Abstract
Increasingly, states rely on Managed Care Organizations (MCOs) to integrate healthcare for dual eligibles. Barriers remain, especially when integrating non-medical long-term services and supports (LTSS). In California, the most effective Cal MediConnect plans were those using innovative ways to collaborate with LTSS providers and agencies providing LTSS to people with complex care needs. MCOs must recognize disability as not just a medical issue, but also a social environment issue. Coordinating care means conducting person-centered assessments that address social determinants of health and meet LTSS needs. Medicare Advantage and other HMOs can now provide non-medical services, giving plans flexibility.
Key Words:
Managed Care Organizations, Cal MediConnect, Medicare Advantage, long-term services and supports
In 2014, California was one of thirteen states to implement a CMS Dual Financial Alignment Demonstration (Kaiser Family Foundation, 2017). The intent was to integrate Medicaid (called Medi-Cal in California) and Medicare benefits using a managed care delivery system. To do this, California leveraged its existing Medi-Cal managed care plans in seven counties to create new “duals” plans called “Cal MediConnect” (CMC) (California Department of Health Care Services, n.d. [a]).
A key feature of the demonstration was that the plans were required to provide care coordination. The University of California conducted an evaluation of the demonstration, which included focus groups with Cal MediConnect members, a randomized telephone survey comparing duals who were CMC members and those who were not, and key informant interviews with stakeholders who were involved in implementing the program (including representatives of CMC plans, providers, and advocates). One primary focus of the evaluation was to assess the effectiveness, successes, and barriers of using managed care to coordinate care for duals. This article reviews those findings and discusses lessons learned and implications for using managed care to coordinate care for duals in the future.
Background
More than 12.2 million older adults and adults with significant disabilities in the United States are eligible for both Medicaid and Medicare (Centers for Medicare & Medicaid Services [CMS], 2020). Most healthcare professionals refer to these beneficiaries as “duals.” The majority (60 percent) of duals are ages 65 or older (MedPAC/MACPAC, 2018) and many have chronic diseases or disabilities. More than half (56 percent) have at least one limitation with Activities of Daily Living (ADLs), while almost a third (30 percent) have three to six ADL limitations.
Duals often are profoundly poor, typically making less than $2,349 a month. Thus, many duals struggle with access to adequate food, affordable medications, and adequate housing. In sum, a large portion of this population will not only have complex care needs, but also need significant non-medical long-term services and supports they will struggle to afford out of pocket (LTSS) (CMS, 2014).
Navigating services from two insurance plans and an assortment of LTSS providers can be very complicated, even for the most healthcare-savvy people. Navigating care can be especially difficult for duals who, more than any other Medicare group, have the lowest education levels, with 51 percent having only a high school education and 28 percent of them living alone. More and more states are turning to managed care delivery systems to integrate and coordinate care for duals. Between 2011 and 2019, the number of duals who were enrolled in integrated programs increased from 161,777 to more than a million. (CMS Medicare-Medicaid Coordination Office, 2019).
Care Coordination through Cal MediConnect
Cal MediConnect plans were required to provide care coordination to members, including coordination of Medicare and Medi-Cal benefits, behavioral health, and LTSS (including institutional skilled nursing and rehabilitation), In-Home Supportive Services (IHSS—California’s Medi-Cal personal care assistance program), and Adult Day Health Care. To begin providing care coordination to this high needs population, some CMC plans created new in-house care-coordination units, and others hired outside entities such as Management Service Organizations to whom they delegated responsibility for care coordination.
Care Coordination Processes: Risk Stratification, Assessments, Care Plans, and Care Teams
Care coordination through Cal MediConnect included a process for risk stratification, health risk assessments, and ongoing care management (Graham et al., 2017a). The first step was risk stratification. Prior to beneficiaries being auto-enrolled, the plans were given Medicare and Medicaid data to analyze and subsequently categorize all new members as high- or low-risk. Members who were defined as “high-risk” had a serious health condition or used more than 195 hours of IHSS hours per month. High-risk members were required to be contacted for a Health Risk Assessment (HRA) within 45 days of being enrolled. All other members (including those in nursing homes) were defined as “low-risk” and could be contacted by the plan for an HRA within 90 calendar days.
To conduct HRAs, plans reached out by telephone to new members at least five times. If they were unsuccessful, they mailed an HRA form to the member’s address to be self-administered. The questions asked in the HRAs varied by plan and were considered proprietary. Data from HRAs were intended to be sent by the plans or their delegated care coordination entities and to providers within ten days of completion (California Department of Health Care Services, n.d. [b]).
Data from HRAs were then used to create individualized care plans (ICPs). Many health plans, especially those with delegated care coordination to Management Service Organizations, had computer-generated ICPs that included specific answers to the HRA and suggestions for care. Plans were required to send a copy of the ICP to members and their providers.
‘Another important collaboration happened between CMC plans and the Alzheimer’s Association.’
When completed HRA identified complex care needs, CMC plans had to bring together interdisciplinary care teams (ICTs). Select medical care providers or care coordinators from other agencies were invited to be a part of the ICTs. For example, if a member used IHSS, CMC plans were required to include the IHSS social worker in all ICT meetings. The ICT meetings varied in structure and duration, with some regularly scheduled at intervals to check on the progress of members’ care; while others were impromptu conference calls to address urgent problems.
CMC plans were required to reassess members annually, and more often for those who were “high-risk.” Additionally, a CMC member could call the member services number at any time to be transferred to the CMC care coordination service to get assistance.
Successes of Cal MediConnect Care Coordination
CMC health plans, providers, and other stakeholders reported several strengths of the care coordination model in key informant interviews. Many successes involved CMC collaborating closely with organizations and agencies that were already experienced in serving duals.
Collaboration Between CMC Plans and In-Home Supportive Services
One key finding from the telephone survey was that between 2016 and 2017 CMC members reported a significant increase in average IHSS hours (Graham et al., 2018). It was speculated that this increase in hours may have been due to the state requirement that IHSS eligibility workers from county social services departments be included in ICTs.
Additionally, some CMC plans conducted specialized training for their care coordinators, who worked with IHSS recipients to help them recognize when members needed to be assessed for more personal care hours. One health plan “co-located” care coordinators in IHSS offices to improve communication. Care coordinators from CMC reported they regularly advocated for their members to be reassessed for more hours by county IHSS workers. Unfortunately, the state requirement to include IHSS social workers in ICTs was downgraded to “guidance” in the second half of the demonstration.
Collaboration Between CMC Plans and HCBS ‘Brokers’
Some CMC plans recognized that to be successful in coordinating services, they needed to collaborate with CBOs that had expertise in serving duals and, in many cases, were already serving their members. At least two CMC health plans contacted with large home- and community-based (HCBS) providers in their regions that acted as “brokers” to manage the coordination of and referral to LTSS providers.
These broker agencies would then contract with both for-profit and nonprofit agencies such as Independent Living Centers, home health, housing, or community-based senior services agencies. Many of these broker agencies had years of experience providing HCBS to duals and coordinating with large networks of community providers. They were able to more easily execute contracts with multiple HCBS providers in a way that CMC plans reported would have been cumbersome for them.
Some of the broker agencies had recent experience working as lead agencies in California’s Money Follows the Person demonstration (California Department of Health Care Services, n.d. [c]). Because of their experience, knowledge, and relationships with the local systems, broker agencies often were able to work quickly to identify and fill gaps in care for CMC members.
Collaborations with Other Agencies Serving Duals
Another successful collaborative approach was when CMC plans contracted with county Multipurpose Senior Service Programs (MSSP). MSSP is a county service focused specifically on care management for older adults at risk of nursing home placement, with the intent of helping them to avoid institutionalization. Though this was not a service that was carved into CMC, some plans contracted and paid the MSSP agency to provide their members with a “light” version of the traditional MSSP care management service (Graham et al., 2017b).
Another important collaboration happened between CMC plans and the Alzheimer’s Association. Through a grant from the California Department of Aging, care coordinators from nine CMC plans received training from the Alzheimer’s Association to improve care coordination and dementia care for their members (Cherry et al., 2018).
Finally, one CMC plan developed a successful collaboration with its regional Long Term Care Ombudsman Program (LTCOP) (Hollister et al., 2016). The LTCO program advocates for people who are institutionalized in nursing homes, a population most CMC health plans had never served prior to the demonstration. Through this partnership, LTCOP and CMC care coordinators conducted joint visits to LTC facilities to meet members in person. The LTCO would help the CMC care coordinator review residents’ charts, identify fraud, and address any complaints their member may have had. The LTCO was also able to help CMC plans identify which of their members might be willing and able to transition into the community and to ensure residents’ wishes were being honored.
Collaborations Focused on Care Transitions
In the CMC program, plans were at risk for payment to LTC facilities. This created a financial incentive to ensure members were using the lowest level of care possible. Some CMC plans created specific programs to identify and assist members who could be transitioned out of institutional LTC settings. One CMC plan worked with the HCBS broker, while another CMC health plan developed internal capacity for transitions within their care coordination program (Graham, Neri, and Bueno, 2017). Both reported successfully transitioning many members out of nursing homes to lower levels of care.
Barriers to Care Coordination for Duals in Managed
Care Care Coordination Workforce
Prior to the demonstration, most CMC plans had no history of providing care coordination to beneficiaries with complex care needs. Instead, their members had been composed mostly of low-income but healthy mothers and children. Thus, plans had to hire and train large numbers of new employees to staff care-coordination departments. Despite reported efforts to adequately train the new CMC care coordinators, some providers reported that many were lacking the adequate training needed to help with complex situations such as hospital discharges or transitions out of institutions (Hollister et al., 2018).
Risk Stratification
Plans used Medicare and Medicaid data to identify members who needed care coordination—a process called “risk stratification.” Though the researchers did not have access to data on the true number of beneficiaries who were receiving care coordination, a telephone survey with CMC showed that only 31 percent of CMC members reported receiving care coordination from their plan. Also, those members with poor health and disabilities were not more likely to report receiving care coordination than other members. Furthermore, 23 percent of CMC members said they were not getting the help they needed with care coordination (Graham et al., 2018). This suggests that the methods used for risk stratification may not have been successful in identifying members who truly needed the service. One CMC plan tried to address this by changing their risk-stratification approach to focus more specifically on high utilizers (Graham et al., 2017a).
Persistent Challenges with Data Sharing
It can be argued that effective care coordination for anyone with complex care needs relies upon timely and accurate exchange of data and information across multiple sites. In CMC’s case, the system relied upon the timely transfer of: Medicare and Medicaid data to the plans; accurate member contact information to the plans; HRA data to care coordinators and providers; and care plan data to all providers and members. Unfortunately, in the CMC program there were problems with all of the data transfers described above.
‘Effective care coordination for anyone with complex care needs relies upon timely and accurate exchange of data and information across multiple sites.’
First, CMC plans reported delays in receiving Medicare and Medicaid data to conduct risk stratification in a timely manner. This may have contributed to the above reported finding that many beneficiaries with complex needs were not identified for care coordination. Next, CMC plans reported that the contact information they received for new members was often missing or inaccurate. As a result, 38 percent of CMC members were unreachable for their HRAs (California Department of Health Care Services, 2015). Also, it may have prevented members from receiving their care plans (only 42 percent remembered receiving one), or including members in their own ICTs (only 12 percent reported being invited to one) (Graham, Liu, and Kaye, 2016).
Lack of Connection and Leveraging of HCBS
Despite successful examples of the CMC plans that collaborated with HCBS providers or county organizations noted above, many HCBS providers whose clients were enrolled in CMC plans reported ongoing frustration due to a lack of collaboration with and referral from CMC plans. Some HCBS providers were disappointed the CMC plans did not invite them to ICTs when they were actively providing services to CMC members (Graham et al., 2017b). From the perspective of CMC plans, contracting difficulties often were cited as a barrier to working with HCBS providers that may not have had the business acumen for reporting, data sharing, and meeting regulatory requirements of a health plan.
Providers and Beneficiaries Lacked Knowledge and Buy-In
While some efforts were made to improve CMC materials for members and providers, several informants noted that many members and providers were particularly uninformed about the CMC’s care coordination benefit. It was speculated that the lack of buy-in from medical care providers was a primary reason why almost 50 percent of eligible beneficiaries opted out of the program (McBride et al., 2017; Grabowski et al., 2017), and this may have been ameliorated if the providers had been better-educated about the value that care coordination could provide to their patients.
In focus groups with newly enrolled CMC beneficiaries, many participants were unaware that they could get a care coordinator and indicated that the notification material they received when they were auto-enrolled did not include information about how to access care coordination (Graham, Stewart et al., 2018). The Medicaid agency continued to work on improving outreach and education to providers and beneficiaries throughout the demonstration (California Department of HealthCare Services, n.d. [d.])
Lessons Learned and Implications for Managed Care
Managed care organizations (MCOs) often lack experience serving populations with complex care needs; and this is the most obvious barrier to effective coordination for dually eligible beneficiaries in managed care delivery systems. One way to overcome the lack of experience is for MCOs to collaborate with CBOs or county organizations that already serve duals in their communities, such as senior service organizations, Long Term Care Ombudsman Programs, MSSP, and others.
These CBOs often already have established relationships with duals and, in areas with high numbers of immigrants they can provide the cultural and language competencies that MCOs often cannot. To promote this collaboration, CBOs can take advantage of business acumen trainings such as that provided by the Administration for Community Living to facilitate contracting with MCOs (Tabbush, 2012; Administration for Community Living, n.d.). And for MCOs, collaborating with one experienced broker agency could help overcome the burden of multiple contracts with CBOs.
MCOs can have an impact in the area of rebalancing care away from institutionalization and toward the community. Placing MCOs at financial risk for institutional care can encourage them to provide options and services for members to avoid nursing home placement. But increasingly, a lack of affordable and accessible housing has become a major barrier to successful transitions to the community. In the future, MCOs may have to collaborate with affordable housing providers to provide innovative solutions to community-based care for their members. Additionally, oversight must be in place to ensure that those who need a higher level of care are not prematurely discharged out of institutions before HCBS and safe housing are ensured.
Finally, and probably most importantly, in coordinating care for duals, MCOs must embrace the social model of disability. A majority of duals have some form of disability, and MCOs tend to focus on disability as a medical problem. To be truly effective, MCOs must acknowledge disability as a “lack of fit between a body and its social environment” (Goering, 2015). For example, CMC HRAs focused primarily on their members’ healthcare (e.g. specialist appointments, medication adherence, and durable medical equipment) but did not typically ask members about social determinants of health such as social isolation, access to food, safety, housing, or engagement in enriching activities—all things that impact quality of life and health.
The good news is that federal rules now allow MCOs (especially Medicare Advantage plans) to provide non-medical services (called “special supplemental services”) that address the social determinants of health (Tumlinson, Burke, and Alkema, 2018; ATI Advisory, 2021 ). MCOs must use person-centered assessment to identify these non-medical needs, and strategically offer services to improve their members’ health and quality of life.
MCOs can be an effective way for states to ensure that Medicaid and Medicare services for dually eligible beneficiaries are integrated and coordinated. And the ability of managed care delivery systems to integrate medical care is well-established. But MCOs that serve duals need to work harder to effectively and strategically integrate non-medical LTSS. MCOs must do this by connecting more effectively with members, educating providers, and collaborating with other sectors to ensure members are getting the services that optimize health and quality of life.
Author Note: Much of the data cited in this paper was part of an evaluation funded by The SCAN Foundation—advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence. For more information, visit www.TheSCANFoundation.org.
Additional funding was provided by the National Institute on Disability, Independent Living, and Rehabilitation Research (grant 90RT5026) and the Administration for Community Living.
Carrie L. Graham, PhD, is a professor at the UCSF Institute for Health and Aging and director of Health Policy at Health Research for Action, a center in the UC Berkeley School of Public Health. She may be contacted at carrie.graham@ucsf.edu.
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