Posts About Dually Eligible Populations


It’s May, and that means it’s Older Americans Month. This year’s theme is Age Out Loud, chosen “…to give aging a new voice – one that reflects what today’s older adults have to say.”

Older Americans are a group that have a lot at stake in ongoing health system transformation initiatives. A vital goal of the Center for Consumer Engagement in Health Innovation is promoting the meaningful role older consumers can exercise when they lift up their voices. Several of our staff members recently met an older adult who perfectly exemplifies what it means to stand up and speak out loudly for better health out of one’s own life experience. Kathy Paul is a 69-year-old resident of Lynn, Massachusetts and an active member of the Massachusetts Senior Action Council. The Council, founded in 1981, is a statewide, grassroots, senior-led organization that empowers its members to use their own voices to address key public policy and community issues that affect their health and well-being.

Kathy spoke out loudly at a press conference in Boston on May 8 [video courtesy of BNN – Boston Neighborhood Network] on the American Health Care Act, a bill that would result in significant cuts to care for older adults. The bill was passed by the U.S. House of Representatives and is now pending before the Senate. Kathy joined Sen. Edward Markey and other community leaders at the event, including speakers from Health Care For All, Community Catalyst, Health Law Advocates, Boston Medical Center GROW Clinic, Disability Advocates Advancing Our Healthcare Rights, Massachusetts Senior Action Council, Massachusetts Organization for Addiction Recovery, the American Cancer Society Action Network and the American Heart Association.

Kathy introduced herself “…not just as an activist, but as a mother of five, a grandmother of 10, and a great-grandmother of five, who is deeply concerned about the future of health care.”

She continued: “As a senior, I live on a very limited fixed income and I rely on MassHealth [the Massachusetts Medicaid program] for my health care. I feel very fortunate because, for the most part, I am very healthy. I don't take any medication and stay very active. But I know the reality of when that's not the case. My husband had several very serious health conditions including diabetes and kidney failure. He had to endure two amputations below the knee and was on dialysis three times a week. If it was not for MassHealth, we would never have been able to cover his care. I am thankful that I was able to focus on taking care of him rather than worrying about how we would pay for the care he needed or being denied because we did not have the money to meet a huge deductibleThis debate is not about party politics. This debate is about the wealthy getting wealthier and the rest of us paying the price. We cannot allow this assault on our right to basic health care to move forward. We must speak up and speak out.”

Kathy first got involved with the Massachusetts Senior Action Council in 2007, while her late husband was still alive and she was putting most of her energy into the demands of caring for him. After he passed away in 2012, it was a turning point in her life. She explains, “With more time on your hands, what do you do? Just sit in the house, stare at the walls and complain, or get out and do something about it? What our group likes to say, ‘we don’t just take it, we take charge!’”

In recent years, ‘taking charge’ for Kathy has meant testifying at the Massachusetts Statehouse against rate hikes for older adults using public transportation services and advocating for genuinely affordable housing options for older adults in the Commonwealth. And on a Monday morning in May, it meant joining hands with her United States senator and telling her story from the podium to a bank of television cameras and assembled reporters.

We can’t wait to see what she’ll do next.

During this month, let us know at @ccehi how you #AgeOutLoud!

With our thanks to Kathy Paul for her guest contributions to this post.

In July, the Ocean State became the thirteenth state to sign a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) to move forward with integrating services and financing for its Medicare-Medicaid population (dual eligible). While many challenges have surfaced with the twelve demonstrations already underway, we see some improvements in this MOU. For instance, the Rhode Island MOU:

  • includes the strongest provisions of any MOU to promote rebalancing from nursing homes to community care
  • is the only MOU that, from the start, offers protections in the form of risk corridors for all three years
  • contains strong policies on assisting enrollees with transitions between care settings.

Still, as with the other ongoing demonstration projects, “the devil is in the details.” And there are still a lot of details to get right for Rhode Island, as outlined in this fact sheet. Rhode Island advocates are hard at work nailing down these details, including ensuring that enrollment goes smoothly and that older adult enrollees receive geriatric-competent care, as our state partners emphasized in a recent Op-Ed in the Providence Journal.  These details will be part of a three-way contract which is currently under negotiation between CMS, the State and the participating health plan (Neighborhood Health Plan of Rhode Island). Most of all, their work ensures that consumers and their advocates are at the table as these decisions are being made.

As we’ve learned over the past two years, getting these demonstrations right takes time, vigilance and course corrections. The RI MOU signifies a cautious step in the right direction. But the hard work starts now. The readiness review process and details of the three-way contract will be important to watch. As with any new health system transformation initiative, ongoing transparent collaboration with consumers and their advocates will be vital to getting it right. 

Rush to Judgment?

 ·  Health Policy Hub   ·   Andi Mullin

Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) is assisting states in integrating care for people who are eligible for both Medicare and Medicaid – primarily low-income people over age 65 and working-age adults with disabilities. In 2011 CMS invited states to submit proposals to operate three-year demonstration projects that would better integrate care for their dually eligible beneficiaries by aligning the financing of Medicare and Medicaid. Massachusetts was the first state to launch its demonstration in 2013, and as of mid-2015, twelve states have begun implementing demonstrations. This population, which is by definition low-income and also disproportionately from racial and ethnic minority communities, has historically received very poor health care, and the status quo is not working for them. The hope for these demonstration projects is that they will be able to provide better coordinated care at lower costs, including integrated higher-quality primary care, behavioral health care and long-term services and supports. Are the projects achieving those goals?

Over the last few months, both the trade and mainstream press coverage has painted a dire picture for the projects. Modern Healthcare, for example, ran a story in April with a headline suggesting that the future of the demonstrations was in question. In July, the industry publication Crain’s New York Business ran an article headlined “Problems Plague Program for Dual Eligibles” (subscription required to view). In early August the Boston Globe reported on the financial losses sustained by health plans participating in the Massachusetts demonstration, One Care.

Each of these articles has identified some real difficulties that exist in the demonstrations. State advocate partners in our Voices for Better Health project also report a myriad of concerns such as lower than anticipated enrollment numbers, poor communication with primary care providers about the demonstrations, cases of disrupted care for enrollees, inadequate readiness review, inadequate financing and risk adjustment provisions, and financial losses for plans. Consumer advocates are working energetically together with beneficiaries, to identify and implement solutions in collaboration with plans, states and CMS.

What’s largely been missing in the press coverage, however, is the impact of the demonstrations on the people they are aiming to help. Responses to the Boston Globe article from an enrollee, a provider and a plan attempt to balance out the picture with real stories of people with complex conditions getting measurably improved care. This is not to say that such successes are yet as widespread as we would like across the demonstrations. But any balanced evaluation of the projects must acknowledge successes, and also be measured against the failings and unsustainability of the current health care system. The existing system is expensive, uncoordinated and inadequate. Too many of these enrollees have been falling through the cracks for decades, and the problems with the demonstrations can only be fairly viewed through that lens.

Most importantly, we must take the long view and give these demonstrations time to work. This is hard. It is far too soon to pronounce either failure or success. Coordinated care can provide better care at lower costs, but reaching this goal will take time. While mid-course corrections are needed, that in no way means we should give up on the project, since we know that the status quo doesn’t work. The kinds of things the demonstrations are trying to do – and in some cases are already doing – are the right things. There is a proven track record in Massachusetts, for example, of improved care for low-income older adults in the Senior Care Options program. The same is true of PACE (Program of All-inclusive Care for the Elderly) sites around the country. These and other working models show that well-integrated coordinated care results in higher-quality care that can reduce preventable hospitalizations and unnecessary nursing home admissions. Given ample time to work, robust state and federal oversight and meaningful consumer input, the dual eligible demonstrations can be just as successful as these models.

Changing how we care for the dual eligibles is not like altering course in a speedboat. It’s more like turning a tanker. It won’t always be smooth sailing, but commitment to the long-term goals of the demonstrations and to fixing problems as they arise, will help us stay the course.

The Dual Agenda, the bi-weekly newsletter of our Voices for Better Health project, periodically features “Eldercare Voices” guest columns, sharing contributions from providers or researchers directly involved in improving care delivery to older adults. This week’s column, Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults, is from Robyn I. Stone, Ph.D., Executive Director of the LeadingAge Center for Applied Research and Senior Vice President of Research at LeadingAge. Dr. Stone shares exciting progress being made in forging partnerships between senior housing facilities and health organizations, with significant implications for health system transformation efforts. We know that where one lives plays a large role in health, both in access to services and in a variety of upstream social determinants of health. The cutting edge work described in this piece highlights the opportunities to deliver coordinated care and services, with a meaningful role played by service coordinators in affordable senior housing facilities, helping foster good health while promoting health equity through culturally competent relationships with residents.

Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults

Guest contributor Robyn I. Stone, Ph.D.   
Executive Director, LeadingAge Center for Applied Research

An estimated two million older adults currently live in publicly subsidized housing properties located in urban, suburban and rural communities nationwide. Findings from a recent federally-funded study of affordable senior housing properties in 12 jurisdictions across the country, conducted by researchers at the LeadingAge Center for Applied Research (CFAR) and the Lewin Group, indicate that elderly residents of low-income housing properties have more chronic conditions, take more medications, are more functionally disabled and have higher emergency department (ED) and hospital visits than their peers living in the community. Approximately 70 percent of these elderly residents are dually eligible Medicare and Medicaid beneficiaries, underscoring their high-risk status and suggesting that publicly subsidized housing may serve as a locus for better management and coordination of services for vulnerable older adults.

Multiple efforts are underway at the federal and state levels, and in the private sector, to reform our health and long-term care delivery systems to better address the country’s care needs, particularly among vulnerable populations. These efforts focus on lowering Medicare and Medicaid expenditures by providing timely preventive care; improving care coordination and service integration; reducing over-utilization; and providing overall population health management at the community level.

The current reform climate, focused on transformation of our health care system, provides a unique opportunity for senior housing/health care organization partnerships to achieve common goals. Since residents of affordable senior housing communities are an ideal demographic for implementing population-based health reforms, they present especially conducive opportunities for the forging of such partnerships.

Continue reading this edition of Elder Care Voices here. 

To mark Older Americans Month, the Voices for Better Health project has debuted a new video highlighting an important strategy to improve the health and well-being of vulnerable older adults. “Building Bridges to Better Health” tells the story of an innovative collaboration between consumer advocates and providers to infuse geriatrics best practices into the Demonstration Projects for people with both Medicare and Medicaid (dual eligibles).

Working nationally and with Voices for Better Health state partners, this powerful partnership draws on the expertise of leaders in the geriatrics community – physicians, gerontologists, nurses, social workers and other providers and researchers – sharing best practices to improve efficiency, quality and outcomes in the demonstration projects. This collaboration has increased the effectiveness of state advocacy efforts around these demonstrations. With people of color making up a disproportionately large percentage of the dually eligible population, we also see this work as helping to build another important bridge – to health equity for all.

While “Building Bridges” focuses on the dual demonstration projects, it affirms that breaking down silos and strengthening alliances with providers is an indispensable approach to creating a path to a people-centered health system, both for older Americans, and those of all ages.

With April being National Minority Health Month and May Older Americans Month, the time is now to stand against the barriers that create the social, health and economic disparities experienced by the older adult population – a population that demographic data clearly tells us is becoming more and more diverse. That’s why we were struck by the most recent issue of Generations, the quarterly journal of the American Society on Aging, which is entirely devoted to these timely and critical issues.

First Let's Talk About the Landscape

African Americans, Latinos and Native Americans in the U.S. receive lower quality health care and experience disproportionately high rates of mortality and health status disparities compared to other high-income countries, say Alberto Palloni and James Yonker. And as author Steven P. Wallace states in his article, “Health inequities are the result of avoidable differences between populations that affect less powerful groups in society. They stem from a pattern of health determinants, outcomes and resources associated with broader social inequities.”

Several other authors in Generations argue that we need public policies and institutions that create healthy environments for older adults with diverse backgrounds, that make the “healthy choice the easy choice.” Determinants such as economic status, safety and adequate housing, are important as these facilitate healthy behaviors.

Valuing caregivers can also help address disparities, author Nancy R. Hooyman argues. Most caregivers and care recipients are women. Hooyman's article points out that gender inequities experienced by women are inextricably linked to the widespread undervaluing of caregiving, saying, “These disparities are reinforced by social institutions of the family and the labor market.” The solution lies in viewing caregiving as a “public value” rather than a private duty, as is often the attitude in the U.S.

Taking a Closer Look: LGBT Older Adults

Generations features a number of articles focused on particular populations, including one about lesbian, gay, bisexual or transgender (LGBT) older adults. According to Karen I. Fredriksen-Goldsen, there are 2.4 million adults 50 and older in the U.S. who identify as LGBT, accounting for 2.4 percent of the population in that age range. She goes on to say that “LGBT adults who are middle-age and older experience significant health disparities, defined as variations in health attributable to systemic environmental, economic and social barriers that place individuals at a disadvantage in the larger society.”

It is critical to ensure comprehensive support services for mid-life and older LGBT adults. Adequate resources will ensure that this population does not experience social isolation and poor health outcomes. The Affordable Care Act (ACA) provides important steps forward in advancing policies that address the needs of LGBT older adults, such as establishing the non-discrimination protections in health care services based on sexual orientation or gender identity. 

Taking Advocacy to the Next Level

So, which strategies and advocacy approaches can take this movement to the next level? Generations authors highlight initiatives underway through the Administration on Aging (AOA), including the Administration for Community Living and the Older Americans Act. For example, authors Boutaugh et al, suggest that these initiatives offer lessons that can help address the issues of access for racial and ethnic minorities. One such initiative the AOA has supported bolsters evidence based health and prevention programs such as the Chronic Disease Self-Management Program. Other initiatives, made possible through the ACA, can also advance health equity for vulnerable, diverse older adult populations, such as the demonstrations to integrate care for those dually eligible for Medicare and Medicaid.

The Bottom Line

The latest Generations issue* keenly reminds us that the transformation of our health care system must fully recognize the diversity of America’s aging population and tackle, head on, the social and health disparities it experiences. Fortunately, the ACA offers myriad opportunities to take on this challenge and, critically, to make older adults’ voices central to the decisions being made about their health. 

*This issue is available to ASA members or for single-issue purchase here.

Spring is a great time to think about transformation, and everywhere you look these days, more initiatives are sprouting to improve the health system. Medicaid is no exception, showing again that it is a program willing and able to help states lead the way toward more effective and efficient care.

Recently, Medicaid officially launched a program of web-based support to speed states' efforts to improve health and health care for Medicaid beneficiaries. The initial focus is on new ways to pay for and deliver services for people with drug and alcohol problems, also called substance use disorders. It's a welcome spotlight on an area of care that has long been in the shadows.

Later this spring, Medicaid plans to roll out a second part of its Medicaid Innovation Accelerator Program (IAP) that will focus on super-utilizers of health care services, followed by other segments on community integration to support long-term services and supports, and on integration of care for physical health and mental health. These areas – all critical for better care for consumers -- were chosen with help from stakeholders using criteria that included need, opportunity and synergy with other federally supported innovations, including the State Innovation Models Initiative and the demonstrations for Medicaid-Medicare beneficiaries (dual eligibles). The IAP is being run jointly by the Center for Medicaid and CHIP Services and the Center for Medicare and Medicaid Innovation. Advocates and other stakeholders can respond to federal officials' request for comments on the three new issue areas at MedicaidIAP@cms.hhs.gov.

For each of these issue areas, Medicaid is providing a year of intensive, tailored technical assistance to a small group of states that is already moving forward, and a series of webinars and resources to any state Medicaid program just getting started on innovations to improve care and outcomes. Both the tailored coaching and the webinars focus on expanding new models, improving quality measures, payment and contract strategies that yield better value, and ways to share lessons quickly across states and the nation. The shape of those innovations will vary greatly state to state.

The states getting high-intensity coaching for substance use disorders work were selected in February: Kentucky, Louisiana, Michigan, Minnesota, Pennsylvania, Texas and Washington. It's great to see that states of all political persuasions signed up. Details of their planned innovations have not yet been released.

Medicaid has also started the web-based support for 19 other states who applied for the IAP. These SUD learning sessions will be grouped by topic areas, such as benefit design, managed care contracting, and integration of primary care and substance use services. The first session dealt with increasing provider capacity, a critical issue for substance use disorders, since only about 10 percent of those with problems get treatment. There's no limit on state participation in the web support, so Medicaid officials say more are welcome. A map of the learning community states and an outline of the topics will be posted on the IAP website in the next few weeks.

If your state is one of those in the intensive group, now's the time to reach out to the state official who is the lead on this. A good place to start is whoever directs substance use disorders services in your state's Medicaid administration. If your state hasn’t already jumped in, you can encourage Medicaid or Health Department officials to check out the opportunities. While advocates aren’t part of the project’s learning community, federal officials are expecting states to engage stakeholders, including consumer advocates. It's critical that consumers be at the discussion tables to make sure the new care models work for everyone.

Why are they starting with substance use? No surprise that it's partly about the money. The top diagnoses among Medicaid beneficiaries that lead to frequent, costly and potentially avoidable re-hospitalizations include substance use and mental illness. Studies increasingly show that screening for substance use and providing effective treatments –such as combining medications and counseling -- saves money and lives. But too few people are screened, many don't get the care they need, and others get fragmented care where treatment for substance use is segregated from care for other illnesses.  

The Medicaid IAP seeks to help states learn from each other, eliminate federal and state barriers to better, less costly care, and improve outcomes for consumers. Sounds like a model we know works. The issues are critical: substance use disorders, super-utilizers of health care services, community integration to support long-term services and supports, and integration of care for physical health and mental health. Let's get involved.

These days, when we shop for even the smallest items, we have online reviews to help us find the best deals. But when it comes to the big-ticket item called Medicaid managed care, it's been a lot harder. Consumer advocates and other stakeholders have struggled to locate information on the performance of the multistate companies that are increasingly winning state contracts to manage Medicaid programs. Without this information, it's impossible to get a complete picture of how well a managed care company is likely to serve consumers.

In this season of giving, Community Catalyst has teamed up with the Kaiser Family Foundation to create an online tool that gathers in one place, for the first time, key data on the records of these companies. The Medicaid Managed Care Market Tracker includes quality scores and state-imposed sanctions. The tracker also enables comparisons across states' Medicaid managed care programs, including network access standards and the percent of premiums that go to care versus profits. All of this can help ensure consumers – both individuals and states – are getting their money's worth.

More than half of Medicaid beneficiaries are already in risk-based managed care plans, and states are rapidly expanding managed care to seniors and people with disabilities. In many states, this is tied to closing the coverage gap or demonstration projects for people eligible for both Medicaid and Medicare. Medicaid managed care can improve coordination, quality and efficiency of services. But it can also be risky for consumers, if the companies put profits ahead of people.

The Medicaid Managed Care Market Tracker lets you peer inside the wrapping of these companies.

For example, you can learn that from 2010 through 2013, for-profit UnitedHealth Group plans were sanctioned in seven states for offenses ranging from improperly denying speech therapy services in Florida (fined $1,305,000) to failing to meet standards for children's preventive services and vaccinations in Arizona (fined $200,000). Or that Molina's Texas plan paid the largest state fine during that period: nearly $3 million for problems including blocking access to needed medications, a skimpy provider network and poor handling of consumer complaints.

You can also learn that UnitedHealth's Rhode Island plan, which did not face any sanctions, received one of the highest overall quality scores – 85.5 out of 100 – from the National Committee for Quality Assurance. The plans scoring higher were all non-profits.

Other data show some states are paying a high price for having the companies manage their Medicaid programs. For example, in Delaware and Nevada, the companies took nearly 25 percent of taxpayer-supported premiums off the top, spending only 75 percent of premiums on care for state residents. These numbers cry out for closer examination of whether consumers are getting the quality and quantity of care they need.

Here are some more ways to use the new tool:

  • Check out plans operating in your state or planning to bid on business in your state
  • Identify how your state's managed care standards stack up to those in other states and advocate for stronger standards
  • Identify the parent companies of plans in your state and their performance, so you can learn more about their corporate standards
  • Educate policymakers as they consider expanding Medicaid managed care and/or contracting with new plans
  • Highlight promising and problematic plans for media
  • Advocate for more public accountability for the public dollars spent on managed care

To learn more about the tool, please join a webinar hosted by Kaiser Family Foundation on Thursday, December 11 at 12:30 PM EST.

Now if we could only turn this into an app....

 “The healthcare world is changing; providers who have been serving a certain population are now serving a completely new population, a more diverse population. When you talk about cultural competency, what you really need to look at is what the customs, beliefs and values of these individuals are.”

Dr. Terri Mack-Biggs, Geriatrician, Hospice of Detroit, Michigan

There is a significant demographic shift taking place in the United States, particularly for older adult populations. According to the Diverse Elders Coalition, the older population will grow far more diverse in racial, ethnic and cultural dimensions over the coming few decades, as the cohort of Americans age 65 and older doubles in size from 2010 to 2050. A particularly vulnerable population within this broad demographic shift is the Medicare-Medicaid enrollee population, sometimes referred to as “dual eligibles.” According to data from 2008, 61 percent of dual eligible beneficiaries are 65 and over. They have trouble navigating through these two complicated health care systems, often feeling lost in a maze of multiple doctors, medications and programs, and these challenges are often exacerbated for individuals from communities of color.

The Centers for Medicare and Medicaid Services’ financial alignment demonstration projects currently underway in more than a dozen states seek to integrate and coordinate care across Medicare and Medicaid for dual eligibles, and to redress many of the problems experienced in the current disjointed system.

Dual eligibles generally have poorer health status and account for a significant and disproportionate cost burden on Medicare and Medicaid, totaling more than $300 billion annually. People of color comprise 44 percent of the Medicare-Medicaid enrollee population, compared to 17 percent of the Medicare-only population. Diverse dual eligibles face a particularly great challenge in finding culturally and linguistically competent care.

A new paper by Community Catalyst examines provisions in the documents guiding the demonstration projects as they relate to addressing racial and ethnic health disparities and lays out a set of recommendations to move toward achieving health equity for dual eligibles. There is much work to be done. As Patrick Aitcheson of the Diverse Elders Coalition explains, “Equitably meeting the health care needs of diverse populations first requires gaining a deeper understanding of the range and richness of the cultural and linguistic groups you are serving. That is the necessary starting point for delivering culturally competent services.”

Findings from Community Catalyst’s survey of the dual demonstration project documents published to date reveal that while the addressing of health disparities is often present as a broadly stated goal, details of how this goal will be operationalized are largely missing. The paper makes recommendations in the following areas:

Cultural Competency in Care Delivery - The rapidly changing landscape calls for increased training of health care professionals and organizations to provide effective, high-quality care that is responsive to the very diverse cultural and linguistic needs of dually eligible beneficiaries of color.

Language Access - Implementing appropriate language access services can reduce barriers and create clearer pathways for dual eligibles to access the right services, which in turn can improve their health,   their satisfaction with the care they receive, and very often reduce costs by more efficiently connecting beneficiaries to the proper services for their needs.

Quality and Monitoring – Ongoing monitoring and development of appropriate quality measures can lead to a more effective demonstration project.

Consumer Engagement – Having representatives from communities of color participating in consumer engagement opportunities is  critical  to ensuring consumers receive the right services, at the right time in the right setting.

The Centers for Medicare and Medicaid Services, participating states, health plans and providers have a unique window of opportunity in these demonstration projects to improve care for dual eligible beneficiaries of color and point the way forward for the health care system more widely. But success will depend on these stakeholders taking concrete, targeted steps to address health disparities, as well as on strong ongoing involvement by consumers from communities of color and their advocates.

Recently, I had the great pleasure of welcoming participants – advocates, providers, health plans and funders -- at the second annual Voices for Better Health grantee convening. When we first met a year ago, the Centers for Medicare and Medicaid Services (CMS) was just at the beginning of launching a set of demonstration projects for individuals with both Medicare and Medicaid (dual eligibles). At the time, Washington state was four months into a health homes demonstration and Massachusetts was a mere three weeks into its managed care (fully capitated) project. So much has happened in the past year: seven states have now launched their projects, more than 200,000 beneficiaries are now enrolled and several more projects are set to begin in the next few months.

While the goal of these projects is to provide high-quality, cost-effective, integrated care to dual eligibles, some of the most vulnerable people in this country, it will be a long time until we know whether that has been achieved. Until then, we see both the promise and the pitfalls illustrated in two stories I shared with convening participants:

First, the promise:

Maria, a middle aged woman with complex medical and psychiatric needs, had approximately 30 Emergency Room visits in the two months prior to enrolling in the demonstration. She has a chronic substance use disorder and has few social supports. She had no effective primary care and her complaints were not validated or listened to. After an initial assessment by her new plan, her care team came together, collected all of her medical records and worked with her to identify a primary care provider and specialists. She received daily support from her care team. Her care manager and behavioral health specialist were available to answer her phone calls, visit her in her home, and accompany her to appointments. Maria has engaged in psychotherapy and psychopharmacology treatment. She is going to the Methadone Clinic daily. Her care team is working to help her with other supports including a change in her living circumstances. She has not had any Emergency Room visits or hospitalizations since she joined

Now the pitfalls: 

Angela has been living with a spinal cord injury for many years and is confined to a wheelchair. For 20 years, she had the same care manager who worked with her to develop a care plan that allowed for a team of personal care attendants to assist her with her activities of daily living. Earlier this year, she received a letter saying she would be enrolled in a new demonstration project and that she needed to select her health care plan. Her deadline for choosing her plan came before any information was available about the plans’ networks. Since that time, the care plan that she had so carefully crafted disappeared. And, months later, she still does not have a new care plan. She has had trouble finding a primary care doctor that is participating in the demonstration or accepting new patients. But, most importantly, the individual caregivers that came into her home to help her can no longer come because they’re not able to get paid through the demonstration.    

These two stories show that the demonstrations are still works in progress. We are very grateful for the leadership and hard work coming out of CMS and, in particular, the duals office. They have been responsive to the concerns of consumers in the design and early implementation. We know that transforming the health delivery system to make it work for dual eligible beneficiaries is a challenging endeavor. Meeting those challenges will not be easy. But to tackle those challenges, consumers, their advocates and allies – like those taking part in the Voices for Better Health convening – must stay engaged throughout each stage of the process: the design, implementation and monitoring.

It is only through this type of engagement that we can realize the vision of a more just, equitable health care system that provides high quality care to the most vulnerable people and allows them to live their lives with dignity and independence.

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