The Centers for Medicare and Medicaid Services (CMS) began approving state dual eligible demonstration projects about four years ago, in 2012 – with the first state (Washington) launching its program in July 2013. There are currently nine states with a capitated demonstration program (California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, and Texas); two states with a managed fee-for-service (MFFS) demonstrations (Colorado and Washington); and one state implementing administrative changes to an existing program (Minnesota) – see Dual Eligible Demonstrations – What States Are Moving Ahead? for more detail.
The question is, now four years after the CMS began approving these programs, where are we? Have states made any progress? In the past two months, three reports have been released – but they have limited information for evaluation:
- A December 2015 Centers for Medicare and Medicaid Services (CMS) report that covers the first six months of implementation efforts in the first seven states to implement a demonstration – California, Illinois, Massachusetts, Minnesota, Ohio, Virginia, and Washington (see Report On Early Implementation Of Demonstrations Under The Financial Alignment Initiative)
- A January 2016 report from the U.S. Government Accountability Office (GAO) on care coordination in the first five states to implement demonstration – California, Illinois, Massachusetts, Virginia, and Washington for the period June 2013-December 2015 (see Medicare & Medicaid: Additional Oversight Needed Of CMS’s Demonstration To Coordinate The Care Of Dual-Eligible Beneficiaries)
- A January 2016 preliminary report on savings and utilization from Washington State – the first state to implement a dual demonstration program (see Preliminary Findings From The Washington MFFS Demonstration)
So what does this initial performance data look like? The only state with performance data to date is Washington. In the first seven months of operation, the demonstration saved Medicare $21.6 million dollars – with 6% less in spending than the Medicare comparison group. Savings to the Medicaid program have not been calculated because not all claims data is complete. Additionally, the state’s preliminary evaluation report also presented Medicare utilization for a baseline period and demonstration quarters. The baseline period is a two-year period preceding the demonstration start date of July 1, 2013. The reported preliminary outcome measures include:
- 30-day all-cause risk-standardized hospital readmission rates dropped from 22.9% in 2011 to 17.7% in 2013 during the baseline period. During the demonstration period, the readmission rate continued to drop to 15.4%.
- ER visits per 1,000 eligibles (excludes visits resulting in inpatient admission or death) dropped from 200.5 per 1,000 in 2011 to 184.9 per 1,000 in 2013 during the baseline period. During the demonstration period, it increased to 189.2 per 1,000.
- 30-day follow-up in a physician or outpatient setting after hospitalization for mental illness dropped from 41.8% in 2011 to 41.2 in 2013 during the baseline period. During the demonstration period, it decreased to 28.4%.
Evaluations of these measures should be cautioned however, as they have not been tested for significance and a conclusive connection cannot be made between the measure outcomes and the related to the demonstration (see First Year Of Washington State Managed FFS Duals Demonstration Shows 6% In Medicare Savings).
Looking ahead, of the thirteen states actively participating in the demonstration, only one state has yet to implement their demonstration – Rhode Island. Additionally, New York is implementing a second demonstration for the intellectual and developmental disability population. Rhode Island expected to implement their demonstration in winter 2016 and New York has a start date of April 2016. For the other states participating, including Washington, the future of the demonstration is less certain.
The most likely reason we have evaluation information for Washington is that the state had terminated funding for their dual eligible demonstration during the 2015 legislative session, effective December 31, 2015. Funding was terminated due to concerns over how savings were calculated and whether the demonstration would actually result in savings. However, due to the preliminary evaluation report released in January, the demonstration has been extended through June 2016 to allow legislators time to review the savings and new report information.
Last summer, CMS announced that states with dual eligible demonstrations would have the opportunity to extend the demonstrations for two years. All states except Virginia have submitted letters to extend their demonstrations, however the letters are non-binding. Virginia has decided to end their demonstration in favor of a more inclusive long-term services and supports program. California’s continuation of the program is based on whether the program can achieve savings before 2017. California does not have an official report detailing cost savings, but the state believes that the demonstration is losing money and the Governor has indicated in his fiscal year 2016-2017 budget that the program will end in 2017 if savings are not generated. Texas’s participation is dependent upon two issues: being allowed to have one passive enrollment period for all dual eligibles and better data sharing between the state and CMS.
For a detailed look at the dual demonstration initiatives in the thirteen states that have programs up and running (California, Illinois, Massachusetts, Michigan, Minnesota, New York, Ohio, Rhode Island, South Carolina, Texas, Colorado and Washington) check out our new market intelligence briefing, What Is The Status Of The Dual Demonstrations Projects?: An OPEN MINDS Market Intelligence Report (free to all OPEN MINDS Circle premium and elite members). The report provides state-by-state detail on the initiative in every state including populations included, current enrollment, estimated saving percentages, services included in the demonstration, geographic reach, and care coordination models. The report answers a number of questions including:
- What Are The Dual Eligible Demonstrations?
- What States Have Dual Eligible Demonstrations?
- What Are The Key Features Of Each State’s Dual Eligible Demonstration?
- How Are Dual Demonstration Savings Calculated?
- What Is The Current Enrollment Of The Dual Eligible Demonstrations?
- What Are The Early Results Of The Dual Eligible Demonstrations?
- What Is The Future Of Dual Eligible Demonstrations?
And for additional resources, check out:
- CMS Considering More Care Coordination Reporting For Dual Eligible Demonstrations
- Data Book: Beneficiaries Dually Eligible For Medicare & Medicaid
- Virginia Medicaid Plans To Implement Managed LTSS In March 2017
- Partners Health Plan To Pilot New York Managed Care Option For Dual Eligibles With Intellectual & Developmental Disabilities
- Dual Eligible Demonstrations – What States Are Moving Ahead?
- Texas Letter Of Intent To Extend Financial Alignment Initiative Scheduled End Date
- California Letter Of Intent To Extend Financial Alignment Initiative Scheduled End Date
- Medicare & Medicaid Financial Alignment Initiative (A CMS Fact Sheet On The Dual Eligible Demonstration Program)
- Financial Alignment Extension Opportunity Memorandum
The year ahead will be an important one for the future of care coordination initiatives for the dual eligible populations. We’ll keep you posted on new developments as they unfold.