Lessons Learned Bringing Care To The Under-Served

posted by Kit Gorton

on May 11, 2016

Chuck is a 58-year-old Tufts Health Plan member who has multiple chronic physical and mental health conditions, including diabetes, congestive heart failure, kidney disease, and depression. On top of his urgent medical needs, he is chronically homeless. Recently he found himself in an emergency room yet again, this time in Florida, far from his last known address in Massachusetts. He ultimately returned to Massachusetts, and with the help of his care team, began looking for subsidized housing so he could focus on his health.

There are many like Chuck in this country. But thanks to a first-of-its-kind demonstration project in Massachusetts – designed to provide extensive health care to adults under 65 who qualify for both Medicare and Medicaid (duals) – he has a better chance to live a healthier life. Tufts Health Plan is one of only two plans in Massachusetts that now participate in the ambitious demonstration project known as One Care – jointly administered by CMS and MassHealth, the state’s Medicaid program.

The program offers extensive services, rooted in the belief that increased benefits and attention early on will help prevent costly medical issues later. While some of these costs are unavoidable, many of them stem from patients foregoing necessary care.

This pilot effort is working to address challenges associated with that very issue. Two-thirds of under-65 dually-eligible patients suffer from a mental health disability, which leaves them wary of the health care system or unable to get to regular appointments. High levels of opt-outs have resulted from patients not understanding what One Care is, not wanting to change doctors, or simply not being interested. In addition, many have unstable housing, causing them to move frequently and increasingly difficult to keep track of. Even among those enrolled, 30 percent of members simply can’t be found.

As the three-year demonstration comes to an end, questions linger: Should the demonstration be extended? Should a permanent successor program be put in place? Could health plans exit the program without disrupting members and providers?

Further reevaluation is necessary for the operating model to evolve into a permanent, sustainable program. Finding and engaging potential members is an unsolved challenge. Underwriting for the under-65 duals is particularly hard for those who have significant behavioral health comorbidities and previously unmet needs. More coordination between federal and state regulators is needed to reduce the number of administrative tasks the plans have to undertake.

OneCare, like other state programs in the CMS Medicare-Medicaid Financial Alignment Initiative, is a groundbreaking demonstration that proves managed care can deliver real value to dually eligible members. Tufts Health Plan was among the first in the nation to sign on. We hope that lessons learned from the demonstration will inform the transition to a permanent program in which Tufts Health Plan would be proud to participate.

Christopher “Kit” Gorton, M.D., is the president of Tufts Health Public Plans, which serves members on Medicaid and subsidized health plans. It is a division of Tufts Health Plan, headquartered in Watertown, Mass.