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Over 9.6 million older people and people with significant disabilities are dually eligible for both Medicare and Medicaid. Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program. The dual eligible demonstration projects, developed pursuant to the Affordable Care Act (ACA), aim to improve coordination of services between Medicare and Medicaid, thereby improving quality of care and making the delivery of care more efficient.

Report on Racial and Ethnic Health Disparities in the Dual Eligible Demonstration Projects

Community Catalyst, a national non-profit consumer health advocacy organization, released a paper examining the dual eligible demonstration projects to assess how well the provisions in the documents guiding the projects address racial and ethnic health disparities. The paper, Miles to Go: Progress on Addressing Racial and Ethnic Health Disparities in the Dual Eligible Demonstration Projects, highlights these racial barriers to care, and presents recommendations for achieving health equity for the dual eligible population.

Community Catalyst found that while the Affordable Care Act includes several provisions that could help reduce racial and ethnic health disparities, the federal government has only required that the dual eligible demonstrations address 1) providing materials for enrollees– such as enrollment notices and descriptions of benefits– in languages enrollees can understand; and  2) requiring health plans to develop a culturally competent provider network that meets the diversity of the target population. The Medicare Medicaid Coordination Office (MMCO) has left it up to the states to decide whether to include additional provisions aimed at reducing racial and ethnic health disparities.

Community Catalyst reviewed various documents for the twelve approved demonstration projects, including memoranda of understanding (MOU), reporting requirements, and marketing materials. They then used four factors to evaluate how the demonstration will impact communities of color: Cultural competency in care delivery; language access; quality and monitoring; and consumer engagement. Several specific features within each factor were examined to see if these were addressed by the guiding documents for the demonstrations.

The Community Catalyst report included the shortcomings of projects and also highlighted successful components. For example, they found that the Washington Managed Fee-for-Service (MFFS) MOU is the only document that provides examples of what it means to deliver services in a culturally competent manner; it requires plans to speak with the beneficiary and their families in their preferred language.

The twelve approved demonstration projects that Community Catalyst reviewed: California, Colorado, Illinois, Massachusetts, Michigan, New York, Ohio, South Carolina, Texas, Virginia, and Washington (both capitated and Managed Fee-for-Service for Washington).

Community Catalyst provided recommendations, in addition to what is in the ACA, for both the capitated and MFFS model. These included:

  • Ensuring a Diverse Workforce
  • Delivering Long-Term Supports and Services in a Culturally Competent Manner
  • Cultural Competency Training for Staff and Providers
  • Care Planning
  • Accountability in Language Access Services
  • Simple and Easy-to-Understand Materials
  • Ongoing monitoring, ensuring appropriate quality measures and capturing data related to racial and ethnic health disparities (including collecting data on use of services and on grievances and appeals stratified by race, ethnicity and primary language and examine for disparities)
  • Ongoing consumer engagement (including requiring delivery systems to have representation from communities of color on their community advisory committees)

Community Catalyst urged states and CMS to address the inequalities in health care for racial and ethnic minorities. "With a disproportionate number of dual eligibles being from communities of color, it is imperative that CMS, states and delivery systems (health plans and provider groups) make it their priority to reduce racial and ethnic health disparities…the ACA includes several provisions that could help reduce racial and ethnic health disparities, including nondiscrimination provisions to ensure consumers have access to health care that is culturally and linguistically appropriate. It is vital that CMS and states require delivery systems to adhere by these laws and implement them for the duals demonstrations."

The complete report, Miles to Go: Progress on Addressing Racial and Ethnic Health Disparities in the Dual Eligible Demonstration Projects is available at: http://www.communitycatalyst.org/resources/publications/document/Miles-to-Go-Health-Disparities-in-the-Dual-Eligible-DemonstrationsFINAL.pdf

Michigan Dual Demonstration Update

The National Journal reported that Michigan is delaying passive enrollment in its dual eligible demonstration project. Notices will go out in late January 2015. Individuals will be able to enroll in the program beginning in February, with services beginning March 1, 2015. Passive enrollment will be effective on May 1, 2015. Through passive enrollment, eligible individuals will be enrolled unless they affirmatively elect not to enroll or affirmatively opt out of the program. The program will now operate through December 2018 instead of the previously announced date of December 2017.

More information is available at http://www.nationaljournal.com/library/209219

UnitedHealth Dual Eligible Update

Crain’s Detroit Business reported that UnitedHealth will close its Medicare Advantage dual special needs plan January 1, 2015, and has decided to withdraw from participating in a dual eligible program in metro Detroit.

More information is available at: http://www.crainsdetroit.com/article/20141114/NEWS/141119843/unitedhealth-phases-out-special-needs-plan-withdraws-from-medicaid

Conclusion

The dual eligible demonstration programs are in the early stage of implementation, in varying levels depending on the state. It is essential to monitor these programs to determine whether they improve care coordination for dually eligible individuals, and effectively address racial and ethnic health disparities.

K. Kertesz, December 2014

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