Community-Based Health Plans Take the (Complex) Path to Integrated Care

Integrated care for dual eligibles can be achieved, but it involves a collaborative, detailed-and often painstaking-process with many challenges.I write from the perspective of a representative of nonprofit, safety net health plans, but also as a former Medicaid director from Minnesota, a state that set up integrated care models for Medicare-Medicaid enrollees in the original dual demonstrations. The early demonstrations to integrate care in Massachusetts, Wisconsin, and Minnesota literally took years of planning and a long pursuit to gain federal authority. From that experience, I know that person-centered integrated care can be achieved.All older adults in Minnesota have benefited from care models first used under the Medicaidsponsored Minnesota Senior Health Options Program (MSHO); geriatric care teams are now common in highly ranked Medicare plans throughout our communities. This managed care model with mandatory enrollment on the Medicaid side has successfully enhanced the state's efforts to offer community-based care: Minnesota now ranks number one in the AARP/ Commonwealth/Scan Foundation ranking "Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers" (Reinhard et al., 2011). A Complicated Path to IntegrationIn my current role at the Association for Community Affiliated Plans (ACAP), a trade association that represents fifty-eight not-forprofit, community-based health plans, I see that the move to an integrated care model that aligns Medicare and Medicaid, acute and behavioral care, and chronic- and long-termcare services is not that easy. If developing integrated programs for dual eligibles were easy, more states would already have done so. The stakeholder process, the rates, and the operational details must be just right. States must realign home- and community-based waivers in place, if they include duals. The enrollment and education process for beneficiaries must be developed with care. And states and health plans alike have to hire and train the right staff, and develop or modify operational protocols and computer systems.The design and roll-out of the demonstrations has not been quick or smooth, despite tremendous efforts on the part of the federal agency to make this shared savings demonstration model work across multiple states in 2013. It is puzzling that the new initiatives did not more directly build upon the framework of the early demonstrations and their extensive contracts and experience. The consumer enrolled in both Medicare and Medicaid must coordinate and navigate across two programs (really four, with the drug benefit under Medicare Part D and Medicaid long-term supports and services managed differently from Medicaid). And each program has its own ID cards, benefits, appeals and grievance processes, plus duplicative and confusing paperwork. Despite the fact that our MSHO demonstrations developed a single ID card, aligned grievance and appeals processes, and produced consumer-friendly materials in multiple languages, each of these issues was addressed anew, usually from the starting point of the Medicare Advantage program. Perhaps, most importantly, the earlier demonstrations recognized the inadequacy of the risk-adjustment processes developed to date, and paid an additional amount (the PACE "frailty factor") to adjust payments to plans to reflect the complex functional limitations of the enrollees.The plans selected by states for participation in the demonstration sponsored by the federal Medicare-Medicaid Coordination Office (MMCO) have been actively engaged in state agency and stakeholder planning, which is apparent to their local communities. But it may be less obvious that inside the plans, there is an almost overwhelming level of activity as the plans get ready to serve the people who will enroll in them.The first decision: participationFirst, plans had to decide whether to participate in the initiative. …