Medicaid Council hears payment reform plan for duals

On Friday, the Medical Assistance Program Oversight Council heard DSS’ plans for a shared savings payment model for people eligible for both Medicaid and Medicare. The Council also heard feedback and recommendations from the Council’s model design subcommittee. The plan is to create 3 to 5 local Health Neighborhoods (HNs) in CT to provide comprehensive, patient-centered care emphasizing coordination, prevention and self-management. HNs are envisioned as local systems of care, collaboratives of providers across the spectrum including hospitals, physicians, behavioral health providers, long term care providers, home health agencies and pharmacists coordinating care on behalf of patients assigned to them. HNs would be paid in a dizzying number of ways including traditional fee-for-service, upfront payments, two levels of per-member-per-month care management payments, and a controversial proposal to share any savings with the state. DSS is also proposing to withhold some portion of one per-member-per-month payment, pool it with any savings, and return them to HNs based on performance on both quality and cost reduction. Responding to provider concerns, the Subcommittee did not agree with the withhold of care management payments which could undermine incentives to invest in care management. Responding to advocate concern that DSS’s shared savings proposal may provide incentives to deny needed care, the Subcommittee recommended an alternative -- to distribute savings to HNs in aggregate, not based on individual HN savings, for the first year and that distributions from the pool are based solely on quality standards. The Subcommittee was split on DSS’ plans to enroll consumers in HNs based on where they get care and allow them only an opportunity to opt-out. Advocates strongly urged DSS to adopt a patient-centered opt-in enrollment system, ensuring people fully understand their rights. Advocates also raised concerns about how HN lead agencies will be chosen and regulated, to ensure that resources “trickle down” to the providers actually providing and coordinating care and are not used to fill a hole in any institution’s budget, make up Medicaid underpayments, and/or losses due to care coordination. Advocates also urged DSS to require care plans for every patient, not just those identified as high risk or high utilizers of care, and require patient signatures to ensure that patients are involved and agree. Advocates also raised concerns about extra services only available to consumers who enter HNs, including chronic illness self-management education, nutrition counseling, fall prevention and medication therapy management. Advocates believe these important and cost saving services should be available to all patients. A 30-day public comment period on the proposal will begin later this month. DSS expects to submit their proposal to CMS in May.

For background, click here to learn more about Medicare’s payment reform plans to link quality and savings.