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76–505—PDF 2011

S. HRG. 112–589 

DUALLY-ELIGIBLE BENEFICIARIES: 

IMPROVING CARE WHILE LOWERING COSTS 

HEARING 

BEFORE THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

SEPTEMBER 21, 2011 

( 

Printed for the use of the Committee on Finance 

COMMITTEE ON FINANCE 

MAX BAUCUS, Montana, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

KENT CONRAD, North Dakota 

JEFF BINGAMAN, New Mexico 

JOHN F. KERRY, Massachusetts 

RON WYDEN, Oregon 

CHARLES E. SCHUMER, New York 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

ORRIN G. HATCH, Utah 

CHUCK GRASSLEY, Iowa 

OLYMPIA J. SNOWE, Maine 

JON KYL, Arizona 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

TOM COBURN, Oklahoma 

JOHN THUNE, South Dakota 

RICHARD BURR, North Carolina 

RUSSELL SULLIVAN, Staff Director 

CHRIS CAMPBELL, Republican Staff Director 

(II) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Baucus, Hon. Max, a U.S. Senator from Montana, chairman, Committee 

on Finance ............................................................................................................ 1 

Hatch, Hon. Orrin G., a U.S. Senator from Utah ................................................. 3 

WITNESS 

Bella, Melanie, Director, Medicare-Medicaid Coordination Office, Centers for 

Medicare and Medicaid Services, Washington, DC ........................................... 4 

ALPHABETICAL LISTING AND APPENDIX MATERIAL 

Baucus, Hon. Max: 

Opening statement ........................................................................................... 1 

Prepared statement .......................................................................................... 23 

Bella, Melanie: 

Testimony .......................................................................................................... 4 

Prepared statement .......................................................................................... 25 

Responses to questions from committee members ......................................... 38 

Enzi, Hon. Mike: 

Prepared statement .......................................................................................... 57 

Hatch, Hon. Orrin G.: 

Opening statement ........................................................................................... 3 

Prepared statement .......................................................................................... 58 

Rockefeller, Hon. John D., IV: 

Prepared statement .......................................................................................... 60 

COMMUNICATIONS

Association for Community Affiliated Plans and Medicaid Health Plans of 

America ................................................................................................................. 63 

Center to Advance Palliative Care and National Palliative Care Research 

Center .................................................................................................................... 66 

Center for Fiscal Equity .......................................................................................... 73 

Continua Health Alliance ....................................................................................... 77 

(III) 

(1) 

DUALLY-ELIGIBLE BENEFICIARIES: 

IMPROVING CARE WHILE LOWERING COSTS 

WEDNESDAY, SEPTEMBER 21, 2011 

U.S. SENATE, COMMITTEE ON FINANCE, Washington, DC. 

The hearing was convened, pursuant to notice, at 10:12 a.m., in 

room SD–215, Dirksen Senate Office Building, Hon. Max Baucus 

(chairman of the committee) presiding. 

Present: Senators Bingaman, Wyden, Carper, Cardin, Hatch, and 

Grassley. 

Also present: Democratic Staff: Russ Sullivan, Staff Director; 

David Schwartz, Chief Health Counsel; Kelly Whitener, Professional Staff; and Matt Kazan, Professional Staff. Republican Staff: 

Chris Campbell, Staff Director; Rodney Whitlock, Health Policy Advisor; and Stephanie Carlton, Health Policy Advisor. 

OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR 

FROM MONTANA, CHAIRMAN, COMMITTEE ON FINANCE 

The CHAIRMAN. The committee will come to order. 

Mahatma Gandhi said, ‘‘A measure of a country’s greatness 

should be based on how well it cares for its most vulnerable populations.’’ Last year, 9 million Americans were enrolled in both 

Medicare and Medicaid. These are often seniors or individuals with 

disabilities whose incomes are low enough to also qualify for Medicaid. 

Most of these dually-eligible beneficiaries live below the poverty 

line, often with severe disabilities or chronic diseases. They are 

some of the most vulnerable people in our health care system and 

often require expensive care. 

In 2009, these patients made up 18 percent of the Medicaid population, but nearly half of Medicaid’s total spending. States and the 

Federal government spend more than $300 billion each year on 

these dually-eligible beneficiaries. 

Unfortunately for all of these patients and for taxpayers, Medicare and Medicaid often do not work well together. Each program 

pays for different types of services. Medicare pays for hospital 

stays, while Medicaid pays for nursing home care. States set most 

of their own Medicaid rules, while the Federal government sets 

Medicare rules. Sometimes these rules conflict. 

The beneficiary is often left on his or her own trying to navigate 

not one, but two, complex health care programs. No one wins in 

this scenario. The Federal government pays too much for care. 

States spend precious dollars on long-term care that could have 

2 

been prevented. Doctors and hospitals find it difficult to work together. And the patient receives inadequate care. 

Congress and those who run Medicare and Medicaid have too 

often overlooked dually-eligible beneficiaries. There has been little 

attention paid to the areas where Medicare and Medicaid overlap 

into the populations served by both programs. In health reform, we 

began to fix this problem and create better outcomes for patients 

while saving taxpayer dollars. The health care reform law created 

an office to focus exclusively on the dually-eligible population, the 

Medicare-Medicaid Coordination Office. For the first time, Medicare and Medicaid will have to work together. 

Some States are creating their own exciting new delivery models. 

As we will learn from our witness today, these examples show that 

coordinated care can lower costs and improve care. Massachusetts 

is working with private health plans to integrate Medicare and 

Medicaid. North Carolina’s Medicaid program has been on the forefront of care coordination. Oklahoma is looking to expand the Program of All-inclusive Care for the Elderly (PACE), a provider-based 

integration system, to the entire State. These initiatives are promising, but they only affect a small fraction of all dually-eligible 

beneficiaries. 

As we work to improve the quality of care while reducing costs, 

we should keep in mind four principles. 

(1) Medicaid and Medicare funding should be coordinated. Both 

programs should have the incentive to lower overall costs, not shift 

costs from one program to the other. 

(2) The full range of health care services, from hospital care to 

long-term care to prescription drugs to mental health care, should 

be coordinated among all providers. 

(3) Providers in States that improve the health of beneficiaries 

and lower costs should be rewarded financially. 

(4) Patient protections should be transparent and comprehensive. 

We must provide dually-eligible beneficiaries with choices that 

meet their health care needs while affording them access to the full 

range of services they require. We took a first key step in health 

reform, but we have much more to do to ensure that the most vulnerable beneficiaries are no longer overlooked. 

Ms. Bella, I am eager to hear the progress your office has made, 

and I thank you for all your work. I look forward to learning how 

you think Congress could improve Medicare and Medicaid so that 

the two programs work more efficiently. 

Many of the States represented on this committee on both sides 

of the aisle are eager to find new ways to care for these beneficiaries, so let us work together to improve. Let us make the 

health care system more efficient, and remember what Mahatma 

Ghandi said: this is the true test of how well our country cares for 

its most vulnerable, the true test of the greatness of our country. 

[The prepared statement of Chairman Baucus appears in the appendix.] 

The CHAIRMAN. Senator Hatch? 

3 

OPENING STATEMENT OF HON. ORRIN G. HATCH, 

A U.S. SENATOR FROM UTAH 

Senator HATCH. Well, thank you, Chairman Baucus, for holding 

this hearing. I believe our topic today represents an area where we 

can achieve some real bipartisan solutions that will lower health 

care costs and save lives. There are more than 9 million Americans 

who are eligible for both the Medicare and Medicaid programs, 

commonly known as dually-eligibles. These patients typically suffer 

from multiple chronic conditions and also have long-term care 

needs as well. 

In addition to complicated medical issues, payment for their care 

is generally siloed between complex Medicare and Medicaid payment rules, and this creates inefficiencies and many unnecessary 

complications. Care for these individuals is also very expensive, 

with annual spending topping $300 billion in Medicare and Medicaid dollars. 

In my home State of Utah, just 10 percent of Medicaid beneficiaries are duals, but 26 percent of the State’s Medicaid expenditures go toward care of these patients. Many States have taken the 

lead to develop innovative solutions for dually-eligibles, such as the 

Community Care of North Carolina model, or the Star Plus program in Texas. We need to help them build on these successes. 

The Federal government has also designed models to address 

care for dually-eligibles, such as special needs plans in Medicare 

Advantage or the program of all-inclusive care for the elderly which 

is known as PACE. And while these approaches have made a difference, there is much more work to do to ensure that every dualeligible gets better care, and that taxpayers get better value for 

their dollars. I look forward to hearing from Melanie Bella, the Director of the Federal Coordinated Health Care Office at the Centers 

for Medicare and Medicaid Services. 

Ms. Bella has taken both a pragmatic approach to problemsolving and a compassionate approach to improving patient care. 

As Congress contemplates reforms to lower our entitlement program spending and to improve the quality of care, the topic of this 

hearing is an important place to start. Clearly, the status quo is 

not serving taxpayers well and it is not serving patients well, either. We can do better, and I believe that we can do it in a bipartisan way. 

So again, Mr. Chairman, I want to thank you for scheduling this 

important and timely discussion, and I look forward to working 

with you on these issues. 

The CHAIRMAN. Thank you, Senator. I am very pleased you are 

here. 

[The prepared statement of Senator Hatch appears in the appendix.] 

The CHAIRMAN. Today we hear from the Director of the newly established Medicare-Medicaid Coordination Office, Melanie Bella. 

Ms. Bella, just as a reminder, your full statement will be included in the record, and I would encourage you to say whatever 

you want to say for 5, 6 minutes. 

4 

STATEMENT OF MELANIE BELLA, DIRECTOR, MEDICAREMEDICAID COORDINATION OFFICE, CENTERS FOR MEDICARE AND MEDICAID SERVICES, WASHINGTON, DC 

Ms. BELLA. I could talk for hours, but I will stick to 5 or 6 minutes. Good morning, Chairman Baucus. 

The CHAIRMAN. And let her rip. Say what you want to say. 

[Laughter.] 

Ms. BELLA. Good morning, Mr. Chairman, Ranking Member 

Hatch, and members of the committee. Thank you for the invitation to participate today. My name is Melanie Bella. I serve as Director of the Federal Coordinated Health Care Office at CMS. This 

office is what we are referring to as the Medicare-Medicaid Coordination Office, to better explain our mission. 

Our single focus is the topic of the hearing today. Medicare and 

Medicaid enrollees, also referred to as dual-eligibles, are a very 

heterogenous group. They include low-income seniors, individuals 

with disabilities, as well as those with serious and persistent mental illness. 

The pathway to becoming a Medicare/Medicaid enrollee can vary 

depending on an individual’s health and set of financial circumstances. Some individuals start on Medicaid and age into Medicare; others start on Medicare and have a functional and financial 

decline that makes them Medicaid-eligible. 

As a group, these enrollees have very complex health care needs. 

Sixty percent have multiple chronic conditions, such as diabetes or 

congestive heart failure. Almost half have at least one mental or 

cognitive impairment, such as dementia or Alzheimer’s disease. Not 

surprisingly, given their higher-than-average health care needs, 

the cost of providing coverage for these individuals is significant, 

but we believe that provides a tremendous opportunity to achieve 

program efficiencies through better integration and coordination. 

Our office is working across programs with States, providers, and 

stakeholders on a number of key initiatives to ensure better health, 

better care, and lower cost through improvement. Specifically, our 

efforts are focused in three main areas: program alignment, data 

and analytics, and models and demonstrations. I will highlight a 

few of those efforts this morning, starting with program alignment. 

Better coordination for these enrollees begins with improved program alignment. Currently, Medicaid and Medicare enrollees must 

navigate two separate programs, as was mentioned: Medicare for 

coverage of basic acute care services and drugs, and Medicaid for 

coverage of supplemental benefits such as long-term care supports 

and services. Medicaid also provides help with Medicare premiums 

and cost-sharing. 

One of the first objectives of our office was to catalog all of the 

places where Medicare and Medicaid bump up against each other 

and where these are creating barriers to care. Through internal 

and external consultation and outreach, we identified opportunities 

to improve alignment between the two programs and published a 

list of these opportunities in the Federal Register. 

The public solicitation brought in over 100 responses from a variety of stakeholders, including providers, health plans, States, and 

beneficiary advocates. We were happy that we even received a few 

comments from Medicare and Medicaid enrollees themselves, tellVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
5 

ing us how the program could work better for them. These comments will help inform our future work and help inform our work 

with Congress as we make recommendations going forward for how 

to make the programs work better together. 

Another key objective of our office is to engage State partners. 

Improving the quality and cost of care for Medicare and Medicaid 

enrollees relies on effective partnerships with States because we 

share the responsibility to both provide and finance care for this 

population. Our office has recently announced several key initiatives in support of our partnership with States. 

One of these initiatives was the establishment of a new process 

for States to receive Medicare data for care coordination purposes. 

Lack of timely Medicare data, particularly Part D data, has been 

a key barrier for States in expanding their care management efforts to Medicaid/Medicare enrollees. These data provide States 

with a powerful new tool to support their efforts to improve care 

for this very complex population. 

Our office is also partnering with the Center for Medicare and 

Medicaid Innovation to establish opportunities through demonstration of delivery and payment reform models to improve the quality 

and cost-effectiveness of care for Medicare and Medicaid enrollees. 

A critical aspect of these demonstrations is the expectation from 

CMS that they include strong beneficiary protections and are informed by meaningful stakeholder engagement at every step. 

I will highlight two of these demonstration opportunities this 

morning. The first is the State demonstrations to integrate care for 

dual-eligibles, under which 15 States were competitively selected to 

design new approaches to better coordinate care for Medicare and 

Medicaid enrollees. I must say, several committee members’ States 

are represented in the group of 15, and so we are very pleased with 

the interest of States in that regard. 

Through these design contracts, CMS is providing funding to the 

States to support their efforts to design person-centered approaches 

to fully coordinate care involving primary, acute, behavioral health, 

prescription drugs, and long-term supports and services. The goal 

of this initiative is to identify and validate new delivery and payment models that can be tested and replicated in other States. 

Early work with these 15 States confirms that a key component 

of a fully integrated system is testing new payment models. As 

such, we recently developed and announced a financial alignment 

initiative that will test new payment and service delivery models, 

and, importantly, these models are open to all States. We believe 

that it is important for CMS and for our office to reach out to all 

States that are interested in improving care for this population. 

Specifically, under this demonstration initiative, CMS is making 

a capitated model available which involves a 3-way contract among 

CMS, a State, and a health plan, and a managed fee-for-service 

model available which involves a recognition of sharing savings 

with a State if Medicaid savings result as a result of improved care 

management. 

A critical link in our partnership with States, both in demonstrations and in our greater efforts, is to be a technical assistance resource to all who are interested in improving care for this population. To that end, we have recently established an Integrated 

6 

Care Resource Center, and I am making that resource available, 

again, to all States. 

Lastly, it is worth noting we also recently announced a new demonstration focused on improving quality of care for nursing home 

residents by reducing preventable hospitalizations. Through this 

initiative, CMS will select organizations to partner with and will 

implement interventions to reduce readmission rates and improve 

the quality of care for those in nursing homes. 

In closing, a high priority for our office is to significantly increase 

the number of Medicare and Medicaid enrollees who have access to 

seamless coordinated care. We will get there by eliminating barriers to integration; effectively partnering with States, providers, 

and other stakeholders; and developing new delivery system and 

payment models. 

The programs I mentioned today are just examples of the work 

that we have begun. Together, in partnership with States, providers, and other stakeholders, and along with your continued support, we can move forward to a more coordinated system that provides higher quality and more cost-effective care for individuals 

who need it the most. 

Thank you very much. 

The CHAIRMAN. Thank you very much, Ms. Bella. Clearly, we 

have selected the right person for the job. 

[The prepared statement of Ms. Bella appears in the appendix.] 

The CHAIRMAN. There are a lot of questions all of us have. One 

for me is, what sort of goals have you set for yourself? What 

metrics? What is quantified? For example, I understand, at least 

for the 2008–2009 data, that 16 percent of Medicare participants 

were dual-eligibles, about 16 percent, but that accounted for about 

25 percent of Medicare spending. That same year, 2009, 18 percent 

of Medicaid patients were duals, but that accounted for about 46 

percent of Medicaid spending. 

Then there are all kinds of areas looked at, like complexity, 

whether it is a complexity metric or whatnot. I am wondering if 

you have set goals for yourself; that is, by a certain date you would 

like to achieve a certain result that is quantifiable. Could you just 

talk about that a little bit, please? 

Ms. BELLA. Sure. It is a great question. We believe that the inefficiencies in care that are harming both quality and are driving 

costs in the system result from the fragmentation, so our ultimate 

goal is to ensure more beneficiaries are served in integrated systems that coordinate all of the benefits and that very importantly 

align the financing between the two programs. 

So our ultimate metric is, how many people can we serve in integrated and coordinated systems? Of the 9 million duals that exist 

today, we believe about 100,000 of them are in such a system 

where it is fully integrated and an entity is accountable, clinically 

and financially, for their care. 

So for 2012, our goal is to have 1 million of the 9 million duals 

into a coordinated, integrated system of care and then to keep 

building year after year, particularly through our demonstrations 

and our work with States as we are able to expand the efforts to 

build these accountable systems of care. 

7 

So at the highest metric, that is what we are holding ourselves 

accountable for, and then it flows down from that in terms of, how 

are we going to do that, how many States do we want to have in 

demonstrations, how are we going to share more data, what types 

of program alignment are we going to address? But it all rolls up 

to that ultimate metric. 

The CHAIRMAN. Right. That is very interesting. Let us say you 

are successful and you get more people in the coordinated care environment. Have you done any calculations of how that will address the disparity between the population and costs in both Medicare and Medicaid? 

Ms. BELLA. We certainly believe that there are three main buckets that we have an opportunity to achieve savings in. One is better care, so, by integrating the care, we are actually going to see 

an improvement in the utilization of care. The second is, we believe 

there is duplication inefficiency in the system in what is being provided today, so that represents an opportunity. The third is, there 

are administrative and operational inefficiencies by the lack of 

interaction of the two programs. 

Quantifying that is a bit difficult at this stage just because we 

are in the early stages of working with States on putting together 

demonstrations, but broadly that should give you a sense of where 

we are going and where we think the cost savings opportunities are 

that will begin to address the inequity, as you say, between the 

proportion of people in the program and the spending on those 

folks in the program. That is what we are working toward over 

time as we get more specific with States on actual new delivery 

and payment models. 

The CHAIRMAN. I think everybody agrees with the direction we 

have to move. How much can you do on your own administratively 

and how much requires legislation? Let me ask it differently: what 

can you do administratively and what can you not do administratively that you think should be addressed, but would require legislation? 

Ms. BELLA. That was part of the purpose of our alignment initiative, to understand that. Many of the areas where there could be 

greater alignment can be addressed administratively or through 

the regulatory process. There are some things that will require 

statutory change. In terms of permanent program changes, those 

would likely be things that we would need to come back to Congress to support. We have an opportunity on an annual basis to 

provide you with recommendations in that regard. 

Right now, we are in pretty good shape in terms of doing the 

testing that we need to do to be able to make informed recommendations going forward, by virtue of being able to partner with the 

Innovation Center and use that new resource to test some of the 

delivery system and payment models, which ultimately is where we 

would need congressional support going forward to make permanent changes. 

The CHAIRMAN. My time has expired. I will have more questions. 

Senator Hatch? 

Senator HATCH. Well, thank you, Mr. Chairman. 

You know, as a long-time advocate for giving States the flexibility to implement solutions that work for their citizens, I personVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
8 

ally appreciate the approach that you have taken on getting ideas 

from the States to design innovative models for the care of duallyeligible beneficiaries. 

However, I am concerned that this will take quite some time, 

and, while we can always benefit from more ideas, many States 

have already implemented innovative approaches to better care for 

duals through various waivers. Now, based on your experience as 

the former State Medicaid Director in Indiana and your work now 

at CMS, what kind of legislative proposals do you recommend we 

evaluate to advance better care delivery for dually-eligible beneficiaries? 

Ms. BELLA. We are doing our best to work with States to offer 

streamlined approaches so that we can get new products and demonstrations out in the field faster and learn what works, and then 

disseminate those to other States. At this point we have the tools 

internally to be able to work with States in a flexible manner. One 

of the main reasons we put out a State Medicaid director letter 

that I referenced earlier was to announce two new demonstrations 

for all States. 

It basically puts it just one step away, almost, from doing it in 

a State plan format, because it is a streamlined approach that is 

very clear on how States can take advantage of these opportunities 

with us. For now, we feel like we have the tools we need to do the 

testing to be able to come back to you with informed recommendations down the road as to what sort of statutory changes might be 

needed in the future. 

Senator HATCH. All right. As I understand it, your financial 

alignment initiative consists of two approaches. Under the first, 

there would be, I think, a 3-way contract where a plan receives a 

prospective blended rate. Could you detail for us how that rate 

would be determined? Then, under the second, a State would benefit from shared savings under their unique approach. Now, how 

would payments to States and savings be determined here? 

Ms. BELLA. Sure. Those are both very good questions. Under the 

capitated approach—and I should say, this is kind of version II of 

a prior meta-demonstration that happened several years ago, 

where Massachusetts actually had a 3-way contract. Minnesota and 

Wisconsin also participated. But we have had some experience with 

this model. 

Essentially what we are doing is, we are looking at building—let 

us say that it is me, I am the dually-eligible beneficiary. We are 

building a rate based on my needs. We are understanding all of the 

services based on historical utilization and expected future utilization, looking at what that rate would be, and then determining the 

Federal/State sharing in the funding of that capitation rate and 

passing that rate to the health plan. But we are doing it in such 

a way that it assumes efficiencies in those three areas that I mentioned earlier. 

Therefore, it is a reduced amount than what either the State or 

Federal government would have paid absent this integrated program. So, essentially, it is a capitated prospective rate that is less 

than what we would have otherwise paid as the result of the coordination we are expecting. 

9 

In the managed fee-for-service model, that is designed where essentially we would set a baseline, a benchmark of what we would 

expect spending to be absent this program. We would measure the 

actual experience of the beneficiaries in the demonstration relative 

to the benchmark. If it hit pre-established savings thresholds that 

the State and CMS would have worked out, the State would be eligible to share in a percentage of those savings. 

There are a couple of key caveats. One is, quality measures have 

to be attained, so we cannot just have savings occur to the detriment of quality. Also, we are measuring States on impact in Medicaid spending as well because we want to make sure, again, we 

are not creating new opportunities to cost shift between the two 

programs. 

Senator HATCH. In its June 2011 report to Congress, the Medicare Payment Advisory Commission (MedPAC) noted that ‘‘Medicare’s requirement for voluntary enrollment in coordinated care 

programs is a key limitation to expansion.’’ Do you agree that this 

is a limitation to expansion of effective models of coordinated care, 

and would you support models that allow States to enroll their 

dually-eligible patients into better models for care coordination? 

Ms. BELLA. One problem that we have with these models is, 

these are very complex patients, these are very complex systems, 

and we have a hard time communicating the benefits of integrated 

systems of care. So what we are seeking to build are systems that 

are far superior to what we have in fee-for-service today, and we 

believe that those systems are ones where beneficiaries would want 

to receive their care and where they would get better care. 

As part of our financial alignment models, we have made public 

the opportunity for States to request passive enrollment of beneficiaries into these models with an opt-out, with the understanding 

that these models also carry very critical consumer protections. But 

to answer your question, States have the opportunity to request 

passive enrollment with an opt-out, assuming these beneficiaries 

protections are met. 

Senator HATCH. All right. My time is up, Mr. Chairman. 

The CHAIRMAN. Do you have more questions? 

Senator HATCH. No, my time is up. 

The CHAIRMAN. Do you have more questions? 

Senator HATCH. I may have some. I am going to ask again. 

The CHAIRMAN. All right. Fine. 

Next, Senator Bingaman. 

Senator BINGAMAN. Thank you for being here. 

Let me ask about two issues. I think you mentioned in your testimony that nearly a quarter of all hospitalizations for dual-eligibles 

are avoidable. I guess a first question would be, in concrete terms, 

what can you do and your office do to reduce these preventable hospitalizations? I know this is something you are trying to accomplish. I am just not really clear in my own mind what changes in 

regulations at the Federal level can do to actually reduce the number of people who go into the hospital who do not need to. 

Ms. BELLA. That is a great question. Given that the majority of 

the Medicare and Medicaid enrollees are in fragmented systems, 

there is no one who is helping them navigate those systems. There 

is no one who is looking at the medication to ensure that it is what 

10 

it needs to be and that there are no contraindications. There is not 

anyone making sure that the primary care foundation is there. So, 

all of these factors contribute to why people end up in hospitals: 

inadequate primary care, medication problems, lack of coordination 

among the various service providers. 

So what our office is doing is trying to put together care models 

and other programs that focus on care coordination for folks, on 

medication management, on care transitions when people are going 

between settings, because we believe that those provide the foundation of keeping people out of the hospital when they do not need 

to be in the hospital. I would say, I would just take your point one 

step further. 

Where this is even more compelling is for beneficiaries who are 

in nursing homes. We actually believe there is a 40-percent preventable hospitalization rate for beneficiaries in nursing homes. 

One of the things we are doing, as I mentioned, is a demonstration 

specifically targeted at that population to stop this churn that we 

see that is going on that is very bad for patients. It is very, very 

costly, and it should not be happening. 

Senator BINGAMAN. A related issue is the problem of hospitalacquired conditions. I think the health care that folks in this 

group—since an awful lot of these dually-eligibles wind up going 

into the hospital at some time during the year, their need to stay 

there or return or whatever is sometimes increased because of the 

conditions that they acquire in the hospital. 

What are you able to do in your office to deal with that problem? 

Ms. BELLA. Well, fortunately there are many department and 

agency initiatives under way that target that very thing. So the 

Partnership for Patients, which you may be aware of, is looking at 

a reduction in patient safety of 40 percent on top of also looking 

at readmissions. So there are several initiatives that are bringing 

together partnerships in States with providers, hospitals, and payers to get at that very issue. 

So fortunately, the dual-eligible population is such a high priority 

that it is a target population within these initiatives that are under 

way. So we have an ability now within the agency to advocate for 

this population and make sure that they are included in all of 

these initiatives, especially when it comes to payment incentives 

and really focusing on and measuring the impacts specifically on 

this population. 

Senator BINGAMAN. This Partnership for Patients program is 

funded at $1 billion, I guess, or there is a $1-billion fund that has 

been set aside for this. How much of the dual-eligible population 

is being reached or in any way impacted by this? 

Ms. BELLA. I can give you sort of a qualitative answer, and then 

I will be happy to provide some follow-up. Broadly, the Partnership 

for Patients is looking generally at the relationship of the hospitals, 

and then we have the Care Transitions Initiative that was part of 

health reform. Many of the dual-eligibles will likely be part of the 

Care Transitions Initiative, which is really focused on communitybased organizations, really trying to work to prevent errors and rehospitalizations. 

So, broadly speaking, it is a small population, the duals, but they 

have a high percentage of the things that the Partnership for PaVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
11 

tients campaign is targeting. Therefore, we believe that the campaign will have a huge impact in terms of the number of duals that 

it touches and the spending that it can possibly help control. And 

like I said, I would be happy to get back to you with some more 

quantifiable information. 

Senator BINGAMAN. Yes. Anything you could give us that would 

document the extent of the savings, the extent of the reduction in 

these hospital-acquired conditions, that would be great. 

Ms. BELLA. Certainly. 

[The information appears in the appendix on p. 55.] 

Senator BINGAMAN. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator Grassley? 

Senator GRASSLEY. Thank you, Mr. Chairman. 

Ms. Bella, if anybody was designing a system from scratch, that 

person obviously would not create a system like we have today for 

dual-eligibles. Medicare and Medicaid pass responsibility for dualeligibles back and forth between Federal and State governments in 

a way that is more likely to discourage than encourage coordination. 

Ideas like giving the Federal government complete responsibility 

for duals through a comprehensive Medigap policy purchased with 

State contributions or giving the States responsibility for duals 

with the use of Federal dollars to pay the acute care would eliminate the counter-productive Medicare and Medicaid relationship. 

So my question to you is: could you give me any good reason that 

we ought to continue the Federal/State partnership for this population without significant restructuring? 

Ms. BELLA. That is, I think, the million-dollar question. It is a 

very good one. The challenge that we face is that the system that 

we have today has evolved over 45 years, so our efforts over the 

past year have been to try to become more informed to answer 

questions like yours. 

So, for example, with the program alignment initiative, we are 

trying to really understand the differences in all areas—enrollment, eligibility, marketing, grievances and appeals, financing, performance measurement—between Medicaid and Medicare, to understand how they got the way they are today and what they would 

look like in a better system, and ‘‘better’’ being from the perspective 

of serving beneficiaries better, as well as serving the taxpayers better. So, that is an example. 

The second area is the data and analytics. We do not know 

enough about this population to understand the drivers to know 

how to design a more effective solution for 9 million of them who 

are very diverse, so the analytic activities we are undertaking 

again will inform that question. 

Lastly, the models and demonstrations are going to be telling. 

There are many folks out there who believe that the Federal government could do a better job, and just as many who believe the 

States could do a better job. There are good things in each program, but each program misses key elements as well. 

So the demonstrations and models should really help to inform, 

how would we take the best of both and put them together in a 

12 

way that, again, is better from a beneficiary perspective and better 

from a taxpayer, a State and Federal government, perspective? 

Senator GRASSLEY. Have you done enough study to know whether there is progress being made that you can see light at the end 

of the tunnel for restructuring so we can get away from the mess 

that we are in? 

Ms. BELLA. I think we definitely believe there is light at the end 

of the tunnel. The question is, how quickly can we get there? The 

challenge we face today is, even when we have seen some promising solutions, it takes a while to get those to scale. That is due 

to a couple of factors. One is, this is a very complex population, and 

the types of care they need, it is not the same as being able to expand, for example, to a population of fairly healthy moms and kids. 

The second is just having the capacity in the field to be able to 

provide the types of services that are needed. There is a lot that 

needs to be done on the long-term support and services side, and 

building that capacity takes time. So, there is light at the end of 

the tunnel. 

I think we certainly see opportunities for alignment between the 

two programs. We have identified where there is major costshifting, and we are trying to put our fingers on those holes, and 

then again be able to continue to work with Congress and others 

on how to take those more broadly and inform future program 

changes. 

Senator GRASSLEY. We have a study published in the September 

issue of Health Affairs by Gina Livermore showing that there was 

$63 billion in 2008 in Medicare spending on working-age people, 

meaning those mostly with disabilities. That was roughly 14 percent of Medicare spending. Medicaid spending on working-aged 

people with disabilities in 2008 was $88, almost $89 billion. That 

means a very large portion of Medicare spending on working-age 

individuals would have been for people who are dual-eligibles. 

Do you think that the senior duals and working-age duals are 

separable populations and should be treated differently in any solution to improve coverage and coordination for dual-eligibles? 

Ms. BELLA. Another very good question. Even if you just split the 

population at those over 65 and those under 65 with disabilities, 

there is still so much diversity, and there is commonality even 

above and below that line, that it makes it very difficult to give you 

a ‘‘yes’’ or ‘‘no’’ answer to that question. 

I think what I would like to say is, with the analytic work we 

are doing, again, to drill down into this population, a lot, Senator, 

depends on folks in both of those groups being in institutional settings. That changes a lot of things and would change the way that 

I might answer that question. If there is mental illness or dementia 

involved, all of those things would influence the answer to that 

question. 

As we do more analytics and really drill down into the subsets 

of the population, I think we would be able to come back to you 

with a very informed answer and a set of at least some analytic 

work that might help inform some thoughtful choices about how to 

best organize the delivery system around the very heterogeneous 

population. 

13 

Senator GRASSLEY. Just a short answer to this: are you thinking 

in the direction of some division along the lines of my question or 

have you not reached that point yet? 

Ms. BELLA. We have not reached that point yet. 

Senator GRASSLEY. All right. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator Wyden? 

Senator WYDEN. Thank you, Mr. Chairman. 

Ms. Bella, I know you have a long record of advocating for these 

folks, folks who are eligible for Medicare and Medicaid, so I think 

that gives me a certain leeway to speak bluntly about where we are 

with respect to this issue. 

My own view is, we have been treading water on this question 

literally for decades. I look back, when I was co-director of the Oregon Gray Panthers, and we were doing exactly what we are doing 

now: we are talking about demonstration projects, small-scale 

kinds of studies. We knew that this was a group that was sort of 

precisely fitted for essentially the house-call arrangement kind of 

approach, a team approach—doctors, nurse practitioners, a multidisciplinary approach. 

Here we are today in pretty much the same place. As you know, 

I, and a big bipartisan group, authored the Independence at Home 

portion of the Affordable Care Act. The same issue. We wanted to 

have a large group of people, but everybody kept ratcheting it 

down. Now we are talking about a demonstration of 10,000 people. 

That is where we are. Essentially that is about where we were 3 

decades ago when I had a full head of hair and rugged good looks 

and I was director of the Gray Panthers and we were talking about 

exactly the same issue. 

So here is my question: since we passed the Affordable Care Act, 

we have another demonstration. My colleagues are absolutely right 

about these State experiments. Two very important things have 

taken place. As you know, the VA has come out with this blockbuster study where they showed, for their group that they were 

taken care of at home, they reduced hospital stays by 62 percent, 

nursing home days by 88 percent, the costs by 24 percent. 

Those folks are almost exactly in the same spot as folks who are 

eligible for Medicare and Medicaid, except for the fact they are 

even sicker. They have 5 chronic conditions and co-morbidities. In 

addition to that, the experts at the University of Pennsylvania 

have said that if you had a fully operational independence at home 

program you could save somewhere in the vicinity of $30 billion annually for Medicare. 

So my question to you is, what is going to have to be done to take 

this program, writ large? As you know, there are millions of eligible 

people. We have these demonstration projects. There is provider capacity, according to what we have seen, for about 2 million people, 

not the whole 9 million you talked about. What is it going to take 

to get this beyond the small groups and get to the point where we 

can get more people care where they want to be at a cheaper price? 

Ms. BELLA. It is a great question. I agree with you that the Independence at Home model and the home visits are an important one 

for a subset of the population that has those needs. Part of what 

14 

we seek to learn from Independence at Home is how to bring the 

Medicaid piece in there as well, since to date the demonstrations 

have been Medicare-focused. So we want to make sure we are 

bringing all of that together for the population. 

We have early experience along those lines, service provided in 

the home with the PACE program also, which, as you know, has 

remained small as well. I guess I am neither hopeful nor naive that 

by creating this office there is a force that might be able to push 

for a broader and faster expansion than we have been able to do 

in the past. No one has ever had the luxury of only having this 

population to worry about and being able to sort of lobby for that 

population. 

Senator WYDEN. Because time is short, with the advocacy you 

are doing, in 5 years how many of these folks will we have in programs at home with the kinds of models that we are talking about? 

Are we going to be able to get to a million within 5 years? I mean, 

the provider capacity is 2 million. You said there are 9 million eligible people. I would like to get your sense so at least we have a 

target and we can say we are going to make this sort of where we 

want to go and get beyond these demonstrations. What are we 

going to be able to do in terms of 5 years from now? 

Ms. BELLA. Sure. We like to have targets as well. What I would 

like to do is get back to you. I would like to go back and make sure 

that—because that type of program, everyone would not fall into 

those criteria. So what I would like to do is go back, look at how 

many of the 9 million we think would be appropriate, and come 

back to you with a quantifiable target that matches our 1 million 

to have in broad systems by 2012. 

Senator WYDEN. But just do take a look at that VA model, because they are essentially, those folks, exactly like the people 

whom we sought to address in the legislation with Independence 

at Home, except they are even sicker. 

Ms. BELLA. All right. 

Senator WYDEN. So that is why we have a model. 

Thank you, Mr. Chairman. 

Ms. BELLA. Thank you very much. 

[The information appears in the appendix on p. 55.] 

The CHAIRMAN. Thank you, Senator. 

Senator Cardin? 

Senator CARDIN. Well, thank you, Mr. Chairman. Let me thank 

you for your testimony. I want to follow up on Senator Wyden’s 

point because I think he is absolutely correct. I served for many 

years in the State, and I know it is extremely difficult to get the 

States to move forward on programs that will save them money, 

when they have to invest to save. Particularly in these budget 

times, it is difficult to just point out Medicaid savings and say 

therefore, yes, let us get on board when they know that they have 

to invest in order to do that. 

What Senator Wyden was asking, and I want to follow up on 

that, is, we need bolder proposals. The demonstration programs are 

fine, but again, there is an inconsistency in the use of the demonstration programs. So I think we are looking for bolder approaches to sort of get more of the dual-eligibles under a managed 

program where they have access to care that they have not tradiVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
15 

tionally had. We need bold proposals that recognize that a large 

number of the dual-eligibles did not get access to care earlier in life 

that has complicated their medical needs today. 

We need bolder proposals that understand that a large number 

have challenges in the mental health area. So, are you looking at 

ways that we can really make a significant change in the way that 

the dual-eligible population has access to care under the Medicare 

and Medicaid programs? 

Ms. BELLA. We are. I recognize it is frustrating that I am going 

to use the word demonstration, but the demonstrations we are 

doing, the financial alignment demonstrations, actually target 2 

million beneficiaries, so their target time frame is 2012. We are 

looking for 2 million of the 9 million, which is more aggressive than 

we have ever been able to be in the past. 

We do have challenges with State bandwidth right now, as well 

as States being able to make an up-front investment, so we are trying to support States so they can take us up on these models. We 

do want to expand faster than we have done in the past, but this 

is a complex population, and putting the two programs together 

and getting the care and the financing aligned correctly is a complex thing, so we want to make sure that we are doing it in a way 

that actually is going to achieve the outcomes that you discuss and 

not actually drive costs to the system, either at the State or Federal level, over time. 

Also, some States are going pretty boldly in focusing on populations with serious mental illness or focusing on different populations, so we also believe we will have a variety of approaches 

that, again, allows us to get a good sense of what things we might 

want to take to even broader populations. 

Senator CARDIN. Do you have a good analysis as to why the dualeligible population, on a per-person basis, is more expensive in 

their needs than the general Medicare population? 

Ms. BELLA. We do. I mean, there are many factors that contribute to that. Part of it is the complexity, the number of conditions, the prevalence of mental illness, the number of medications 

that they take, their lower socioeconomic status. There are higher 

levels of cognitive impairment. We have a higher proportion of racial and ethnic minority populations served. We have a fair amount 

of that, and I would be happy to provide follow-up. 

Senator CARDIN. And that is consistent with some of the information that I have reviewed and my staff has provided to me. 

It seems to me that, if we are going to take bold steps forward, 

these are the type of issues we have to address: the racial disparities, the poverty issues, socioeconomic issues, the mental health 

issues. If we are going to make significant progress on the dualeligibles, we have to understand the reason why we have higher 

cost issues and then have programs that aggressively deal with it. 

So it is not just the delivery model, it is dealing with how we are 

going to overcome those type of disparities we have had in the past. 

Ms. BELLA. Yes. 

Senator CARDIN. Are you doing that? 

Ms. BELLA. Yes. Part of what we are doing is a lot of analysis 

to drill down on all the factors that are driving the cost to understand the subsets of the population and use that to inform our 

16 

work to design new care models and delivery systems that address 

the gaps and the care opportunities specific to sub-populations. 

Senator CARDIN. So the Affordable Care Act provided for the Office of Minority Health and Health Disparities, as well as a center 

within NIH. Are you working with them to deal with the fact that 

the dual-eligibles are a higher proportion of minorities? Are you 

working in that regard? 

Ms. BELLA. We are working with them. We will be requiring our 

States to help us understand how their demonstrations will feed 

into the disparities targets that we have set at the Federal level, 

and as an agency. 

Senator CARDIN. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator Carper? 

Senator CARPER. Thanks. Do you pronounce your last name 

Bella? 

Ms. BELLA. Bella. 

Senator CARPER. Like Bella Abzug? 

Ms. BELLA. Like what? [Laughter.] 

Senator CARPER. Former Congresswoman. 

Ms. BELLA. Oh. 

Senator CARPER. All right. 

I want to ask a question about PACE, if I could. If somebody just 

dropped out of the sky, they had no idea what this PACE program 

was about, just knew nothing, how would you explain it very simply so they could actually understand it? 

Ms. BELLA. With the PACE program, someone who has very serious needs and is very frail would be able to get their needs met 

through the PACE program by going to a certain side of care for 

their medical and social needs. 

Senator CARPER. All right. 

I am told, and you have talked a little bit about this, that the 

PACE program contains some difficult age, health, geographic, and 

investment requirements that will often discourage patients and 

health care providers from participating in the program. My staff 

tells me there are just barely 20,000 people, I think, nationally who 

participate in the PACE programs. The potential for actually getting a better result for less money, or a better result for the same 

amount of money, is actually pretty good, but that is not many people to be participating. 

In your view of the PACE program, what have you learned about 

the program’s effectiveness in improving health care outcomes and 

reducing costs? Would you just please share with us your recommendations for how to improve the PACE program and how it 

may overhaul the eligibility requirements to encourage more patients and more providers to participate in the program? 

As you prepare to answer that question, one of the things I have 

focused on is how to get better results for less money. Dr. Alan 

Blinder, former Vice Chairman of the Federal Reserve, sat right 

where you are sitting a couple of months ago on a panel on deficit 

reduction. He said unless we do something to reign in health care, 

the growth in health care costs, we are doomed as a Nation on the 

deficit side. 

17 

So I asked him later in the Q&A, so what should we do about 

those health care costs, Dr. Blinder? He said, ‘‘I am not an expert 

on this stuff. All I know is, find out what works, and do more of 

that.’’ That is what he said: ‘‘Find out what works, and do more of 

that.’’ I wonder if PACE could be one of those things where, if we 

find out what works, we could do more of that. But how do we do 

more of this? 

Ms. BELLA. Sure. Great questions. So the PACE program, as it 

is currently structured—— 

Senator CARPER. Do you think this committee probably asks 

more great questions than most committees you go before? [Laughter.] 

Ms. BELLA. No. I think, though, that—— 

The CHAIRMAN. I was going to say, that is my impression. I have 

never heard a witness—— 

Ms. BELLA. Oh, you do not understand. This is my favorite subject in the whole world, so all the questions, I love them. I am a 

bit obsessed with the topic, so I love them all. 

The PACE program, as it is currently designed, is for a very frail 

population, as you allude to. But the care model is also geared toward a very frail population, so when we make changes in the eligibility standards, for example, we just need to look at how we 

might make changes in the care model, in the financing of all that, 

just to make sure that is all aligned. 

So, for example, if we brought in the eligibility standards, we 

may want to change a little bit about how we pay for it and how 

the teams are structured, because you do not want to pay at the 

same level for such a complex population. So, bearing all those 

things in mind, there is great interest in a couple of things, the 

first, I would say, being dropping the eligibility age, so now you 

have to be 55 or older. There has been a lot of talk about, should 

we make that available to a younger population that has disabilities, for example? Again, thinking through that, it is worth considering as long as we think about, are there other changes we would 

make to the care model, for example? 

As far as the providers go, again, some flexibilities that have 

been brought to our office have to do with kind of relaxing a little 

bit the need to have all the services provided right there. One of 

the issues is whether a patient can continue the relationship with 

the current provider. So we are trying to figure out, how do you 

take the PACE concept and allow it to work with some community 

contract providers, for example, without violating the integrity of 

the model? 

So, is it something that works? Yes, it works very well for this 

population. As we look at changing the composition of the population, we would have to look at, how do we make it work to broaden it and make it scaleable? Those are things that are appropriate 

for our office to do, and things that we are doing with the National 

PACE Association through its recommendations, as well as with 

our colleagues in CMS. 

Senator CARPER. That was a good answer. [Laughter.] 

Ms. BELLA. Thank you. 

Senator CARPER. All right. Let us talk about one more last, quick 

question. I think the Simpson-Bowles Deficit Reduction CommisVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
18 

sion recommended, among other things, a policy that would include 

all dual-eligibles enrolling in Medicaid managed care. Even though 

some States currently do not have any Medicaid managed care operations, Delaware is one that does. Many States are planning to 

move their managed care beneficiaries into managed care programs 

as a way to get better results for less money. 

Here is my question: is the increased use of Medicare managed 

care programs for dual-eligibles an effective way of providing 

health care services at a lower cost, and how could the States and 

the Federal government work together to ensure that Medicaid 

managed care programs deliver high-quality and coordinated 

health care services to dual-eligibles? 

Ms. BELLA. So, just as we think PACE is a viable option, we 

think managed care is a viable option. We also know that there are 

States that do not have managed care, so they need options as well. 

The important thing, I think, in your question is that the entity 

that is providing the services has the responsibility and the accountability for both Medicaid and Medicare, and that is what is 

important about the proposals we are putting forward. 

So the managed care approach we are putting forward combines 

both Medicaid and Medicare in ways that you would not get the 

benefits of that integration if we focused on a proposal that only 

advocates Medicaid managed care, for example, or Medicare managed care. Importantly, though, there will be States that will not 

have managed care for any number of reasons, and that is why we 

have put forward also a managed fee-for-service alternative, again, 

because we need duals in those States to also be in more integrated 

systems for all the reasons we have discussed: quality, cost, all 

those things. 

Senator CARPER. All right. Thank you very much. 

The CHAIRMAN. Thank you, Senator. 

I think to some degree, when a lot of us think about this problem, at least I do, it seems like the whole thing is inherently unstable. We have Medicaid, we have Medicare, totally different payment systems, totally different structures, totally different culture. 

We are trying to fit a round peg in a square hole to some degree. 

If you had a magic wand and you could enact anything you wanted—you know a lot about this problem. I mean, thinking big, there 

are no constraints on you, what would you do? Would you follow 

the VA model? Would you abolish all this stuff and set up a third 

category of elderly poor and a third totally separate pool? What 

would you do? Forget about statutes needing to be changed. Forget 

about anything else. What makes sense? 

We are all kind of frustrated that we have been at this for a long 

time. There has been some progress, but it is costly, it is inefficient 

in care, people just are not getting the care that they really should 

get, is my understanding. I am asking the question a little bit at 

length so you can think. [Laughter.] 

So you can come up with whatever you want to come up with. 

But this is Melanie Bella, and I can do whatever I want to do. 

Ms. BELLA. And anything I say does not leave the room, right? 

The CHAIRMAN. I am sorry? 

Ms. BELLA. Nothing I say leaves the room. 

19 

The CHAIRMAN. Nothing you say. Just carte blanche. Just, what 

should we do here? 

Ms. BELLA. So, fundamentally, the problems are, there is no— 

again, I will use myself as an example. Pretend I am a dualeligible. I have a separate prescription drug plan, I have separate 

Medicare and separate Medicaid. Nobody is responsible for making 

sure I have what I need in the most cost-effective and the leastrestrictive setting, so the first principle has to be, we have to have 

all the services together and some type of accountability for the 

services. 

The second principle has to be, we have to figure out a way that, 

regardless if we shifted out of the Federal government or shifted 

out of the State government, it is hard for me to believe, even with 

a magic wand, we would ever let one or the other off the hook from 

a payment perspective. So we have to figure out how we get the 

funding aligned as you figure out how you might develop a new 

system. 

So I do not have an answer for you. I know what the system has 

to have in it, and it is those two characteristics. There are different 

ways that we could design it depending on various other opportunities or constraints as work proceeds, both with our office and I 

know with the super committee and the various other efforts under 

way. 

The CHAIRMAN. All right. Well, let us not throw a bomb in all 

this. Let us keep to the system we have. How can we help you 

move more quickly, more efficiently to accomplish the things you 

are trying to accomplish? What can we do to help you? 

Ms. BELLA. Well, you have made a great—— 

The CHAIRMAN. Should we give you quantifiable goals, or should 

you come up with those goals and tell us what they should be? Do 

you want us to just harangue you? What works? 

Ms. BELLA. We can commit to—we have a pretty good set of 

goals, and we want to hold ourselves accountable for this, and we 

certainly will continue to do so with this committee and your colleagues. You have done a great thing by creating this office, and 

I think what we need to do right now is, we need a little bit more 

time to finish some of the exercises we are going through, looking 

at the data and the alignment and then the models and demonstrations. 

Really, what we would like is to be able to continue to, I think, 

have a dialogue on an ongoing basis about what we are learning 

and changes that we might be able to make along the way. The 

Secretary will be providing an annual report to you. We have done 

one; we will do this annually. Each time that we uncover potential 

statutory needs or recommendations, those will be included. 

So I feel like we have a good vehicle for communicating with you. 

What we are trying to do right now is be able to put some activities 

in place that allow us to come back with very concrete and informed responses to your question about, how can you continue to 

help us even more as we evolve? 

The CHAIRMAN. So, when is the next sort of decision point? When 

is the next sort of benchmark as you look down the road in the 

next several months? That is, a time when we can come back and 

talk again. 

20 

Ms. BELLA. Well, I do not think you will want to talk to me this 

close, but October 1st is a big date for us. All the States that are 

interested in doing one of our financial alignment demonstrations 

submit a letter of intent by that date, so we will have a very good 

idea of take-up and the number of beneficiaries that we could perhaps begin testing in these models. By the end of the year we will 

have a pretty good sense of when the start date for those will be. 

I think early 2012, we would have a very good update on where 

we are with our alignment initiative, with our data efforts, and we 

would have a much better picture of the States that we will be 

working with and the number of beneficiaries they hope to serve 

in these new models. 

The CHAIRMAN. So what would you like to accomplish by early 

2012? 

Ms. BELLA. I would love to have a large number of States that 

are going forward with us in one of these payment models that gets 

us close to the 1 to 2 million beneficiaries range. We would like to 

have the majority of our analytic work undertaken so that we can 

talk to you about some of the subpopulation analysis and answer 

questions like Senator Grassley is asking. We would like to have 

recommendations. 

We would have, again, presented a second annual report to Congress by that time, and we would have an update for you on some 

of the areas that have a greater opportunity for alignment, and 

which of those things we have been able to tackle administratively 

or through regulation and which things would require statute. 

The CHAIRMAN. All right. Well, why do we not do that? Why do 

we not get together sometime in 2012? 

Ms. BELLA. All right. 

The CHAIRMAN. We will have a follow-up hearing to just see what 

we have accomplished, how we can help, the areas where we have 

slipped a little bit. Maybe we will be surprised because you have 

gone a lot further than we expected. 

Ms. BELLA. I will hope to surprise you, yes. 

The CHAIRMAN. All right. 

Senator Wyden? 

Senator WYDEN. Thank you, Mr. Chairman. 

Just one other question if I could, Ms. Bella. On page 8 of your 

testimony you say, ‘‘Access to Medicare data is an essential tool for 

States seeking to coordinate care, improve quality, and control 

costs for their highest-cost beneficiaries.’’ Senator Grassley and I 

have introduced a bill to make that Medicare data available to the 

public. Would that not be helpful as well here for families and others to have that kind of data as we try to work to get that 1 to 

2 million population served as quickly as possible? 

Ms. BELLA. Certainly we know there is great interest in getting 

access to these data. Those data are at the beneficiary level, so it 

is pretty personal. 

Senator WYDEN. Well, all of this, and all the reform proposals, 

take everybody’s name, ID, any of that sort of thing off. 

Ms. BELLA. Exactly. This does not though, because it is beneficiary-level so that it can get in the hands of providers and care 

managers to truly be used to develop their care plans and help 

them do navigation. So I certainly understand the interest in takVerDate Nov 24 2008 17:52 Dec 10, 2012 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 R:\DOCS\76505.000 TIMD
21 

ing aggregate data and getting it out in the hands of folks who can 

use it to help make sure people are getting better care. I just would 

say the distinction in what is in the testimony and what we are 

giving to States is beneficiary-level for the very purpose of being 

used for specific care coordination programs. 

Senator WYDEN. Well, I will send you the bill, and, for the 

record, I would like a written response, because I think it is exactly 

the same thing. I mean, your point about making sure that it is 

bullet-proof in terms of protecting the privacy of patients and individuals is spot-on. I think Senator Grassley has had a longstanding 

interest in this, and I have done that. So I would like your response for the record because, if this data is useful to the States, 

it seems to me it ought to be available to the public because it goes 

right to the point that you are saying: this kind of data can help 

coordinate care, improve quality, and control the costs. So, if you 

would respond in writing, that would be great. 

Thank you, Mr. Chairman. 

[The information appears in the appendix on p. 56.] 

The CHAIRMAN. Thank you, Senator. 

Thanks, Ms. Bella. I really appreciate your very hard work. You 

are clearly dedicated. I would just urge you to obviously keep at it. 

If you need help from this committee, just let us know. 

Ms. BELLA. All right. Thank you very much. 

The CHAIRMAN. It is all teamwork. Thank you. 

Ms. BELLA. Thank you. 

The CHAIRMAN. The hearing is adjourned. 

[Whereupon, at 11:15 a.m., the hearing was concluded.] 

(23) 

A P P E N D I X 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD


76505001.eps
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76505.002
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76505.003
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76505.004
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76505.005
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76505.006
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76505.031
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76505032.eps
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76505.036
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76505.037
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76505.039
(63) 

COMMUNICATIONS


76505040.eps
64 


76505.041
65 


76505.042
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76505.043
67 


76505.044
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76505.045
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76505.046
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76505.047
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76505.048
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76505.049
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76505.050
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76505.051
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76505.052
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76505.053
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76505.054
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76505.055
79 

Æ 


76505056.eps