Michigan's Dual Eligibles plan would affect about 200,000 people who are elderly, mentally ill, or physically or developmentally disabled and poor. The purpose of the plan is to reduce costs and improve care. But the premise on which federal and state governments justify the idea that the share of spending can be reduced for the Medicare/Medicaid eligible population is questionable. As stated in the introduction to the Kaiser Commission Report, "Dual eligible beneficiaries are among the poorest and sickest people covered by either Medicare or Medicaid and consequently account for a disproportionate share of spending in both programs." How is the share of spending disproportionate after one accounts for the characteristics of this population?
I think it is safe to assume that medical and hospital costs are generally too high and that we pay too much for prescription drugs and medical devices and equipment. But almost half of the Medicare/Medicaid population are people under 65, many of whom receive Medicaid-funded mental health services through Michigan's Community Mental Health system. Cost increases in areas covered by CMH have been relatively stable:
"Per capita health care costs in the US increased by more than 5% per year between 2002 and 2009, with a total increase of 57% during that period. The public mental health system has seen an increase of approximately 2.2% per enrollee per year in that same period." (from the MACMHB Guide to Integrated Care for Dual Eligibles)
Finding ways to control the high cost of medical care is laudable, but the fear by individuals and their families who receive services through the CMH system is that reducing the costs of mental health services can only be achieved by reducing the number and quality of services available and by cannibalizing existing programs for people with developmental disabilities and mental illness to fund services to other under-funded populations.
Other objections to the plan include:
The use of state-wide standardized assessments to determine needs and identify services is contrary to the idea of Person-Centered Planning. Assessments should be used by the PCP team to determine needs and services, but assessments alone should not be the determining factor. The state plan for dual eligibles reduces the PCP meeting to a little get-together to ratify the decisions that have already been made through the assessment process.
The proposed revisions to the Dual Eligible Plan's "Care Bridge" give more control over assessment and determination of services to an Integrated Care Organization, ICO, a Medicaid health plan, thereby giving decision-making power to the medical system of care rather than the mental health system. While locally controlled Community Mental Health agencies may continue to play a role in assessing and determining needs of people with developmental disabilities, they do so under contract to the ICOs, organizations that have little experience with the populations served by the CMH system. Case management services may or may not be provided by CMH agencies, further diminishing the role of publicly controlled local CMH agencies in implementing and overseeing the provision of services.
Overall, according to the Kaiser Commission Report, there are crucial questions that remain to be answered regarding how the 26 state's will implement their plans.
(Page 16) As CMS continues to review the 26 states’ proposals and finalizes MOUs [Memoranda of Understanding] to implement demonstrations in selected states over the coming months, attention should be given to several key questions, such as:
- How will beneficiaries be notified about the demonstrations and enroll and disenroll?
- How will Medicare and Medicaid contributions be calculated, risk-adjusted, and adjusted over time?
- What will the source(s) of savings be, and how will savings be shared among CMS, the state, plans and/or providers?
- How will the demonstrations affect access to home and community-based services?
- How will medical necessity determinations be made, and how will beneficiaries appeal decisions with which they disagree?
- Will beneficiaries be able to retain their current providers and services and access an adequate provider network?
- How will plans and providers meet the needs of and provide reasonable accommodations to beneficiaries with a range of physical, mental health, and cognitive disabilities?
- How will quality be measured, and how will the demonstrations be monitored and evaluated?
- To what extent will the specific standards that health plans must meet to participate in the demonstrations vary from existing Medicare Advantage and Medicaid managed care requirements?
- How will stakeholders continue to be engaged throughout the design and implementation process?
CMS’s financial alignment models for dual eligible beneficiaries are based on the Center for Medicare and Medicaid Innovation’s (CMMI) new § 1115A demonstration authority created in the ACA [the Affordable Care Act]. The following questions and answers explain the scope of the Secretary’s authority and the process for testing new payment and service delivery models under § 1115A.
What is the scope of the Secretary’s [of Health and Human Services] § 1115A waiver authority?
The law [the Affordable Care Act] prohibits administrative or judicial review of the Secretary’s selection of models, organizations, sites, or participants; the elements, parameters, scope, and duration of models; determinations regarding budget neutrality, termination or modification of a design and implementation; and determinations about the expansion and scope of models.
Wow! A law that is outside the reach of administrative or judicial review? That's a chilling notion. This means the plan will have to be absolutely perfect before it is finally submitted to CMS by the state. What could possibly go wrong?