everything is going to be housed in the state Medicaid agency directly. Although Medicaid may be the primary payer for these services there, depending on state structures, there may be response operational
00;42;26;10 responsibility resting in the state's behavioral health agency in the state's aging agency or the substance use disorder and treatment agency, for example, and further state delivery systems can be configured in a variety of different ways within these different agencies and different, different arms of state government, or even County level of government. We've touched on the use of Medicaid managed care and managed care can be bifurcated by benefit category. So what plan may be responsible for acute care services, but not necessarily responsible for behavioral health or long term care, or that
00;42;58;12 plan may subcontract those services out. And or there may be some carve-outs where the state is directly administering aspects of business benefits through their Medicaid fee for service programs. And all of these configurations look very different across the States. There are States that have really prioritized integration and managed care and have nearly all there are benefits of managed care. And there are States that are on the other end of the spectrum, primarily fee for service and likely will be for the foreseeable future. So further we know from States that have already
00;43;29;05 gone down the integration path, that a commitment to the integration work from the Medicaid director at the senior level and at the Medicaid directors kind of executive team is a really necessary component of a successful integration, but from the most recent data that AMD has on average Medicaid director, tenure, which admittedly is about a year old.
00;43;50;04 [Jack Rollins]: So things might have changed a little bit, but our most recent data point is that the average tenure for a Medicaid director is only 21 months. So not even two years. So when you're having that level of turnover at the, at the highest level of the agency, it can be difficult to have that sustained executive leadership commitment to integration, and it can be possible for integration to unfortunately become one of a back burner issue for lack of a better term. Uh, as new Medicaid directors come
00;44;22;10 into play as state, as state administrations change through election cycles, et cetera, uh, there will be different priorities and folks will have a different will be tasked when they take that with advancing different priorities. And so one of the key challenges that I see for a widespread integration on the timeline that the report contemplates, which is eight to 10 years, uh, is building a strategic framework that can carry over across transitions at the top executive leadership. And that has
00;44;52;10 widespread buy in at the state level, such that regardless of how party affiliations change in state executive leadership, there is still that commitment, that engagement and that buy-in to integration. And
00;45;07;08 [Sheila Burke]: Go ahead, Jack. I'm sorry. Gotcha.
00;45;09;03 [Jack Rollins]: Sure. I just wanted to note that there are many States that probably don't even have that type of strategic framework in place today. And so it's going to take some time just to build it and to, to build that engagement. So when we start, when the report talks about an eight to 10 year timeline, I do believe that States are going to need every bit of that. And that's even setting aside the budget challenges and posts by COVID-19 and the oncoming recession
00;45;34;07 [Sheila Burke]: Actually, Jack, I do want to come back to that in a moment, um, and that is looking at well really two issues. One is the heterogeneity of the population. I think people lose track of the fact that they're not all aging into Medicare and low income, therefore duly eligible, but the unique challenges this population presents because of the difference in demands in terms of the services that they need. I think people lose track of that. They think of it in the context of Medicare and the elderly, not in terms of those under 65, uh, who come as a result of
00;46;07;27 disability status. Um, I also want to come back to the question of what is it that the States need. I mean, one of the things we talked about in the report is the assistance that the States need and preparing as you note, some are essentially at the far end of essentially, fee for service and still doing a fee for service model. Others are moving towards a more managed care environment where they are more coordinated. Uh, so when we, when we come back around, I do want to talk about what is it that would be most helped to the States. And I know
00;46;37;02 Tim will have a thought of this as well, in terms of what have they seen with the demonstrations in terms of, you know, whether it's the architecture, whether it's data systems, uh, that essentially allow them to move. I was particularly interested in your point about the short term for most Medicaid directors, um, and how that challenges, the ability to set in place, a strategic plan that carries over from, um, essentially, you know, director to director in, during, you know, turnovers that occur because of
00;47;08;08 elections and how that can change things dramatically. So let's do come back to what is it high on the priority of the States in terms of a list of things that they need?
00;47;18;00 [Sheila Burke]: Uh, finally, let me turn to Lois for some initial comments, um, and begin Lois. Um, you have a particular perspective having had experience in Massachusetts and in other knowledge, um, you know, what the art of the is, uh, and particularly whether all MA plants, I mean, we've talked about the heterogenative population, we've talked about the difference in state Medicaid plans. Um, but what about AMA plans? I mean, are they all equally able to participate and, um, are they in a position to
00;47;49;29 integrate, uh, fully, uh, and sort of what's the difference in terms of high performance, but Lois, let me turn it over to you,
00;47;58;12 [Lois Simon]: Sheila and good morning to everyone. I appreciate your having me here today to talk and to comment on a topic very near and dear to my heart characterizes my DNA. Um, and a policy that I think is critically important to so many across the country. I want to thank, uh, the Bipartisan Policy Center for leadership, Katherine and her team in particular in establishing this framework and sustaining this commitment to
00;48;32;10 really looking at and delving deeply into the issues that have served as barriers to integration and to put forth recommendations that are transformative. And frankly, I, I'd also like to thank Tim for his leadership. Um, the MMCO has done extraordinary work, um, throughout the past number of years, to really further the ability for dual eligibles to
00;49;01;07 have far better coordinated care. And as Gayle pointed out earlier, integration's not a new topic we've been at this for some time.
00;49;11;15 [Lois Simon]: Um, the earliest demonstration of the successes of the pace program beginning with on lock and the early dual eligible demonstrations that really took from those experiences with pace, the opportunity to expand to a broader population than pieces able to serve. So we've been at this a long time and has been cited twice this morning already, and yet less than 10% of duels have the ability to have been, uh, benefiting, uh, from fully integrated care. So for BPC to put pedal to the
00;49;48;23 metal, if you will, is quite apropos, um, if we're to ensure that our country's most vulnerable receive the kind of coordinated care that we are capable of, and that they're deserving of one only has to look at the current crisis in our country with COVID-19 impacting all of us to be
00;50;12;13 reminded of the credit quality of wealth coordinated healthcare that covers all of the domains of our needs, our physical health, behavioral health, functional supports, and responses to social determinants of our health, like food and housing security and safety, and even greater depth of appreciation, um, has been instilled within me for the experience of the
00;50;41;28 dual dual eligibles that most of us are serving. Um, in addition to all of the fears and difficulties that we've been challenged by in living through COVID-19, it's unconscionable to imagine, um, the kinds of disparities that both Gail and Tim have spoken of, um, that relate to people who are dual eligible, but also the fears that are
00;51;12;07 associated with inadequate food supply or basic access to medications or eviction are increased risk because of living in a congregate living situation and the, like the work that integrated plans do and can do because of their very structure. And the flexibilities that are afforded that are inherent in that structure really shines a bright light on the art of the possible as Sheila has termed it for these populations. And during
00;51;45;23 these difficult times, I've been learning about the incredibly responsive and effective and creative interventions that both fight a snips and MNPS across the country, um, have been putting forth that have been so validating of what's possible when a health plan possesses all the opportunity and the risk policy and program and not reimbursement, really
00;52;17;07 driving what's possible for people.
00;52;20;12 [Lois Simon]: And even still, we have such a long way to go this report by BPC provides us with a pathway towards scaling integration of the foundational piece parts, Medicare and Medicaid financing services and administration of benefits. But we have a long road to hope. These are indeed the foundational pieces, but as those plans and other organizations who've been at this for some time, no, well, there's so much more that
00;52;51;14 needs to be done. The opportunities for innovation are really boundless and we need to be committed to continuously upping our game. Take, for example, what we've learned just from this COVID crisis, people in congregate living settings, and I'm not just talking about nursing homes, but also assisted living and independent housing for the elderly and persons with disabilities can be made so much safer. There are excellent examples across
00;53;25;21 the country of well-designed housing based service, coordination and supports, but here are the four inadequately connected in a systematic way with others responsible for the healthcare of their residents, health plans, primary care practices, ACS, and the like these housing programs have demonstrated clear ability and opportunity to reduce emergency room
00;53;52;22 hospitals in the hospitalizations and exacerbations of chronic illness, let alone to provide frontline response and the pandemic, but they're not formally connected. They're not formally integrated as part of the work that's done in health plans. Overall, the same can be said for family caregivers who provide the backbone of long term services and supports to their loved ones each and
00;54;20;22 every day. They're the unsung army of heroes, 53 million of them across the country. They too are first responders to the day to day needs of their loved ones, with unique observations and insights that when harnessed appropriately by the healthcare system can help to mitigate all manner,
00;54;42;29 [Lois Simon]: Oh, the adverse events, But we don't integrate them effectively. In our interdisciplinary teams, we don't adequately empower and support them in Karen in the care that they provide. And they provide not only personal care and things like shopping and housekeeping, but actual skilled care dressing changes and observation of swollen ankles for people with congestive heart failure moms, we need to
00;55;13;18 recognize the unique role that family caregivers play, and perhaps we'll do so increasingly. So into the future. We need to embrace and equip them with the information and ongoing support that they need to perform their responsibilities and connect the actionable data that they can provide to the healthcare professionals responsible for their loved ones. We need to invest formally in the integration of this forgotten workforce with our
00;55;47;12 healthcare system, beginning of health plans, responsible for integrating Medicare and Medicaid service. Those are just two of the many meaningful and great opportunities for continued innovation as we look into the future. But first we need to get these foundation blocks built, and that's what BPC is recommended policy framework accomplishes. And it's really so exciting
00;56;14;16 as Tim pointed out, you know, engaging dual eligibles is in and of itself. Um, work that health plans have really needed to learn how to effectively relationships need to be formed, and they need to be based on trust, which needs to be earned. And in the two examples I've given those that people live with, whether it's housing staff or their own family members providing
00;56;44;04 care, or not only the most proximate people, but they're trusted and certainly, um, you know, able to be integrated effectively with healthcare professionals. Thank you so much. You've given us a, an enormous amount to think about and reflecting on as well, which your colleagues have pointed out in terms of the challenges. I wonder if we can pause for just a second and look specifically, or your experience in Massachusetts, um, and
00;57;16;18 essentially, you know, you were head of a dual eligible special needs plan.
00;57;21;19 [Lois Simon]: Um, and you know, I think about it, I was still on the finance committee staff. Would we, first of all, look at online, uh, that 20 odd years ago, and essentially transitioned that to a, a demonstration to pace that went on for a very long period of time, but tell me your experience in Massachusetts. And then I'm interested in understanding what has really limited the engagement or the enrollment, you know, pace just never scaled. Um, at least as much as we had hoped that it would, uh, and on, on lock was a unique set of circumstances in Chinatown
00;57;56;13 in San Francisco. Uh, but what, what has been your experience in Massachusetts and what do you think has held back the scaling of those kinds of experiences? Let's begin with Massachusetts took a very unique approach to integration on to the best of my understanding. They've done something that hasn't been done the same way in other States. They begin with seniors who are dual eligible, and it was a number of years
00;58;25;27 before with, uh, before they extended integrated care to persons with disabilities below the age of 65. And it's important also, I think to know, so Massachusetts was an early adopter through a dual demonstration back in the early two thousands for seniors, uh, and early adopter of, of integration. But up until that point, seniors weren't engaged in managed
00;58;56;25 care in Massachusetts. They weren't a part of Medicaid managed care. Um, persons with disabilities were only minimally engaged in managed care through the years. And so Massachusetts really went at this, um, in a, in a, um, a very different kind of way. They really approached development of
00;59;24;05 a program that was the whole enchilada. It was with no carve-outs for seniors. It was physical health, behavioral health, long term services, and supports. And again, managed care being very, very new to the population.
00;59;40;21 [Lois Simon]: So I think that earning the trust that managed care, um, could be a good thing, was an initial barrier that needed to be overcome. Um, but I think that it was a very well thought through senior product that was clinically and programmatically based had key elements in it, like an interdisciplinary care team, the requirement of individualized
01;00;12;15 plans of care, the participation of people who were known to the elder population and trusted, which were social workers working in area agencies on aging. I think all of those kinds of elements were very important and enabled what was and continues today to be a voluntary program, to be successful in as much as the enrollment was not, and still is not as robust
01;00;44;07 as we would aspire for it to be the voluntary disenrollment in the program was quite and continues to be quite minimal. So I would say that some of the barriers have been the enrollment process. Um, the opportunity for all who are eligible to really know of the availability of the program, um, marketing is left to the plans, but there hasn't been a very broad based,
01;01;14;16 um, public policy approach to marketing the program. Um, and then we of course, went into the federal alignment demonstration years later for persons with disabilities, where we did take a different approach, which was passive enrollment with the opportunity for consumers to opt out. And I think we've learned a great deal from that approach.
01;01;40;03 [Sheila Burke]: So let's pause on that for a moment, cause that's an, actually a question that we've talked about and that is the enrollment process, uh, and the challenges it presents. Um, and I'm interested in, uh, Jean's reaction to this, but also Tim's. Um, and that is the question of auto enrollment, uh, with the ability to disenroll, uh, in Jack, I'm sure you have a point of view on this as well. Um, is that part of the solution to the scaling up, which is to let people opt out, but essentially to get
01;02;10;16 them in and let them be exposed to the systems I'm interested in, in really all of your comments about that as a method, Tim, do you want to begin.
01;02;21;01 [Tim Engelhardt]: To define it in program that Lois Was referring to? We use passive enrollment, which means we notify an individual that they have been assigned to enroll into a particular product and they get multiple notices and they get at least 60 days in which to decide that they can opt out of that assignment or stick with it. Um, and even after they stick with it, they had the opportunity to disenroll from that particular health plan or that program. Um, passive enrollment has led to, um, a major increase in integrated care. As I mentioned earlier about a
01;02;56;04 million people and engraved care products, about half of them are in these demonstrations. And majority of those, uh, through the vehicle of passive enrollment, um, passive enrollment has its downsides, right? It doesn't feel as friendly as, um, educating somebody assertively and helping them make an assertive choice. Um, it, uh, runs the risk that people simply
01;03;21;17 didn't understand or didn't didn't receive even the notifications that were sent to them. Um, and therefore their status kinda changes and their access to different types of providers changes accordingly. On the flip side, though, as I mentioned, it drove the marketplace in an important way. There's a push pull dynamic. We say, where are the great innovative health plans in serving this population? The answer they're waiting for people to be enrolled like, like, like is this chicken and egg challenge. And so passing
01;03;51;12 on what kind of drove some of the market to make meaningful investments in serving this population. So there's another person level impact too, which is we constantly hear of anecdotes in which someone was passively enrolled into a product, the health plan in which they were enrolled has a requirement from us and from the state that they identify that individual reach out to them and develop a care plan and do an assessment and time and time again, that process of finding someone exposes someone who had been
01;04;23;03 completely poorly served or not served at all by their existing fee for service arrangement. And so the frequency with which you identify on that social determinants of health, unmet behavioral health treatment, very common. And so passive enrollment had this, I don't want to call it an unintended consequence, but it has resulted in kind of pushing out the identification of unmet needs in an important way that doesn't exist in the absence of that mechanism.
01;04;51;20 [Sheila Burke]: Your thoughts on your experience in talking with folks about essentially being enrolled.
01;04;58;19 [Jean Accius]: Well, Sheila, I think Tim did a very good job of capturing some of the pros and some of the benefits and some of the unintended consequences of passive enrollment. I think one of the things that's key, uh, as part of this conversation, uh, especially in terms of what we did, where we go from here is the element of trust. Uh, and the, uh, at the element of being able to be informed, uh, particularly of, uh, throughout the entire process, uh, to ensure that, uh, consumers are fully informed about exactly what does this mean for me? Uh, what are the trade
01;05;31;20 offs? Uh, and, and I think that what we've heard and what we've seen in the past, and again, there's always opportunities to improve on that front, uh, is that to the extent to which we can do a better job of communicating, why is there a change? What is the benefit for the consumer in that change? How are they empowered in that process? And of course, clearly, uh, within any form of a, of enrollment arrangement, ensuring that the consumer has adequate, uh,
01;05;58;28 safeguards and protections and rights, and that they understand that, uh, those rights are critically important. And then of course, who should they call in the event that they run into some challenges, uh, along the way. So I do think that as we think about, uh, moving towards more integrated models, ensuring that we have those elements in place, I was going to be really important of for consumers. And then also for the range of other stakeholders involved. ,
01;06;27;16 [Tim Engelhardt]: I'm sorry, can I, Jean is right. It almost always is. Um, I want to remind us though that like the concept of passing our own men is not totally foreign to Medicare, as we have known it for a long time. When you turn 65, we functionally passing me, enroll you into a fee for service system that has its own shortcomings. The fact that 20% of hospitalizations resulted in readmission is an indicator that we have not
01;06;58;00 like perfected that default system yet. And so I think the challenge for us is building the evidence base to say, which of these particular approaches is going to work best for a particular individual, and then setting the defaults to that particular setting. And the more we can learn about the, the impacts of integrated care approaches helps build that evidence base so that, you know, going on like behavioral economics approach is building on
01;07;28;15 the way most of us were auto assigned into a retirement plan. And we kind of identify these options, you know, the, the beneficial default and then wrap protections around it so that people can make other choices should they so desire.
01;07;43;29 [Sheila Burke]: So Jack you're likely to be at the other end of the phone, uh, or all of your state Medicaid directors are, um, I mean your, I mean, how are the Medicaid directors responding to this? I mean, um, you know, it's an interesting question that heterogeneity of the population make it interesting because how the elderly might respond as compared to those under 65, who are disabled in terms of what their options are. And it brings up as well, the question of the networks and what the expectation is that the plans that Jack your thoughts and that of the Medicaid directors
01;08;16;23 in terms of enrollment in the enrollment process. And then, and then let's do pivot for a moment to talk about networks, uh, but also who are offering these plans. Um, you know, whether it's the pace demonstration and the slow response in terms of the number of plans willing to participate, has the ownership, uh, sort of, um, uh, of the, of the programs made a difference, um, the integration or the, the increase, the number of, for profit plans
01;08;47;07 coming in, has that made a difference in terms of willingness to sort of engage, but Jack, let me turn to you first on the enrollment question, when let's talk about networks and let's talk about who the plans are and how that has changed over time.
01;09;01;12 [Jack Rollins]: Sure. So I'll do the enrollment side. I think that, you know, a passive enrollment to encourage more of a default option or uptake of integrative care is an effective mechanism for promoting more sustained enrollment in integrated care. But I think what we've also seen and some of the evidence that we seen from certain States participating in the demonstrations, the financial alignment initiatives, is that going for completely understandable reasons to ensuring consumer choice and informed choice on the Medicare side has, has in some States produced challenges for
01;09;33;00 sustainable enrollment in integrated care models. And in some cases has led States to reconsider their participation in those models. So there, there are definite trade offs here, and it's one end it's somewhat exacerbated by what will likely be an ongoing disconnect between Medicare's ability to opt out at any point in time versus generally a more defined enrollment period on the Medicaid side. Um, I think you're probably only going to be having plan changes on an
01;10;05;06 annual basis. Um, and so there's, there are potential challenges there for sustaining integration. Um, so I think that it's important to, to make sure that again, I think I do want to build on 10 and Jane's points that the beneficiary completely understands what is on offer here. Uh, cause I don't want to, I don't want folks to walk away from this conversation thinking that the state view is that the ability to opt out of an integrated care product, anytime this is a bad thing because there are individuals where
01;10;32;19 that is probably going to be the appropriate choice for reasons of physicians or healthcare providers that that individual trusts and participates with and has an ongoing relationship with, for whatever reason may not be in that network. And that's a completely legitimate and appropriate decision to make. But we also want to be cognizant of thinking about taking it up to that system and plan level, uh, that we have the ability to promote financially viable, um, and sustained enrollment in the,
01;11;03;21 in these integrated care products. And there's just, hasn't always been the case from historical experience.
01;11;09;09 [Sheila Burke]: So it leads me to reflect on this question of networks, um, your point that people may not be satisfied because their provider is Not involved, uh, questions about whether or not the full array of benefits essentially is available. Behavioral health comes to mind as being one that is often contracted out separately and, uh, not necessarily fully integrated. Um, what do we know about network issues, um, in terms, and to my reflect on, on your experience in terms of the demonstrations, but also,
01;11;41;14 uh, you know, Lois in terms of, um, what you've experienced, are networks, the establishment of a full network, uh, one of the challenges in terms of getting engagement in these managed care plans,
01;11;55;12 [Lois Simon]: Okay. Coming from a plan on that needed to develop a network for seniors, and then years later, a network for persons with disabilities, it is critically important for a plan to have within its network. All of the specialized providers that the individuals to be served are customed to seeing if a barrier is not to exist. Um, the notion of behavioral health as being
01;12;31;20 anything other than fully integrated, um, is a totally foreign concept to me, particularly in that over 70% of persons with disabilities in our MMP program in Massachusetts were individuals with comorbid behavioral health issues and to not have the ability to really address the totality of needs
01;12;58;00 that that population, um, presented with on it certainly, you know, is unfathomable. Um, and we have a lot of work to do not only to bring about the inclusion of providers that were appropriate to the needs of the population, but also in addressing gaps in the network that were identified as a consequence of the work that we did. Um, you know, the most notable of
01;13;29;23 which was the identification of so many people going into acute inpatient psychiatric settings that really needed inpatient care, but not for acute episodes, but rather for respite, um, and for intervention. And we just did not have sufficient capacity in Massachusetts to address that. And we had to, uh, both work with our, uh, payers to, to our payer to recognize
01;14;02;04 that, but also took it upon ourselves to innovate and create some of that capacity, um, ourselves.
01;14;11;00 [Tim Engelhardt]: Um, we have to recognize a couple of realities for this population. One is that many, uh, older adults or people with disabilities and chronic illnesses have numerous specialists. They see numerous different providers to move from the complex web of, um, uh, kind of a network structure that someone has built come on their own. We're in a fee for service context into a limited network circumstance is, is understandably, um, you know,
01;14;46;04 scary for, for people whose lives independence depends on literally daily access to certain types of providers. And I think that's really important for all of us to remember as we walked down this road, but also important to remember, um, the 30th anniversary of the Americans with disabilities act is that still today, people with disabilities report, um, more
01;15;12;10 challenges finding providers that will see that even in the Medicare program where coverage really shouldn't be the primary issue. And so that is all of these dual kind of challenges in connecting people with the right types of services, you know, that vastly complicate our did even the concept of what it means to have a network it's, it's maybe not the number of cardiologists you have, but it's the variety and accessibility and
01;15;44;11 cultural competence of this almost infinite array of traditional and nontraditional service providers,
01;15;54;02 [Sheila Burke]: Jack, who sets the rules in your view with respect to a network. I mean, is that something that the federal government auto established that you ought to have an x, uh, is it something to Tim's point where there's enormous variation geographically by specialty? I mean, there are States where the number of GYN, uh, are limited or behavioral health specialists are limited. How do we navigate that between the feds and the States in terms of establishing what the rules of engagement need to be for
01;16;24;27 these plans, if they are in fact, to be, uh, made available what are the rules that we ought to be compliant with?
01;16;32;06 [Jack Rollins]: So I think that generally speaking, the States are probably best positioned to understand the, the intricacies and the nuances of the types of providers that certainly in the Medicaid home and community based service world that are probably pretty critical components about the service network that's supporting dual-eligible beneficiaries. So having broad federal parameters, and that States need to have network adequacy standards for these type of provider types, but not being prescriptive at the federal level about what that standard looks like similar to the
01;17;02;07 approach that CMS has taken in the Medicaid world and the Medicaid managed care regulatory framework where network adequacy standards. I believe the current regulations do require some time and distance for certain provider types, but others it's more left to the state determine. And I think that's the appropriate solution because frankly, a lot of these providers very small, generally invisible to federal oversight mechanisms anyway. And I think that we've seen some of that playing out in the COVID-19 context with the provider relief fund. It's been very challenging for the federal government to be able to consistently identify those providers. And I think
01;17;34;06 that that's going to remain the case. It's the States that generally have the more direct relationships with them and it's the state and it, whereas managed care plans contracted by the state that had those more direct relationships. So from my view, it's probably something that the States are best equipped to execute on.
01;17;50;23 [Sheila Burke]: Well, it's an interesting question, particularly with the advent or the dramatic increase in the use of telehealth, uh, and query whether or not time and distance will be as compelling a factor going forward because of the availability of being able to do things online, then, uh, you know, whether, uh, we know those are going to be continued for the near term through 21, I guess, uh, in terms of the waiver under the Medicare program, but real questions about whether we need to rethink essentially what availability means, uh, and the resources. Uh, and I'm
01;18;23;26 struck by your comment about cultural sensitivity and the ability of people of color to essentially access of providers of color or of similar backgrounds in terms of language and issues. And presumably tele-health will help us, uh, to the extent that we can identify. So, but a very important point I'm going to, um, I have now begun to get some questions from our audience and the time we have left, uh, the first, uh, was, uh,
01;18;53;16 how will we, how will propose models such as the director, provider contracts, impact networks for integrated products and potentially disrupt integration? Anyone?
01;19;08;10 [Tim Engelhardt]: Sure. I believe the reference is to a new innovation model out of CMS that we refer to as direct contracting and to, to oversimplify, um, involves something akin to capitation payments, but in a fee for service context to an organization, with which you don't actively enroll per se, to which you're attributed, um, and in which you, you maintain freedom of choice. I think the promise of the model is toward
01;19;41;13 greater levels of benefit, flexibility, approaching a little bit that, um, is available in a capitated managed care setting. As we know it. Um, I think one of the interesting dynamics that we'll learn from is the extent to which it changes contracting practices and current Medicare advantage and, and related programs. A lot of the direct contracting approach is
01;20;09;15 replicating things that have been underneath
01;20;13;09 [Katherine Hayes]: The hood of the Medicare advantage program, especially like what we have traditionally thought of is sub-capitation to primary care practices. And so I think the concepts of evolving risk and flexibility closer to the delivery of service, the beneficiary level is one that has been growing over time. This allows us to test how it might work in a slightly different context, and we're kind of excited to learn as we go
01;20;39;17 [Sheila Burke]: Um, another question, how can plans, and this goes back to a question I raised at the outset, how can plants and state authorities better articulate the benefits of care coordination to consumers goes back to your early comments, Jean, uh, uh, Lois in terms of the trust element, Jack, in terms of what the state Medicaid programs are essentially expected to do. So how do we do a better job of communicating
01;21;05;08 that information to the consumer? Jean, start with you.
01;21;12;15 [Jean Accius]: I think that's a great question. And I think that, uh, I thoroughly enjoy these conversations, uh, with, uh, the rest of the panelists because of the fact that it just demonstrates how difficult, uh, and challenging, uh, it is to really transform systems and do so in a quick, um, or as quickly as one can. Uh, there's a couple of things I, I want to kind of go back to then Tim kind of pointing to this, uh, his earlier points about, uh, engaging consumers, uh, as part of that outreach
01;21;43;21 effort, uh, requires, uh, building that trust, uh, and really being in it for quite some time. And there's no that we've seen, uh, some States and some demos really ensure that, uh, consumers are part of the design implementation and execution process, uh, whether that is the councils that are being created or the advisory boards that are being supported. And I think it's critically important. Those who are closest to the problem are also critical in helping us try to cocreate solutions in order to address those. Uh, and to the extent to which we can, uh, bring in
01;22;16;09 consumers, uh, into the process of evaluating some of the communication aspects or ask him, what else could we potentially do, or really thinking about ways in which we can try to quote unquote simplify, what is frankly, a very complicated and complex experience and system? I think the better off we'll be, uh, I did want to mention and wanted to give a lot of kudos to, um, one of the recommendations that's in the report and that is around our state health insurance assistance programs and the need to ensure that
01;22;46;14 they have adequate funding and support, uh, in order to really help provide that one-on-one, uh, health insurance counseling, and also to support families who are doing it.
01;22;55;12 [Jean Accius]: Uh, Lewis said it earlier that, uh, family caregivers are really the backbone of our systems and oftentimes don't necessarily get the recognition that they deserve. Uh, we released a report last year that found that family caregivers were doing a very medical nursing tasks, like giving injections, like given wound care, really helping to try to navigate these systems. Uh, and frankly didn't have the information or the training or the support that they needed in order to do so. Uh, and they are also the ones who are also getting this information,
01;23;26;18 having to try to, uh, help their family member make these decisions. Uh, so I do think that the more that we can involve the consumers and to that process, uh, the better we will be
01;23;37;13 [Sheila Burke]: Lois, you wanted to comment so or,.
01;23;40;03 [Lois Simon]: Well, Jean, thank you. I, you know, the, the point about both consumers and family members as appropriate, I think is such a critical point. Um, as the daughter on of both my parents at the end of their lives and a professional who knows the system, I have witnessed upfront and close the complexity of trying to navigate it and really identify at the right time, the appropriate resources that need to be
01;24;12;17 brought to bear. So, um, you know, I think we all have our own stories to tell about that. The one other point that I would make is highly functioning, dual eligible, special needs plans, employee, staff, that are reflective of the communities that they serve and the staff's ability to engage individual dual eligible participants and community groups is really
01;24;41;08 enhanced through that affinity and understanding of cultural context and the circumstances of their members.
01;24;49;12 [Lois Simon]: So I think, you know, the question about what could plans do, not that, um, most plans don't strive to in fact think about how to, um, you know, in fact, uh, you know, connect with the communities that they attempt to serve. But I think, um, really getting to the grassroots of outreach, um, in communities with staff reflective of those communities is a really important statement, both about the plan and about the willingness
01;25;21;15 and the capabilities to serve.
01;25;24;09 [Sheila Burke]: Uh, the last question in our short time we have available, um, was how should the strategies with respect to integration and exposing consumers vary depending upon population? I mean, should it be different again, we've talked about the extraordinary heterogeneity of the population, should the strategies differ in how best to essentially engage different populations and families, uh, in terms of making them aware of the benefits of integration and helping them essentially engage in that
01;25;56;27 population. So last question, quick round of quick response, Jack,
01;26;03;13 [Jack Rollins]: I would say that probably we'll have to, I think we can see some commonalities in terms of principles for, and I think that
01;26;09;06 [Jean Accius]: That's Jean and Lois done an excellent job of articulating so that the things that are effective. And I know that some States have through membership advisory councils that are composed of direct recipients of Medicaid services that are representative of the types of individuals that receive them are a useful mechanism here. But I think having listening to those communities and having those, that input shaped the variable engagement strategies that reflect the differ, the differing needs of the duals populations that are in a state are going to be an
01;26;39;13 obvious component. I think that grounding it in that engagement, but varying the engagement by, based on the input provided is probably the most viable path forward.
01;26;48;01 [Sheila Burke]: Okay. Lightning round Jean, one minute on that Jean you're muted.
01;26;55;16 [Jean Accius]: I would agree. I would agree with Jack. I think if we're taking a consumer centric approach to this, uh, that there, uh, that, uh, really kind of thinking about the end user and what their needs are and how to ask you to reach out to them is going to be critically important while at the same time, having some broad framework to ensure that there is some consistency, uh, throughout the system
01;27;15;28 [Sheila Burke]: Right. Okay. Lois, one minute.
01;27;19;06 [Lois Simon]: The only thing I would add to my esteemed colleagues comments is for us not to forget the heterogeneity of the population to be served and what we'll work on in serving elders and, uh, the dependence and in many cases on, uh, outreach, you know, to those around them, family, caregivers, as an example, maybe less desirable or appropriate or possible on as it pertains to, you know, people who are younger with living with
01;27;52;01 disability associated with a severe physical disability as an example. So I think we've got to have stratified approaches to the various subpopulations that we're trying to serve.
01;28;04;17 [Sheila Burke]: Tim, you get the last minute,
01;28;07;02 [Tim Engelhardt]: It was well said, thanks for the chance to be here.
01;28;10;06 [Sheila Burke]: Alright. I want to thank the entire panel for their remarkable contributions throughout the length of this process. Uh, and through our preparing the report, responding to our recommendations, uh, and their availability to us when we had questions. Um, our primary goal is as we stated to improve the beneficiary experience and the outcomes that they are confronting, uh, and over time, we think there are in fact potentials for serving these populations. There are savings potentially
01;28;41;14 available as a result of reduced hospitalizations, readmissions, ER visits, uh, and essentially the utilization of long term care of services. Uh, but essentially, uh, this is another step in a very long process. That's gone for a long time that began with on lock, but is moving forward. So my thanks to everyone, my thanks to the Bipartisan Policy Center as well for another really terrific discussion, uh, be well and stay safe. All, thank you very much.
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In 2018, over 12 million Americans were eligible for both Medicare and Medicaid. These “dual-eligible individuals” are more likely to have multiple chronic conditions than people eligible for Medicare only. Historically, this high-need population must navigate the Medicare and Medicaid programs separately, which can result in poorly coordinated care and worse health outcomes. Over the past year, the Bipartisan Policy Center has worked to develop policy recommendations to integrate the Medicare and Medicaid programs to provide a seamless experience for beneficiaries.
Please join our online event on July 27 as we release policy recommendations to improve the integration of Medicare and Medicaid, as well as discuss the impact of COVID-19 on this vulnerable population.
Featured Participants
Keynote remarks by:
Sen Tom Daschle
Former Senate Majority Leader; Co-Founder, Bipartisan Policy Center
Gail Wilensky
Former Administrator of the Health Care Financing Administration; Senior Fellow, Project HOPE
Katherine Hayes
Director of Health Policy, Bipartisan Policy Center
Arielle Mir
Vice President of Health Care, Arnold Ventures
Panel discussion with:
Jean Accius
Senior Vice President, AARP Global Thought Leadership
Tim Engelhardt
Director, CMS Medicare-Medicaid Coordination Office
Jack Rollins
Program Director for Federal Policy, National Association of Medicaid Directors
Lois Simon
Executive Vice President, Policy and Programs at Seniorlink
Moderated by:
Sheila Burke
Strategic Advisor, Baker Donelson, Fellow, BPC
Possible participants to be added
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