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A Health Plan for the neediest and for the nation

Posted by John McDonough  October 24, 2012 08:49 PM

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If our upcoming elections were about addressing big issues and finding real solutions, then the conversation about Medicare and Medicaid would focus on a group known as the "dual eligibles." They are among the most expensive population to care for in the world, and a lot is happening now to improve care and lower costs for these folks. In figuring out how to do this as well as possible, Massachusetts is way out in front, thanks to a group you've never heard of called the Commonwealth Care Alliance (CCA).

First, what's a dual eligible? It's 9 million individuals enrolled in both Medicare and Medicaid at the same time. Duals are in Medicare because of age or disability, and in Medicaid because of low income. Medicare covers what Medicare covers, and Medicaid covers everything else. Duals are much sicker and more chronically ill than most other groups, and much more expensive. For example, about 15% of everyone on Medicaid is also on Medicare, and about 40% of all Medicaid spending pays for their care. For the most part, duals' care is uncoordinated, wasteful, and even harmful. Most Medicaid enrollees living in nursing homes are duals.

The Affordable Care Act (ObamaCare) seeks to address the needs and costs of the duals by setting up a new Medicare Medicaid Coordination Office within the U.S. Centers for Medicare & Medicaid Services (CMS). CMS is using its ACA authority to create a national structure of coordinated care plans to enroll as many duals as possible into these plans. Currently, at least 26 states are working to negotiate memoranda of understanding with the Administration, and Massachusetts is the furthest along.

Yesterday, Dr. Bob Master, the CEO of CCA, wrote a post on the Health Affairs blog describing the new initiative and encouraging the Obama Administration to move ahead with its plans. In the post, he also talks about the progress of CCA in providing comprehensive and coordinated care to about 5,000 elderly and disabled duals in Massachusetts.

Massachusetts has been leading the nation in creating better systems of care for duals for about ten years now. Groups now urging the Obama Administration to slow down are fearful of how the transition may go in the rest of the nation where CCA-type organizations simply don't exist. There is even concern in Massachusetts where CCA and the four other similar groups -- the Senior Care Option plans -- currently enroll only a fraction of the 180,000 senior duals.

The pressure to move fast is related to the budget pressures facing the states and the feds. Medicaid cutbacks seem inevitable as part of the coming federal budget crisis, and states are facing their own pressures. Providing better and more effective care for the dual population is seen by many as a way to lower spending while improving care, one of the elusive and rare win-wins.

Once again Massachusetts is out front in finding new models and paths to fix our badly broken system. Not many folks know about CCA -- but they are helping to redefine health care in profound and important ways.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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