Medicare Commission Raises Questions about Care Coordination

Before I comment on the latest MedPAC report....

Thursday's big news from the Supreme Court continues to elicit commentary from health care, legal and political analysts. For what it's worth, I found Justice Robert's opinion to be in perfect harmony with what I learned in law school: if the Supreme Court can find a way (any way) to find that an act of Congress is constitutional, then it is incumbent upon the court to do so. The application of this principal is aparent in the Chief Justice's majority opinion where he wrote:

“The Affordable Care Act is constitutional in part and unconstitutional in part. The individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause. That Clause authorizes Congress to regulate interstate commerce, not to order individuals to engage it. In this case, however, it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance. Such legislation is within Congress’s power to tax.”

Moving on...

MedPAC, the independent Congressional commission established to advise the U.S. Congress on issues affecting the Medicare program, issued its annual report on June 15, evaluating Medicare payment issues and making recommendations to Congress. Contained within its 237 pages is the Commission’s examination of several issues central the experience of Medicare enrollees. Consistent readers of this blog will not be surprised by my focus on those portions of the report pertaining to improving care coordination for beneficiaries dually-eligible for both Medicare and Medicaid services.

It is the hope of the administrators in both Baltimore, Maryland (home of CMS) and Springfield, Illinois (home of Illinois Department of Health and Family Services - HFS) that the implementation of integrated care will improve care and reduce costs for the dual-eligible (Medicare and Medicaid enrollees) population . Keep in mind, that approximately 340,000 Illinois residents (3 percent of the state's population) are dual-eligible beneficiaries and as a percentage of population, it is identical to the national percentage. On average, these dual-eligible beneficiaries have greater health and long term services and supports (LTSS) needs than beneficiaries who have only Medicare or Medicaid coverage, due to greater prevalence of chronic conditions (e.g. CHF, COPD, Diabetes, Heart Disease, etc.) in this population.

In its report, the Commission raises several questions regarding the demonstration projects currently being funded by the CMS in collaboration with the states to promote the development of integrated care for dual-eligibles. The demonstrations are expected to last three years and are approved for 15 states. Although the Commission supports the goals of the demonstrations, it does raise concerns about whether the demonstrations could negatively effect dual-eligible beneficiaries' access to quality care. Concerns include:

  • Is the scale of the demonstration in some states too large and actually represents a large-scale program change rather than a demonstration?
  • Will there be an orderly process for disenrollment if the demonstration fails?
  • Are there health plans present in every demonstration state with the requisite experience and capacity to handle the large scale demonstration?

Reading the report, one senses the Commission's exasperation with the demonstration projects' lack of clarity relating to enrollment, provider capacity and evaluation criteria. Although Illinois currently does not have an integrated Medicare and Medicaid program, it is the intention of HFS to move to this model and the concerns raised by the Commission should serve as a guide for Illinois policy-makers, regulators and legislators as Illinois moves towards integrating care for dual-eligible beneficiaries. What do you think?

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    Bruce Lederman has over 25 years experience in the senior care field as a direct care provider and thought leader. Bruce was CEO and president of his own firm that operated skilled nursing facilities in Illinois. He is a former nursing home administrator and has consulted to numerous elder care providers on planning for strategic growth as well as process improvement. Recently he served as board chair of CJE SeniorLife, a leading non-profit elder care provider in the Chicago area. Bruce is currently employed as chief strategy officer for a company providing skilled nursing services in communities throughout Illinois and Missouri.

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