Understanding Care Coordination Experiences in a State Medicare-Medicaid Financial Alignment Demonstration

By Craver, Gerald A.; Gimm, Gilbert et al. | Journal of Health and Human Services Administration, Fall 2018 | Go to article overview

Understanding Care Coordination Experiences in a State Medicare-Medicaid Financial Alignment Demonstration


Craver, Gerald A., Gimm, Gilbert, Hill, Katherine E. Vatalaro, Journal of Health and Human Services Administration


INTRODUCTION

In the United States, over 10 million low-income seniors and individuals with disabilities are eligible for Medicare and Medicaid benefits (Medicare Payment Advisory Commission and Medicaid and CHIP Payment Access Commission [MACPAC], 2018a). Known as dual eligibles, these individuals represent some of the nation's sickest and poorest citizens, accounting for over $300 billion in U.S. healthcare spending annually (Doll, Hellkamp, Goyal, Sutton, Peterson, & Wang, 2016). Most have a complex array of health and long term service and support (LTSS) needs requiring services from different providers, and face a host of social and environmental barriers that limit their ability to access timely services and follow treatment regimens (Fox & Reichard, 2013; Gimm, Blodgett, & Zanwar, 2016; Ortega, 2016). The care they receive is often poorly coordinated, being provided mostly through the fee-for-service (FFS) Medicare and Medicaid programs (Grabowski, 2012). The lack of coordination is further complicated because these programs operate independently, resulting in conflicting coverage and payment policies, fragmented service delivery, and provider cost shifting (Medicare Payment Advisory Commission [MedPac], 2016). This environment promotes unnecessarily high costs and poor quality of care for many dual eligibles (Centers for Medicare and Medicaid Services [CMS], 2011).

Policymakers have considered various strategies to improve care for this population. One example authorized under the Affordable Care Act and administered by the Centers for Medicare and Medicaid Services (CMS) is the Medicare-Medicaid Financial Alignment Initiative, which is testing two state-level payment and service delivery models: a capitated managed care payment model and a managed FFS model. Under the first model, CMS and ten states, including Virginia, contracted with 61 health plans to coordinate care for approximately 372,000 dual eligible beneficiaries. Under the second model, two states used their existing FFS healthcare delivery infrastructures to provide care coordination for about 47,000 beneficiaries. The demonstrations, which are scheduled to end by December 2020, represent one of the largest initiatives CMS has ever undertaken to improve care for dual eligibles (CMS, 2011; MedPac, 2016).

CMS contracted with RTI International to conduct a national evaluation of the financial alignment demonstrations. (States and other organizations could still conduct their own evaluations.) The national evaluation included site visits to states, interviews with program staff and advocates, focus groups with beneficiaries, and analyses of utilization and cost outcomes (Walsh et al., 2013). The final evaluation is not due until after 2020; however, preliminary evaluations suggest that while all demonstrations were implemented successfully, challenges were encountered, such as difficulty communicating with beneficiaries, educating providers about the demonstrations, and coordinating healthcare across different settings (Summer & Hoadley, 2015; Chepaitis et al., 2015; Rollins, 2016; MedPac, 2016).

These previous studies provided an overview of the financial alignment demonstrations, but did not include detailed information from individual beneficiaries, care coordinators, or providers. Therefore, the purpose of the present study was to examine how these individuals experienced care coordination in one state financial alignment demonstration by using qualitative data collected over 27 months of fieldwork. The study describes how beneficiaries, coordinators, and providers viewed and adjusted to a demonstration, while interacting to improve beneficiairy healthcare quality. By providing insights that can be used to improve upon or design similar coordinated or integrated care delivery systems for complex populations, this study has immediate relevance for both public health policy and practice.

COMMONWEALTH COORDINATED CARE PROGRAM

On March 1, 2014, Virginia implemented its financial alignment demonstration, the Commonwealth Coordinated Care (CCC) Program, for beneficiaries aged 21 and older who received full Medicare and Medicaid benefits. …

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