Comments on dual eligible proposal center on behavioral health co-lead

Comments at Friday’s Complex Care Committee meeting focused on the late addition of requiring a behavioral health co-lead to DSS’s proposal to manage care for CT’s dual eligible. The pilot proposal would create five health neighborhoods, a collection of local providers across the care continuum, working as a team to coordinate care for about 5,000 people eligible for both Medicare and Medicaid. DSS and several multi-stakeholder committees have been working on the proposal for about a year. Until a few weeks ago, the plan was for the neighborhood to be administratively headed by a single local lead organization that would assemble the providers in the neighborhood, have content expertise in patient-centered care, etc., financial solvency, and would submit the application to DSS. However, very recently, DSS and DMHAS added a requirement that there be two co-leads – one medical and one for behavioral health. The concern was that 38% of dual eligible have serious mental illness and that their needs might not be addressed in a neighborhood headed by a medical lead. Both advocates and providers voiced concerns about the new proposal. The largest concerns include the lateness of the addition and inadequate time to integrate it into the larger, very complex plan. The law of unintended consequences is strong. Other concerns include reducing the number of applicants and available choices for the state and for consumers, anti-competitiveness, troubling involvement of state agencies in the competition and shared savings, a multitude of operational and financial questions, and that this may open the door to other co-leads. Many feel that it is not necessary, or even helpful, to designate a behavioral health co-lead to ensure that the 38% of patients with serious mental illness get the care they need and that medical and behavioral health are integrated. Creating co-leads undermines the foundational concept of a neighborhood of care. Despite the still-open comment period and concerns voiced from the beginning, DSS responded at Friday’s meeting that they intend to submit the application with the behavioral health co-lead. They only solicited comment on how to do it. It is unfortunate that this last-minute surprise addition has undermined what has been a collaborative process largely resulting in a consensus proposal. While there is much agreement on the rest of the proposal, other areas of concern include how savings will be shared across and between neighborhoods, how improved quality will be rewarded, how voluntary enrollment will be, care plans for every neighborhood consumer, conflicts of interest in co-leads also providing services, the need for robust evaluation and monitoring, and fairness in available services. The opportunity for public comments closed Friday. DSS plans to submit the plan to CMS very soon.