California and Dual Eligible Beneficiaries
Steve Hernandez
Florida Atlantic University
Dr. Nancy Shehadeh
Introduction to Health Care Systems
3
Table of Contents
Introduction…………………………………………………………………..3
Access to Health Care………………………………………………………...3
“Cal MediConnect” Financing………………………………………………..5
Quality of Care for “Dual Eligibles”………………………………………….6
Concerns About “Cal MediConnect’s” Quality of Care………………………7
Conclusion……………………………………………………………………13
References…………………………………………………………………….14
4
Introduction
As the United States of America ushers in a new era in
health care, several states continue to innovate solutions to
address the rising cost associated with individuals who are
eligible to receive both Medicare and Medicaid. Also known as the
“dual eligible” demographic, “Dual Eligibles” are estimated to be
the most expensive demographic in the United States health care
system, and often experience poor continuity of care.
Discrepancies in preventative care also exist among the “Dual
Eligible” demographic (Sundaram, 2014).
California will implement a program that aims to provide
better continuity of health care services and lower costs
associated to providing care for the “Dual Eligible” demographic.
Appropriately named “Cal MediConnect”, the program will begin
implementation in April of 2014. Factors considered below for
“Cal MediConnect” included patient access to health care,
financial model for “Cal MediConnect” and quality of health care
services for “Dual Eligibles”. The pressure to transform “Dual
Eligibles” into a cost efficient health care demographic, is not
5
without its challenges. A detailed look at California’s plan for
its “Dual Eligibles” health care program, will reveal “Cal
MediConnect’s” potential issues. However, optimism for the pilot
program’s success exist in regards to its ability to lower costs
and better coordinate care.
Access to Health Care
The “Dual Eligible” demographic include seniors and non-
elderly people with significant disabilities, many who are among
the poorest and sickest beneficiaries covered by either Medicare
or Medicaid. The existing health care delivery models for this
demographic involve very little coordination that frequently
leads to having patients balance their own health care, a process
that has proven very costly (Sundaram, 2014). The current method
to access health care, has led to poor continuity of care and
preventable health problems among the “Dual Eligible”
demographic.
6
According to the website Calduals.org (2013), about 80% of
“Dual Eligibles” in California receive care on a “fee-for-
service” basis. When “Dual Eligibles” access health care, they
must carry multiple insurance cards and know different program
regulations in order to successfully navigate multiple separate
systems to receive care. This has led to difficulties in
receiving the appropriate services at the right time and place,
and has lead to duplication of tests and procedures and sometimes
unnecessary hospitalizations.
Furthermore, there exists discrepancies in how “Medi-Cal”
(California’s Medicaid program) enrollees access care. California
Health Care Foundation (2013) states, “Medi-Cal” is the nation’s
largest Medicaid program with nearly two million more enrollees
than the next largest state. Additionally, “Medi-Cal” is the
source of health care coverage for more than one in five
Californians under the age of 65, and one in three children in
California. The California Health Care Foundation (2013) goes on
to mentions that adults with “Medi-Cal” are nearly twice as
7
likely to report difficulty getting a doctor appointment, then
other insured adults in California.
Moreover, in 2009, the Kaiser Family Foundation estimated
California’s total “Dual Eligible” demographic to be over 1.2
million. California’s plan to address their “Dual Eligible”
population is called “Cal-MediConnect”, and will be piloted
across the state in eight counties. An estimated 456,000 “Dual
Eligibles” will be eligible for passive enrollment, with a
maximum of 200,000 in Los Angeles County (Davenport, 2010). An
estimated one-third of those beneficiaries already are enrolled
in managed care for “Medi-Cal”, Medicare, or both.
“Cal MediConnect” Financing
“Cal MediConnect” is a three-year pilot project California
will use to promote coordinated health care delivery to seniors
and people with disabilities who are part of the “Dual Eligible”
demographic. According to the website Calduals.org (2013), “Cal
MediConnect” will be implemented no sooner than April 2014 in
eight counties. The “Cal MediConnect” program will coordinate
medical, behavioral health, long-term institutional, and home-and
8
community-based services through a single organized delivery
system.
The Kaiser Family Foundation (2013) states California’s “Cal
MediConnect” program will test a capitated financial model, in
which managed care plans will receive capitated payments from
Medicare and California’s Medicaid program (Medi-Cal). The
capitation payment for Medicare Parts A and B services will be
determined using a blend of the Medicare Advantage benchmarks and
the Medicare Fee for Services standardized county rates weighted
by whether “Dual Eligibles” who are expected to transition into
“Cal MediConnect” are enrolled in a Medicare Advantage plan or
Medicare Fee for Service in the prior year. According to Kaiser
Family Foundation (2013), the “Cal MediConnect” plans will be
financially modeled as follows:
Plans will be paid the full benchmark amount. Medicare
Advantage baseline spending will include costs that would
have occurred absent the demonstration, such as quality
bonus payments for applicable Medicare Advantage plans. The
baseline capitation payment for Medicare Part D services
9
will be the national average monthly bid amount as well as
the average projected low-income cost sharing subsidy and
the average projected federal reinsurance amounts. The
baseline Medicaid capitation payment will be based on
historic state spending… and on a blend of the Medicaid
managed long-term care capitation rate that would apply to
“Dual Eligibles”.
California’s capitated financial alignment also contains
provisions requiring portions of the capitated reimbursement be
withheld. However, “Cal MediConnect” can earn these “withheld”
funds back if certain quality measures are met. California also
requires incentive payments from the “withheld” funds to county
behavioral health agencies based on successful achievement of
service coordination measures (Avik, 2012).
Quality of Care for “Dual Eligibles”
The quality of care for “Dual Eligibles” is a growing
concern across the United States. In our health care system,
10
there exist many “loophole” incentives that discourage health
care providers, Medicare and Medicaid programs from coordinating
“Dual Eligible” care. Lack of care coordination directly affects
the quality of care “Dual Eligibles” receives throughout the
delivery of health care services. Furthermore, another reason
quality health care for “Dual Eligibles” has also proved
challenging exist because according to Center for American
Progress (2010), the Medicare and Medicaid programs often work at
cross purposes. Medicare and Medicaid have an incentive to shift
liability to the other through coverage interpretations and other
“loopholes” that avoid costs.
The aforementioned dynamic creates a dilemma for care
provided by Medicare and Medicaid. Each program seeks to limit
its costs and enrollees shift between acute and long-term care
settings. The relationship is worsened because Medicare bears the
most responsibility for acute care while Medicaid covers long-
term care. Because of these separate financing streams and
conflicting incentives, Medicare and Medicaid cannot realize
equal savings from their investments in improved care. The Center
11
for American Progress (2010) goes on to say “Better long-term
care coordination, for example, may result in reduced
hospitalizations. But this means any investments by state
Medicaid programs may result in Medicare savings…”. The above
mentioned incentivizes lack of coordination between the Medicare
and Medicaid programs, and proves disappointing for “Dual
Eligibles”.
Concerns About “Cal MediConnect’s” Quality of Care
The “Cal MediConnect” program aims to improve the quality of
care for “Dual Eligibles” by improving its coordination. However,
opposition exist towards the idea of whether or not the quality
of care will actually improve. According to the National Senior
Citizens Law Center (2012), the eight plans selected for four
counties by the California Department of Health Care Services
have cause concern. Seven out of eight plans have received a
global health plan rating of one out of five stars.
12
Furthermore, The Medicare evaluations for these eight plans
have done little to ease concern. Although total participation in
“Cal-Mediconnect” will be from eight counties, eight plans
selected for Los Angeles, Orange, San Diego and San Mateo
counties have seen The National Senior Citizens Law Center (2012)
declare them “low-performing on at least one composite Medicare
quality measure”. The eight plans in the four counties mentioned
above, possessed quality concerns such as receiving notices of
non-compliance from the Medicare program, and low rankings on
performance. The National Senior Citizens Law Center (2012)
stated “One of those has been marked as a low-performing plan for
three consecutive years…Another plan was recently sanctioned by
Medicare as a result of beneficiary access problems.”
In Los Angeles, Health Net and L.A. Care Health Plan
received a one out of five star rating pertaining to Medi-Cal
quality ratings, and a 2.5 star rating pertaining to Medicare
quality ratings. Problems areas identified in Medicare audits
consisted of access to services and plan performance. Health Net
has received below-average ratings for their drug plan’s customer
13
services. According to National Seniors Citizens Law Centers
(2012), these low scores were due to low ranking for timely
decisions on appeals of claim denials. In the past, Centers for
Medicare and Medicaid Services (CMS) has sanctioned Health Net by
suspending Health Net’s drug plan auto enrollment privilege, and
suspending marketing and general enrollment in Health Net’s drug
and health plans.
Moreover, L.A. Care Health Plan’s additionally scored poorly
on overall ratings from past members. Key patient safety measures
were rated low, and have caused concern since the poorly
preforming categories are related to proper administration of
blood pressure, cholesterol and oral diabetes medication.
Additionally, National Seniors Citizens Law Centers (2012) states
that the L.A Care’s health plan also under preformed in key
individual measures related to managing chronic long term
conditions and care for older adults, specifically “Yearly
Assessment of How Well Members Do Activities of Daily Living” and
“Yearly Pain Screening/Management”.
14
In Orange County, CalOptima has been the plan selected for
the “Cal-Mediconnect” pilot program. CalOpitma is a county
organized health system that administers health insurance
programs for low-income families, children, seniors and persons
with disabilities in Orange County, California. The health plan
is the second largest health insurer in the county. According to
the CalOptima.org (2014) website. The CalOptima health plan
provides coverage to one in seven residents and almost a third of
Orange County’s children through two major programs, Medi-Cal
(California's Medicaid Program) and OneCare (a Medicare Advantage
Special Needs Plan) intended for low-income seniors and persons
with disabilities who qualify for both Medicare and Medi-Cal.
However, there exist concern regarding CalOptima’ s Part C
health plan. Although preforming above average overall in
Medicare quality of care ratings, CalOptima performed poorly on
key measures related to the managing of chronic long term
conditions and the care for older adults including yearly
assessment of how well members do activities of daily living and
yearly pain screening/ management. Additionally, CalOptima’s Part
15
D plan was under par for members’ abilities to get prescriptions
filled easily when using Part D. The National Seniors Citizens
Law Centers (2012) reports CalOptima’s Medicaid plan also
received poor results. CalOptima earned one out of five stars
rating from Medi-Cal for “Rating of All Health Care and Getting
Care Quickly” and earned a two star rating for the category of
“Getting Needed Care and Shared Decision-Making”, a report that
causes alarming concern about the potential quality of care that
“Dual Eligibles” will receive in the “Cal-Mediconnect” program.
In San Diego, four plans have been selected to provide care
to the “Dual Eligible” demographic. San Diego is California's
second largest city with a population of 1.3 million in the city,
and almost 3 million residents throughout the county. The city is
the eighth largest in the United States, according to the
SanDiego.gov website (2014). The reasonable need for multiple
plans is justifiable in San Diego, just as in the case of Los
Angles.
Nevertheless, the health plans selected to participate in
the pilot program have ranked overall average in quality ratings
16
in the past. However, the health care plans have fared poorly on
key measures. The plans selected for San Diego are Care 1st,
Community Health Group, Health Net and Molina Healthcare.
According to The National Seniors Citizens Law Centers
(2012) report, Care 1st received and overall average plan rating
from Medicare. However, Care 1st Part D ranked below average on
ten out of twenty key Medicare measures including the
“Availability of help or information when members need it” and
“The ability of members to easily fill prescriptions”. Care 1st
also performed poorly on patient safety measures, specifically
related to the proper administration of blood pressure,
cholesterol and oral diabetes medication. Care 1st Plan C also
received below average ratings specifically on Medicare measures
of “Getting needed care” and “overall rating of health care
quality”. Medicare also gave below average scores to measures
relating to managing chronic long term conditions and care for
older adults and a measure called “Yearly review of all
medication taken”
17
Although Care 1st’ s total Medicare rating was overall
average, its Medicaid rating was poor. The health plan received a
one star rating in all medical quality measures. Key Medi-Cal
measures included in the evaluation were “Rating of Health Plan”,
“Rating of All Health Care”, “Getting needed care”, “Getting Care
Quickly” and “Shared Decision Making”.
Community Health Group is San Diego’s second health plan
that will participate in the “Cal-MediConnect” pilot program.
Because of the health plan’s relative small size, there is
insufficient data to accurately calculate Medicare quality
measures. However, The National Seniors Citizens Law Centers
(2012) reports that the ratings that do exist, have caused
concern over the ability of the plan to provide quality health
care. Community Health Group received below average ratings on
four measures that include “Complaints About Health Plan” and
“Complaints About Drug Plan”. Furthermore, Medi-Cal rated
Community Health Group’s adult plan far below average in measures
relating to responsiveness care, prompt appointment and care, and
attaining a needed specialist.
18
Health Net of California is the third plan selected to
participate in the “Dual Eligible” demonstration program in San
Diego. Of the four participating San Diego plans, Health Net
received the highest overall rating in its Medicare plan. Health
Net received an above average rating of 3.5 stars for its
“Overall Plan Rating” measure. However, Health Net did preform
below average in certain measures due in large to problems
Medicare found with the plans “access to services” and Health
Net’s “Plan Performance”, due to serious problems identified in
Medicare audits, according to The National Seniors Citizens Law
Centers (2012).
Additionally, great concerns arises in Health Net’s drug
plan. According to The National Seniors Citizens Law Centers
(2012), “CMS sanctioned Health Net by suspending its drug plan
auto-enrollment privileges for some low-income Medicare
beneficiaries (including dual eligibles) and by suspending
marketing and enrollment of new members in its drug and health
plans”. Health Net’s poor preforming key measures related to
timely decisions on appeals of claims denials and managing
19
chronic long term conditions and care for older adults. In
addition, the plan’s Medi-Cal ratings were poor overall. Health
Net received a one star rating in all key Medi-Cal quality
measures.
San Diego’s forth health care plan participating in the
“Cal-Mediconnect” program is Molina Healthcare. Molina Healthcare
possessed the worse combined ratings for Medicare and Medicaid
plans of the four health plans in San Diego. The plan’s Medicare
rating received a 2.5 overall plan rating. Molina’s Part D drug
plan received below average marks on 9 of 21 quality measures.
Additionaly, Molina performed poorly in key measures such as
“Members Choosing to Leave Drug Plan” and “Member Experience with
Drug Plan”. The Part D plan also received the lowest possible
rating on patient safety measures, according to a report from The
National Seniors Citizens Law Centers (2012). Additionally Molina
stands at risk of termination of its Medicare contract due
largely in part of consecutive years of poor Medicare summary
plan ratings. Molina’s Medi-Cal ratings reflected poor results as
well, receiving only one star in all Medi-Cal quality measures.
20
The final county that will be discussed is San Mateo. San
Mateo’s “Dual Eligibles” population is estimated to be slightly
under 14,000, according to the California Health Care Foundation
(2013). The San Mateo plan participating in the “Cal-Mediconnect”
program is called Health Plan of San Mateo. Of the eight health
plans discussed, Health Plan of San Mateo stands as one of the
better rated plans overall in both Medicare and Medi-Cal quality
ratings. The plan received a 3.5 star rating, an above average
rating from Medicare for “Overall Plan Rating”. However, Health
Plan of San Mateo received below average ratings on its Part D
drug plan, with the key measure of “Member Experience with Drug
Plan” rated below average.
Additionally, Health Plan of San Mateo’s Part C health plan
received a below average mark in measures associated to
responsiveness of care and customer service. Moreover, Health
Plan of San Mateo received the highest ratings of the plans
discussed in its Medi-Cal quality ratings. According to The
National Seniors Citizens Law Centers (2012), the plan garnered
the third highest adult score statewide for the key measure
21
“Rating of Health Plan” as well as the third highest adult score
for the measure “Rating of All Health Care”.
Conclusion
The transformation of health care delivery in the United
States will prove to be a long journey. The ideas vary across the
country on methods necessary to improve health care efficiencies
in the United States, and state’s Medicaid plans have an
important role to play going forward. “Dual Eligible”
beneficiaries accounted for more than 250 billion dollars on
health care benefits through the Medicare and Medicaid programs
across the country, according to the Congress of The United
States Congressional Budget Office (2013).
California’s “Cal-Mediconnect” will test efficiencies of
providing improved coordinated care between both Medicare and
Medicaid beneficiaries. The state hopes improved coordinated care
for the “Dual Eligible” demographic, will not only lower the cost
of care for this demographic, but also improve the quality of
care through improved coordination.
22
References
Cal Duals Organization (2013). Dual Eligibles Fast Facts. Retrived from: http://www.calduals.org/background/fast_facts/#5
CalOptima (2014). Retrieved from: https://www.caloptima.org/en.aspx
California Department of Health Care Services (2013). Low Income Health Program. Retrieved from: http://www.dhcs.ca.gov/provgovpart/Pages/lihp.aspx
California Health Care Foundation (2013). Medi-Cal Facts and Figures: A Program Transforms. California Health Care Almanac. Retrieved fom: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/M/PDF%20MediCalFactsAndFigures2013.pdf
Congress of The United States Congressional Budget Office (2013).Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies. Retrieved from: http://www.cbo.gov/sites/default/files/cbofiles/attachments/44308_DualEligibles.pdf
Davenport, K., Markus, R., Feder, H., Feder, J. (2010). ImprovingCare and Reducing Costs for Individuals Eligible for Medicare and Medicaid. Retrieved from: http://www.communitycatalyst.org/doc-store/publications/dual_eligibles.pdf
Kaiser Family Foundation (2013). Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared. Retrieved from: http://kaiserfamilyfoundation.files.wordpress.com/2013/11/8426-05-financial-and-administrative-alignment-demonstrations-for-dual-eligible-beneficiaries-compared1.pdf
23
National Senior Citizens Law Center (2012). Assessing the Qualityof California Dual Eligible Demonstration Health Plans. Retrieved from: http://www.nsclc.org/wp-content/uploads/2012/05/Plan-Ratings-Report-May-2012.pdf
Roy, Avik (2012, November). Forward! Obama Privatizes Medicare for 3 Million 'Dual-Eligible' Low-Income Seniors. Forbes. Retrieved from: http://www.forbes.com/sites/aroy/2012/11/30/forward-obama-privatizes-medicare-for-3-million-dual-eligible-low-income-seniors/
Sundaram, Viji (2014, January). Coordinating Health Care for California’s 'Dual Eligibles'. New America Media. Retrieved from: http://newamericamedia.org/2014/01/new-program-will-allow-elders-to-age-in-place.php
The City of San Diego Administration Department. (2014). Facts History. Retrieved from: https://www.sandiego.gov/administration/programs/assistance/factshistory/facts.shtml
Top Related