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Investment in Integration for the Dual Eligibles Pays Off

By Andrea Maresca, Director of Federal Policy and Strategy

For too long, many individuals dually eligible for both Medicare and Medicaid, and the providers and plans who serve them, have been forced to cobble together services from disparate and complex health care delivery systems. Policymakers have hypothesized for decades that better integration of Medicare and Medicaid services could help improve health outcomes for people enrolled in both programs.

One of the earliest attempts to test the integration hypothesis can be traced back to 1997 when the Centers for Medicare and Medicaid Services worked with the State of Minnesota to start a pilot program called Minnesota Senior Health Options (MSHO). MSHO was created with the goal of better serving dually eligible beneficiaries age 65 and older. MSHO health plans coordinate Medicare and Medicaid benefits their members receive.

In 2013, Minnesota and CMS agreed to build on the state’s long history and experience of working towards integration. The agreement was led at the federal level by the Medicare and Medicaid Coordination Office. The next generation of the MSHO platform was designed to:

  • Enhance integration of services for Medicare-Medicaid beneficiaries in new provider payment models;
  • Clarify and simplify information and processes for beneficiaries and their families related to Medicare and Medicaid coverage;
  • Better align oversight of MSHO plans by the state and CMS; and
  • Improve administrative efficiencies for the MSHO plans and government agencies that serve MSHO enrollees.

On June 16, the Department of Health and Human Services (HHS) published a report about the MSHO program, which documents forward progress for MSHO enrollees. In large part this is due to the decades of commitment and innovative strategies advanced by the state and federal agencies and their partners on the ground. A key feature of the MSHO program is that members are assigned a care coordinator who helps them with of their Medicare-funded and Medicaid-funded services, including elderly waiver services and up to 180 days of nursing home care.

The HHS report compared the experiences of similar beneficiaries inside and outside of MSHO and found that MSHO enrollees were:

  • 48 percent less likely to have a hospital stay, and those who were hospitalized had 26 percent fewer stays;
  • 6 percent less likely to have an outpatient emergency department visit, and those who did visit an emergency department had 38 percent fewer visits;
  • 2.7 times more likely to have a primary care physician visit, but those who did visit their physician had 36 percent fewer visits; and
  • 13 percent more likely to receive home and community-based long term care services and no more likely to have a long-term nursing home admission.

This is without a doubt good news for Minnesota’s beneficiaries.

Likewise, for policymakers and stakeholders, this report shows us one model which can deliver effective care for those with the greatest need and highest cost. It shows more effective programs and rules are possible while still protecting the most vulnerable subset of Medicare-Medicaid dual eligible beneficiaries.

HHS’ researchers conclude that additional initiatives that use fully integrated care models similar to the MSHO program may have merit for other states. This conclusion deserves serious attention.

We – states, federal policymakers, providers and advocates – should amplify the learnings from this model. However, in order to scale effective care delivery transformation across the country, we must also be willing to adapt the model to the unique health care landscape in states.

Scaling this type of effort will not happen overnight. It will not happen in three or four or even five years. And it is not likely to look exactly like MHSO – a program that was designed and is continuing to evolve to reflect the unique culture and provider landscape in one state.

Make no mistake, there are important lessons to carry forward for the next wave of states that wish to strengthen integration and coordination for dually eligible individuals. And we intend to prioritize advocacy for federal policies which support these integration efforts, like Minnesota’s, and simplify the pathways to extend these improvements for more dually eligible individuals.

NAMD looks forward to sharing Minnesota’s experience with other states and federal policymakers.

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