Innovations and Future Developments for Medicare, Medicaid, and Dual Eligible Beneficiaries

The rising cost of prescription drugs, CMS initiative updates, and successes in home and community-based services for dual Medicare and Medicaid beneficiaries were discussed at the America’s Health Insurance Plans’ National Conferences on Medicare and Medicaid, and Dual Eligibles Summit in Washington, DC.

Patrick Conway, MD, deputy administrator for innovation and quality, and chief medical officer at CMS, spoke to the importance of defining measure sets to align the public and private sectors. He also touched upon the new service and delivery models being tested and announced that CMS will likely be putting out a request for information for health plan innovations.

“We’re thinking about things like plan design, including but not limited to value-based insurance design; thinking about care delivery issues, like telehealth and hospice; we’re thinking about beneficiary and provider engagement, and are there ways we can adjust to allow you to achieve higher quality and lower cost for beneficiaries,” Dr Conway said.

Melanie Bella, director of the Medicare-Medicaid Coordination Office at CMS, opened the Dual Eligibles Summit on Tuesday, with an update on the initiatives to care for the 10.2 million people in both programs.

There are currently 13 states participating in the Financial Alignment Initiative (with the state of Washington in both models available). In the 5 states with live capitated models, 150,000 beneficiaries are being served. There are 2 states—Washington and Colorado—using the managed fee-for-service model.

Once the models are live, there is constant communication between the states, CMS, and the health plans, as well as site checks.

“This is brand new,” Ms Bella said. “It is complicated, it is hard, it is resource intensive, and it requires [a] kind of day-to-day collaboration, especially when we launch. Because the beauty of doing this this way is that when we identify things that can be fixed, we can fix them. But we can only do that if we’re all in constant communication.”

Bill Henning, executive director for the Boston Center for Independent Living, echoed Bella’s statement that the dual eligible population can be difficult to engage. After Massachusetts launched its dual eligible program in October 2013, there were not a lot of sign-ups.

“There was no big excitement; there will be no big excitement tomorrow,” he admitted. “We’re a work in progress, and I think that’s probably the message that’s most important.”

He went on to explain how important it was to be on the ground floor and really understand the disabled patients being served aren’t looking to be fixed or cured—they want to be acknowledged as people trying to live their lives. Mr Henning called healthcare and access to healthcare the “most important disability rights issue in America.”

Finally, panelists discussed the rising cost of prescription drugs, focusing on hepatitis C and Gilead’s $1000-day pill, Sovaldi. National Association of State Medicaid Directors Executive Director Matt Salo explained how state Medicaid programs likely don’t have enough tools to either bring down the costs of these expensive drugs or control utilization because the population affected is so large.

Mr Salo added that the greatest fear of state Medicaid directors is that the way they prioritize treatments will be challenged in the courts by an entity like the CDC or the FDA with the thought that there should not be any limits placed on getting treatment to those in need.

“Then we’ll be left with no real control on price, no real control on utilization, and this is an area that’s going to put states in a very, very difficult position,” he said.

Sharon Levine, MD, director and senior advisor of public policy, pharmacy, and professional development at The Permanente Medical Group, Inc, said that US taxpayers are essentially subsidizing companies so they can sell lower cost versions of their drugs to the developing world.

“Is it okay for manufacturers to continue to base all of their profitability on the US market?” she wondered.