Patrick Administration Readying Plan To Link Medicare, Medicaid Services

Describing a “fragmented” system of care for the 115,000 Bay State residents eligible for both Medicaid and Medicare, Massachusetts' top Medicaid official said Wednesday that the Patrick administration is preparing to unveil a plan for a new system of services that could save millions of dollars and chip away at an issue that is vexing policymakers across the country.

“I think the important point to make is, there are a set of Medicaid services and there are a set of Medicare services. That is the status quo,” said Julian Harris, director of the state’s Medicaid Office, known as MassHealth. “There is no coordination across those services.”

“We’re going to add some additional services … because we have a belief that those additional services will improve the quality of care and actually help to save money,” he added. “I think people will be very excited to have access to a model that includes additional services and includes access to better coordination of services that already exist.”

Harris said Medicare and Medicaid were established in 1965 with little expectation that Americans would someday seek to access both programs simultaneously. Residents eligible to access Medicare and Medicaid – known as “dual eligibles” – are between the ages of 21 and 64. Most suffer from behavioral health disorders, while others experience chronic physical conditions or have developmental disabilities, and in some cases they fall into multiple categories. Cutting costs for dual eligibles has become a focal point of efforts to curb soaring health care costs around the country.

Harris said he envisioned moving many of the 115,000 dual eligibles to a new plan by January 2013.

Although Patrick administration officials say their proposal has been well-received by advocates clued in on the broad framework, some opposition has formed over a proposal to “passively enroll” all 115,000 eligible residents in the new program, requiring them to actively opt-out in order to maintain their current health plan. Critics of the plan also say they’re worried that residents will lose access to community-based care, although administration officials have waved off that argument.

Massachusetts was one of 16 states in April to receive a $1 million grant from the Obama administration to design a new plan to care for dual eligibles, funding authorized by the 2009 health care law signed by President Obama. Using that grant, the state will seek proposals from health care providers to design a new offering for dual eligibles – called an integrated care organization – that will make use of available Medicare and Medicaid services, and offer additional services not covered by either program. Harris said the state envisions proposals will include options for patients to access community-based care.

Harris described the Patrick administration’s efforts as an attempt to eliminate waste of health care dollars because of a lack of coordination between the two programs. For example, he said, Medicare isn’t authorized to repair a broken wheelchair and may simply order a new one when requested by a patient, whereas on Medicaid, some wheelchair repairs are accessible. In another example, he said, a patient who has both bipolar disorder and diabetes may miss an insulin injection during a bout of depression or mania and end up in the emergency room.

“If that member had had access to a community health worker … they would actually have avoided that ER visit,” he said. “Neither Medicaid or Medicare actually pay for community care workers.”

But Al Norman, executive director of Mass Home Care, argued that the administration has taken too heavy-handed an approach by requiring participants to actively opt out, rather than to voluntarily join an integrated care organization.

“They’re using terms like voluntary opt-out, which is bureaucratic babble,” he said. “It’s like being put in a plan that you didn’t choose and you have to get yourself out. This is not the best way to go. For an actuarial plan, that might make a lot of sense. We’re not developing plans for actuaries. We’re developing plans for poor people … Many of them are not sophisticated health care consumers.”

Norman contended that there is no assurance that integrated care organizations will feature an “independent” adviser to patients to ensure they are getting only needed care, rather than a care coordinator who is “owned by the health network.” He added that he expects that only large networks will apply to form integrated care organizations, calling a reassurance by Harris about community-based options for patients a “meaningless statement.”