Promise, Peril of Duals Program

Advocates see potential for improvement but also are concerned about consumer protections in the transition of roughly 1.1 million Californians into Medi-Cal managed care. The state is launching a managed care pilot project for beneficiaries who are dually eligible for Medicare and Medi-Cal, California’s Medicaid program.

“This is really a critical moment in time for dual-eligibles and represents an amazing time to improve care for duals,” said Kevin Prindiville, deputy director of the National Senior Citizens Law Center office in Oakland. “But it’s also a time to be very careful and cautious about how we proceed to move forward.”

Prindiville, one of several speakers at an informational forum last month, said California is still negotiating   with CMS officials, so some of the details of the plan are still uncertain.

“These proposals offer great promise and great risk,” Prindiville said. “The promise is that they will improve care, decrease unnecessary hospitalization, and save the system some cost. The risk is that, since they’re in capitated environments, that could create new barriers to care, or new financial incentives that will actually limit care to this high-needs population.”

Fay Gordon, a NSCLC attorney in Washington, D.C., said one of the bigger consumer-protection issues in the duals project is enrollment choice. The federal government has made it clear that it will support passive enrollment, but that consumer choice also will be paramount, Gordon said.

“Federal officials have made it very clear,” Gordon said. “CMS will not approve a lock-in for the Medicare side.”

That is not an official policy decision yet, she said, and that will be one of the clarifying points once state and federal officials agree on details of the transition.

That should happen as soon as a few months from now, according to Mary Andrus, assistant vice president of government relations at Easter Seals.

“What we’re excited about is this is an opportunity for bridging these important services of acute care and the long-term support services,” Andrus said. “We see this as an opportunity to do things differently.”

Like other advocates, though, she cautioned that moving quickly could harm a fragile patient population.

“What will be important to watch for is that these services are ongoing and patient-centered,” Andrus said. “We’re talking about major changes in the way care is delivered, and we’d like to make sure there are places for the caregivers to talk about what’s working, what makes sense, how to do this right.”

Prindiville put it a different way: “There is a lot of concern about whether states are moving too fast,” he said, “given the size of some of these [dual-eligible] programs.”

He reiterated that the negotiations and eventual agreements bear careful watching: “There is a lot of information in these proposals, because there’s a lot of potential for change when we talk about integrating Medicare and Medicaid,” Prindiville said. “There’s a lot of information, but also there’s a lot of detail missing, so far.”

Related Topics

Capitol Desk Medi-Cal Medicare