Washington, DC – A new report released today by the Bipartisan Policy Center offers recommendations to incentivize states to integrate care for individuals eligible for both Medicare and Medicaid. It calls for integration to occur within eight years as a way to improve care coordination, health outcomes, and cost savings. The report also provides an alternative federal fallback program within five years in states that choose not to integrate care.
An estimated 12.1 million low-income, elderly patients, and individuals with disabilities are eligible for both Medicare and Medicaid. However, significant barriers exist that make receiving integrated care between these two complex programs almost impossible, leaving patients overwhelmed and without adequate services to manage their chronic medical conditions and other cognitive or physical limitations. These individuals are also at greater risk of contracting COVID-19 compared to Medicare-only beneficiaries, so the need to improve their quality of care is critical.
“We have been working to integrate care for this vulnerable population for decades, and today, only 30 percent of beneficiaries are in integrated care models, and less than 10 percent are in seamless fully-integrated plans,” said former Senate Majority Leader Tom Daschle, BPC health project leader. “Now is the time for a comprehensive approach.”
The report identifies three models of care states can use to achieve integration: 1) improved Fully Integrated Dual Eligible Special Needs Plans 2) the Programs of All-Inclusive for the Elderly (PACE) 3) a flexible model negotiated between the secretary of Health and Human Services (HHS) and a state, building off the managed fee-for-service model used by the State of Washington.
“It’s time to create a new infrastructure of care for this vulnerable population,” said Katherine Hayes, BPC director of Health policy. “We believe these models of care will provide a more patient-centered system and greatly improve both the quality and value of care this population receives. Currently, these individuals are at a disadvantage of navigating two separate programs with different benefits and eligibility requirements to address their health and long-term care needs.”
Recommendations in the report include:
- eliminating regulatory barriers to aligning Medicare and Medicaid.
- offering financial incentives and technical assistance to states through planning grants and guaranteed shared savings, if integration of services reduces costs over time.
- providing federal resources for consumer education about care options to improve the enrollee experience as well as an auto-enrollment option with an opt-out feature, and a 12-month, continuous Medicaid eligibility mechanism.
- encouraging closer coordination between the Centers for Medicare and Medicaid Services (CMS) and the Administration for Community Living.
- Increasing funding for counseling and ombudsman programs to help beneficiaries make informed choices about the benefits and trade-offs of integrated care.
“CMS needs the authority to align program requirements to make health care seamless for these beneficiaries,” said Gail Wilensky, former Medicare and Medicaid administrator and co-chair of BPC’s Future of Health Care Initiative. “The report recommends giving broad authority to the HHS secretary to align conflicting program requirements, so long as the authority does not result in a loss of eligibility, access to care, or beneficiary due process rights.”
BPC believes if these proposals are adopted there is potential for savings over the long-term, primarily from reduced hospitalizations and readmissions, ER visits, and post-acute care. However, the report emphasizes that a simplified, seamless system will require upfront federal investments to states.
Recommendations in the report were developed based on feedback from current and former state and federal officials, consumer-based organizations, Medicaid managed care plans, health care providers, and an online request for comments.