New Care System Expected for 'Dual Eligible' Patients

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

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