Last week we discussed dual eligible individuals; people using services under both Medicare and Medicaid and specifically “full” dual eligible. These are our friends and neighbors that use a large number of services under both programs. We noted there are 7.4 million full dual eligible citizens of the United States and that more than 168,000 of our fellow Missourians are considered full dual eligible.
Because of the cost and the need for better case management of the services provided dual eligible, the Affordable Care Act created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make the two programs work together more effectively. They are charged with testing new approaches to care coordination which permits states to keep any earned Medicaid savings but also share in the Medicare savings resulting from their management efforts. The biggest of these initiatives is the Financial Alignment Demonstration. In this demonstration CMS is testing predominantly two models to better integrate primary, acute, behavioral health, and long-term supportive services for full dual eligible. The Medicare- Medicaid office wants 2 million of the 7.4 million full-dual eligible Americans enrolled in these demonstrations by the end of 2014.
The two models being tested by the Financial Alignment Demonstration are:
- The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
- Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.
So what’s the difference? The Capitated model and the Patient Centered Medical Home model are both, equally, managed care models. Operationally, the capitated model, through capitation, transfers the risk of financial loss from the state and federal government to a private third party who administers the program to control cost and provider behavior. The Patient Centered Medical Home Model addresses cost and provider behavior by establishing a single point of coordination to design and manage care plans, case manage individuals, and coordinate all services. It then shares the total system savings with providers who meet its quality and cost benchmarks.
As of March 2013 26 states have submitted proposals and 5 have executed memorandum of understanding with CMS (California, Washington, Ohio, Illinois, Massachusetts). The other states remain in negotiations with CMS. Missouri submitted its proposal on May 31st, 2012. Missouri chose to submit a Patient Centered Medical Home Model. Of the currently approved five states, Washington State is operating a Patient Centered Medical Home Model. Iowa and New York like Missouri are expected to receive approval soon.
Home Healthcare, HCBS services and medication management services (MTM) provided through a community pharmacy can play a fundamental role in improving a dual eligible citizen’s health and reducing the cost of their care, regardless of the Financial Alignment Demonstration model chosen by a state.
To make a positive difference in an individual’s health you have to first have a relationship with the individual. To build a relationship you have meet the person where they are; and where full dual eligible are concerned that primarily consist of home or the hospital. It’s better and cheaper for everyone to meet at home.
Where the capitated model is concerned, effective use of Home and Community Based Services (HCBS), services like personal care and basic nursing, and MTM through community pharmacy reduces medical expenditures and can result in better beneficiary satisfaction and increased profit for the insurance company. There is no better return on investment for an insurance company than reducing costly hospitalizations and rehabilitation time spent in Skilled Nursing Facilities after acute events like falls or strokes.
The Patient Centered Medical Home Model likewise benefits greatly from a robust home care component. Where it’s difficult for many dual eligible patients in a Medical Home to get to their doctor’s office, a home health provider, like Pyramid Home Health Services, who provides fully interactive tele-health can bring their doctor into their home. In fact, at Pyramid Home Health Services we use Android tablets and multi-split screen technology to simultaneously case conference with a patient, our nurse in the home, the patient’s physician and the patient’s Pyramid pharmacist. If labs are necessary they can be attained on the spot. If medication regimen need to be changed home delivery can ensure those changes are made the same day. Most importantly everyone knows what’s going on real time and our patient does not end up in the hospital because they could not get to the physician’s office. Now that’s a health care home that can work for our dual eligible citizens.
Pyramid Home Health Services has been Missouri’s premium home care provider since 1972. We offer a full array of home health, HCBS, Hospice and Pharmacy services. We are also a leading provider of both tele-health and tele-monitoring services for individuals with chronic illness. If Pyramid Home Health Services can assist you, your family, patients or plan beneficiaries call us at 888-880-6565 or visit us at www.pyramidhhs.com.