The closer the startup of the first CMS-funded demonstration program for Medicare-Medicaid dual eligibles gets, the more one basic fact becomes clear: This stuff is hard! The latest indication of how hard occurred when three of the six health plans selected for Massachusetts’ duals demo, which is slated to go live Oct. 1 as the first capitated CMS-backed initiative to do so, withdrew from the demo after the Medicare capitation rates finally were released last month.
The dropouts — a Blue Cross Blue Shield of Massachusetts joint venture with ValueOptions, Boston Medical Center HealthNet Plan and Neighborhood Health Plan — are not small or unsophisticated players. Neither is Magellan Health Services Inc., which decided to sell its 49% stake in Fallon Total Care, one of the plans that’s staying in the demo, to its partner because “the rates offered were not sufficient to generate a return,” Magellan CEO Barry Smith said in the firm’s second-quarter earnings call with investors July 25. Yet all these firms sound sincere when they praise the CMS Medicare-Medicaid Coordination Office’s efforts to make these demos workable — which it looks like they may be, albeit in a smaller and slower way than originally conceived.
What then are the problems? Well, start with trying to coordinate Medicare and Medicaid, two programs that long ago developed their own ways of doing things and didn’t show any interest in working together. Then add, especially in Massachusetts, the clout of big provider systems needed for the demo and and their unwillingness to commit to accepting plan payment rates that perhaps had to be low based on Medicare’s resources for the program. And put on top of this the tremendous needs of the duals, a population that has a high incidence of mental as well as physical illness and needs a host of supplemental benefits in addition to basic medical care.
So what do you think will happen with these duals demos? Will more big plans drop out in the other four approved capitated states before those demos start up in 2014? Or will the fact that states such as California have more infrastructure and experience in dealing with low payment rates for extremely vulnerable populations — as Health Net, Inc. President and CEO Jay Gellert suggested in his firm’s earnings call July 25 — enable them to go ahead without withdrawals? Since everybody seems to agree that CMS integrated care demos “are the right thing to do,” will right make might?
http://aishealth.com/blog/medicare-advantage-and-part-d/triple-trouble-mass-duals-demo-why-three-plans-pulled-out
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