CMS dual-eligible demos called into question
Despite a recent report stating that CMS needs to do a better job overseeing the 13 state-administered dual-eligible demonstration programs, some stakeholders say the initiative is on the right track.
According to the report from the U.S. Government and Accountability Office (GAO), which examined care coordination under the demonstration intended to improve care of individuals who qualify for both Medicare and Medicaid (i.e., dual-eligibles), Medicare and Medicaid programs spent an estimated $300 billion on these beneficiaries in 2010. Dual-eligibles often have complex health needs, increasing the need for coordination across the two programs.
In 2013, as part of the Affordable Care Act, CMS began the duals demonstration, also known as the Financial Alignment Demonstration (FAD). The goal is to integrate Medicare and Medicaid services and generate savings for these programs, improve patients’ care coordination and outcomes, and bridge gaps.
Under the umbrella of the FAD, there are two main models: the capitated financial alignment model (C-FAD), and the managed fee-for-service financial alignment model. Thirteen demonstrations are under way across 12 states. New York is operating two demos.
“An objective of the capitated FAD is to streamline and coordinate primary, acute, behavioral, pharmacy, and long-term services and supports for this vulnerable population of seniors and individuals with disabilities,” says Tom Standring, vice president of Long Beach, California-based Molina Healthcare, a healthcare company with the most C-FAD contracts in the country.
Thus far, none of the states have withdrawn from the demonstrations. “In fact, we are planning for two-year extensions in most states,” says Tim Engelhardt, director, Federal Coordinated Health Care Office, CMS. “States have invested immense amounts of time and energy in the program. It’s a testament to the commitment of state leaders to better serve dual-eligible beneficiaries.”
Virginia is the only state that has signaled it will let the C-FAD expire after three years. “Enrollment is not high enough for the state to realize expected savings, and the state doesn’t have a lot of history with managed care—particularly Medicare—which made getting providers on board more difficult,” Standring says.