Duals Demonstration Gets Green Light

CMS and California health officials yesterday announced they agree on a framework for the launch of the duals demonstration project starting as soon as October.

About 456,000 Californians who are dually eligible for Medicare and Medi-Cal coverage in the eight demonstration counties will be qualified to participate in the duals project.

State officials announced yesterday the project will be launched under the name Cal MediConnect.

“This is a wonderful next step toward integrating care in California,” said Diana Dooley, secretary of the California Health and Human Services Agency. “We have been working on this for two years … We really want to use this to meet the triple aim of better care, better outcomes and lower cost.”

The agreement delays the planned launch of the project by a month. State officials had hoped to start in September. It also excludes the state’s request for a six-month lock-in period for enrollees, which state officials felt would stabilize the transition. In this agreement, enrollees will be free to opt out of the demonstration at any time.

The eight counties in the demonstration project are Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara.

Department of Health Care Services is overseeing this pilot transition of dually eligible seniors and persons with disabilities into Medi-Cal managed care plans. Toby Douglas, director of the department,  said there is one other big difference between the original proposal and the final product — size.

The state originally wanted to include 800,000 people in the demonstration project. That number has been cut back to 456,000 Californians eligible for Cal MediConnect. In Los Angeles County, where 275,000 of those eligibles live, the agreement sets a maximum cap of 200,000 people who can be enrolled in the demonstration project. Douglas said that cap is important to make sure plans have the capacity to make the transition work properly.

“This is a change from our original proposal, in terms of enrollment strategies,” Douglas said. “We will have phased-in enrollment … San Mateo County will be finalized by January 2014, and in contrast, Los Angeles County will be phased in over a 15-month period.”

The size of the project worries Kevin Prindiville, deputy director of the National Senior Citizens Law Center, a national legal advocacy group with an Oakland office.

“We think that’s positive, that state and federal officials have been listening to concerns about the size of the demonstration project,” Prindiville said, “but we’re still concerned that that’s a really big demonstration.”

Four other states (Illinois, Massachusetts, Ohio and Washington) have similar Medicaid/Medicare demonstration projects, he said, “But Los Angeles County alone will dwarf any other state.”

“Part of the plans’ capacity question is, do they have a network sufficient to provide access? Do the plans have the expertise … [and experience] to serve this big group of duals?,” Prindiville said. “That’s still very aggressive.”

The state is trying something different with Los Angeles County, where the enrollment will be all-voluntary for the first three months, and then switches to passive enrollment — meaning that beneficiaries at that time can opt out, but if they do nothing, they’re automatically enrolled.

“The voluntary enrollment period should be done across the state in all eight counties, before passive enrollment starts,” Prindiville said.

The real concern is not one specific problem, but a series of problems and confusion caused by the four-pronged monster of the project’s large size, rapid timeline, overall complexity and the pressure to save money, Prindiville said.

“We continue to be supportive of the overarching goal, we also want systems aligned and pointed in a patient-centered model,” he said.

“But wishing does not make it so,” Prindiville said. “You start with the goal of coordinated care, but those other things create pressures, and we’re worried that the one thing [that will be left] is saving money.”

This “Medi-Medi” population is a frail one, with multiple chronic conditions and multiple conditions, “so any transition for this population is a difficult one,” Prindiville said.

The complicated frailty of this population is exactly the reason the state wants to implement this transition, Douglas said. “[With] multiple conditions and multiple medications, this is a population that would benefit from coordination of care,” Douglas said at an earlier meeting. “And that’s what we’re trying to do, instead of the fractured system of care they’re getting now.”

Related Topics

Capitol Desk Medi-Cal Medicare