State Update
Vital Signs: March 2012
For the past two years, the Patrick Administration has been
developing a system of integrated care organizations (ICOs) to
deliver comprehensive care to Massachusetts residents 21 to 64
years of age enrolled in both Medicaid and Medicare. Combined state
Medicaid and Medicare spending on these approximately 115,000 "dual
eligible" individual is projected to reach $3.85 billion in
2012.
At this point, hearings are complete, and pending Centers for
Medicare and Medicaid Services (CMS) approval, we anticipate the
first enrollments to begin in January 2013. Key concepts of the
proposed integrated care organization model include
patient-centered care with comprehensive care coordination,
including services such as home health, behavioral health, and
acute care.
The MMS joined the Massachusetts Hospital Association, the Home
Care Alliance of Massachusetts, and the Massachusetts Association
of Behavioral Health Systems last year in support of the
administration's approach, while also giving our perspective on key
issues that must be addressed.
The Society's initial concern was that since Medicare and
MassHealth rates for services differ significantly, Medicare funds
should not simply be placed into MassHealth accounts for payment at
MassHealth rates.
The Society signed a letter to that effect last year and was
pleased by subsequent provisions specifying that ICOs will operate
under a patient-centered medical home model that guarantees
continuity of care by requiring good faith efforts to contract with
patients' existing physicians either as network providers or
through out-of-network coverage. Enrollment in the program will be
automatic for patients; however, they will have an opportunity to
opt out of the system and continue with existing providers under a
fee-for-service system.
Central to the effectiveness of the pilot project is the
adoption of adequate payments for providers who choose to
participate. ICOs must provide meaningful rates to providers both
in and out of network to make this pilot work for patients,
providers, and the Commonwealth. The MMS strongly suggested that
bidders be required to reimburse providers at least at the 2011
Medicare rates rather than at lower MassHealth levels.
The proposal is awaiting CMS approval, and we are a long way
from the creation of a new and comprehensive system. The MMS will
continue to work with interested parties and the Patrick
Administration as the proposal progresses. Physicians are advised
to watch for the development of ICOs and to carefully weigh the
pros and cons of participating under contract with these entities
as they emerge.
- William J. Ryder
