Four years in, insurers and regulators are still struggling to stabilize enrollment and show savings in the federal integrated care demonstrations for beneficiaries dually enrolled in Medicare and Medicaid, ongoing in 10 states.

Among the challenges carriers are facing are patient opt-outs, physician opposition and churn issues, said key stakeholders at the Sept. 26 America’s Health Insurance Plans’ (AHIP) National Conference on Duals. But despite the difficulties, insurers and state leaders have been committed to demonstrating that a model like this can improve quality of care for dual eligibles.

In the opening keynote at the AHIP conference, Tim Engelhardt, director of the CMS Medicare-Medicaid Coordination Office, said the U.S. spends $300 billion a year on care for the existing 11.4 million duals and gets “less than maximal value” for the money. Engelhardt’s office was established under the Affordable Care Act (ACA) to oversee improvements for the dually eligible population.

Under the ACA, the federal government launched the Financial Alignment Initiative (FAI) demonstration in 2013, which allows states, health plans and CMS to partner in a capitated program to improve outcomes, while increasing patient satisfaction and lowering costs for those dually enrolled in Medicare and Medicaid. The program is slated to continue until 2019.

According to an Aug. 3 Kaiser Family Foundation (KFF) report, there were nearly 400,000 dual eligibles enrolled in Medicare-Medicaid Plans in 10 demo states as of July 2017. The states participating in the capitated demos are California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, Texas and Virginia.

Those who care for “this vulnerable population” can’t afford to have “a classic insurance industry mindset,” Engelhardt said. “We aren’t just aggregators of risk, payers of unpredictable claims. We need to be facilitators of care delivery, coordinators of care and integral parts of our communities and partners to social service agencies.”

Moreover, the majority of dual eligibles are frequent users of the health care system, which makes it even more important to those who work in this segment to figure out a way to coordinate their care, Engelhardt added. Despite the “seemingly seismic upheavals” taking place in the health care industry, “the duals market marches forward, and this is especially true of those products that integrate Medicare and Medicaid services,” he said.

Engelhardt said as he tours the country and speaks to states about their duals programs, “the best of the best out there — the curve-breakers — are the fastest to tell me the 10 things they are doing wrong. And these are seemingly small, tangible and specific things,” he said. His advice to attendees? “Go back home and sweat all of the small stuff. The stuff that often feels really small to health plans and CMS is often the most important to beneficiaries.” An example he gave was how important non-emergency medical travel benefits are to beneficiaries. This aspect of care is often not on the radar for plans, but for patients, it can be a deciding factor in the selection of a health plan, he said.

States Work Through Challenges

Toby Douglas, senior vice president of Medicaid Solutions at Centene Corp., was on a panel of stakeholders at the AHIP conference who reported on the status of the pilots in their states. Centene is among nine plans with duals enrolled in more than one state, according to KFF. As of July, Centene had 32,000 beneficiaries in five states.

Douglas serves as a commissioner for the Medicaid and CHIP Payment and Access Commission (MACPAC), and for 10 years was an executive in the California Medicaid program.

He said California didn’t have a lot of experience with integrated care before it began in the FAI pilot in 2014. In addition, California’s Medicaid programs were operating in silos. With a driving force to balance the state’s budget, California was ripe for welcoming an integrated care scenario, as offered by the pilot — and so far, it has seen “a lot of success. Those that have stayed in the demo have had positive experiences,” he said.

According to KFF, as of July, California’s demo had the largest enrollment of all the states participating, with 118,000 enrollees.

Yet, despite California’s comparative success, opt-outs have been a big problem, according to Douglas. It has been difficult to get all the stakeholders on board, especially consumer advocates, who sometimes don’t understand the integrated program, he said.

In addition, there is physician resistance to the demo because of concerns about a negative impact on their bottom line, leading physicians to encourage patients to not sign up for the duals program.

What’s more, there have been some data integrity issues with state data not matching the CMS data. He also said sometimes states and federal stakeholders “don’t always partner well.”

And last but not least in the list of challenges, “the elephant in the room” is consumer choice, an issue that requires finding ways to attract and please beneficiaries.

Centene has counseled doctors and patient advocates to help them understand the importance of an integrated duals program. Douglas stands firm in the importance of efforts to improve care for duals. Though there has been “a lot of political rhetoric” over the last 20 to 30 years about the growth of health care costs, it’s not going to be fully addressed without looking at duals, he said.

AHIP panelist Elizabeth Goodman, chief of long term services and supports for MassHealth — Massachusetts’ Medicaid program — said Massachusetts was the first state to participate in the demo, launching its One Care and Senior Care Options (SCO) program for dual eligibles in 2013. One unique aspect of the Massachusetts One Care and SCO programs is that they are contracted to provide long-term services and support navigators under a state statutory rule, Goodman said. “It has really been part of the secret to our success.”

These navigators have contributed to some good ratings for the program. A surprising finding for the state has been the performance of the health plans in the pilot in the Medicare star ratings program, she said.

Massachusetts has six health plans in SCO, with one too small to measure. Of the other five, the ratings were good, with one earning 3.5 stars; three plans earning 4.5 stars; and one plan with 5 stars — “which is amazing,” she said.

Gary Jessee, managing director at Medicaid consulting firm Sellers Dorsey, who also spoke at the conference, agreed that physician support has been a barrier, with opt-out rates a challenge in the duals pilots. Up until this year, he served as the deputy executive commissioner for medical and social services at the Texas Health and Human Services Commission. Texas entered the pilot in 2014.

Jessee said he attributed some of lack of support to “a stigma and a perception that our dual program wasn’t working.” Frustrations came from physicians not supporting the pilot. “Change is hard. You can’t have innovation without a partnership,” Jessee said. The Texas pilot had some success by fielding calls from potential members, who received letters from their plans alerting them to the program. When these potential dual participants called on the phone, the state educated them on the duals program, and for the most part, they understood it and supported it when they had the one-on-one opportunity to learn about it, he said.

Enrollment was also a problem, because so many Medicaid beneficiaries qualify then disqualify for Medicaid, month by month, depending on income levels, Jessee said. To address the churn, Texas set up an arrangement with CMS to get automatic re-enrollment if a member lost eligibility and then requalified. This saved a lot of energy, time and money.

Another problem was working with CMS, which he felt expected that the Medicaid pilots would all be alike. “But it wasn’t like that,” Jessee said. The Texas pilot worked with CMS to help the agency understand the unique ways that Medicaid programs work. “It’s coming along,” he said of the discussion.

Jessee is passionate about coordinated care for duals. “Changes are going to continue,” he said. “We want to go forward, not backwards.”

Read the KFF report at