Dual-eligible demos raise patient-access concerns

Washington Members of an advisory board that recommends Medicare policy to Congress worry that patients could face access-to-care problems as a result of demonstration projects planned for poor, disabled beneficiaries who qualify for both Medicare and Medicaid.

The Medicare Payment Advisory Commission held an April 5 hearing to discuss the Centers for Medicare & Medicaid Services’ plans to test new care models for dual eligibles in about a dozen states. Up to 2 million beneficiaries could be moved into these demonstration projects during the next couple of years, said MedPAC analyst Christine Aguiar, MPH. Some individuals automatically would be enrolled into capitated or managed care models depending on the state, but beneficiaries would be given options to leave the experiments.

Some MedPAC commissioners said they were uncomfortable with the idea of using “passive enrollment” to force patients to participate in the demos.

The overall project appears to go beyond the scope of a traditional demonstration, as large segments of the dual-eligible population would be moved into managed care systems, said Herb Kuhn, a MedPAC commissioner who is president and CEO of the Missouri Hospital Assn. and a former CMS deputy administrator. Programs appear to be financially oriented endeavors for a vulnerable and costly patient population, Kuhn said. He expressed concerns for patients’ rights, including the ability of beneficiaries to move back to their prior coverage when they are dissatisfied with new managed care plans.

Shifting patients off current coverage plans could be very difficult, said Commissioner Thomas Dean, MD. He is chief of staff at Avera Weskota Memorial Medical Center in Wessington, S.D. Relationships and understandings achieved between patients and health professionals should be considered before shifting patients out of current care models. Patients must be matched with a range of services to meet their needs, he said. “Some are complex patients, and you can’t just move them.”

Others defended the concept of being more aggressive about moving beneficiaries into patient-centered care models, saying the dual-eligible population is not well served by the current system.

There are 9 million low-income seniors and individuals with disabilities who qualify for both Medicare and Medicaid coverage. In 2008, dual eligibles comprised 20% of the Medicare population and 30% of the programs’ spending, according to an April report by the Kaiser Family Foundation. Dual eligibles were 15% of the Medicaid beneficiary population, but represented 39% of Medicaid spending that year.

Studies have pointed to the nation’s fractured health care system as a cause for higher spending among the dual-eligible population. The Kaiser Family Foundation report notes that dual eligibles have higher hospitalization rates and often are in poorer health than others on Medicare.

“The status quo is not good for many of these patients,” said MedPAC Chair Glenn Hackbarth. “The fee-for-service payment system is especially problematic for patients who need sophisticated care coordination.”

The American Medical Association also weighed in on the planned demonstration projects.

“The AMA believes that coordination is critical for patients eligible for both the Medicare and Medicaid programs, and CMS’ proposal for states to participate in demos related to these dual-eligible patients will help to provide some flexibility and allow for the innovation needed to achieve this coordination,” said AMA President Peter W. Carmel, MD. “We share the concerns discussed at the MedPAC meeting and will closely monitor CMS’ demos to ensure the best results for Medicare and Medicaid patients and physicians.”