Pilot mixes Medicare, Medicaid, long-term care
Pilot mixes Medicare, Medicaid, long-term care
But doesn’t each one have enough problems?
Just when you thought Medicare and Medicaid each had enough intractable problems of their own, here’s a Baltimore-based pilot project that seeks to combine the two and add a third piece to the puzzle: long-term care.
The University of Maryland’s Center on Aging recently scored an $8 million grant from the Robert Wood Johnson (RWJ) Foundation designed to encourage providers to test a model that would use managed care to integrate Medicaid’s long-term care services with Medicare’s acute care services.
Already, the project is attracting a lot of interest, even from large health systems that aren’t ready to jump into the actual pilot project application competition itself. "That’s one we’ll be watching closely," says Deny Radefeld, executive director of the Scott and White Health Plan, the HMO product of Scott and White Health System in Temple, TX. The HMO has 129,000 enrollees who are served by 500 physicians and 17 satellite clinics.
Pros and cons jump off the page right away as Radefeld weighs the prospects. On the one hand, Medicare and private insurers are squeezing providers’ profits more than ever. On top of that, many state and federal lawmakers are layering on costly requirements specified lengths of stay for a variety of procedures, as well as certain requirements of physician choice while payments remain the same or decrease.
As our population ages, demand will grow’
But there is potential, too. One promising trend for Scott and White is the system’s ability to cut costs. In 1996, premiums dropped 5% for beneficiaries, and the provider HMO’s cost was lower than the 1996 national average.
"We haven’t done any extensive study of long-term care," says Radefeld. "It will be in our future. In the immediate future, it seems hard to put them [Medicare, Medicaid, and long-term care] together. But, as our population ages, demand will grow more and more."
Another feature the pilot project will test is the waiving of many of the state and federal requirements that might hinder that kind of integration today, says Mark Meiners, PhD, director of the Medicare-Medicaid Integration Program at the University Center on Aging.
According to RWJ’s grant requirements, providers in ten states including physician groups, hospitals, insurers, and Medicaid agencies are qualified to participate.
Potential beneficiaries would be "dual eligibles," that is, those individuals who are eligible for both Medicare and Medicaid essentially elderly and impoverished. That’s estimated to be 5 to 6 million people in the United States as a whole, says Meiners.
At the get-go, these beneficiaries bring challenging hurdles for cost-effective, quality care, experts point out. These challenges include complex and chronic care needs that require lengthy stays in a variety of both acute care and long-term care settings.
That’s a tall order by anybody’s yardstick, but there is a way to make this kind of economic/ medical model work, Meiners contends. Health plans can coordinate the entire continuum of health and long-term care services, and successfully contain costs and provide high-quality of care. The bigger hurdle, says Meiners, is that current Medicare and Medicaid care policies present so many obstacles to this kind of sweeping integration.
Here’s what Meiners says the pilot has hope of delivering:
• higher quality of care;
• controlled costs;
• full continuum of care to beneficiaries;
• avenue for providers to purchase the most efficient service package for their clients without regard for traditional payer regulations.
Providers in up to 10 states will be selected to participate in the initial two-year grant cycle.
[Editor’s note: Application kits are available at www.inform.umd.edu/aging. Or, you can call the University of Maryland Center on Aging at (301) 405-2471.]
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