Retooling the Medicare/Medicaid Model

National health reform is on a fast track. And most proposals draw heavily on the experiment in Massachusetts, which has led to a phenomenal coverage success. But there is a lesser-known innovation in Massachusetts that may offer greater lessons to our nation in improving health and lowering cost. It is called Senior Care Options, and it targets a population largely ignored by health reform — seniors. To understand its novelty, a quick review of Medicare and Medicaid is instructive.

Both public programs are overseen through one federal agency, the Centers for Medicare and Medicaid Services (CMS). Medicare is administered by the federal government and provides health insurance to seniors 65 and older. Medicaid is funded by the states and the federal government, but administered by individual states. It provides insurance to low-income families, disabled individuals, and seniors. Families represent three-quarters of Medicaid’s enrollment, but only 30% of the costs. Seniors account for much of the rest.

A child on Medicaid costs $1,700 per year. A senior in a nursing home costs $70,000. Herein lies an irony. Medicare was created to provide care for seniors. But that care is putting the greatest pressure on state Medicaid budgets. Why? Medicare does not pay for most long-term care services — the most expensive care for this population. And since most seniors cannot afford long-term care, once they become frail they ‘spend down’ their assets (or previously transferred them to their children) to qualify for Medicaid.

In order to deal with this growing burden, states are investing in innovative community supports and services — like home health and personal-care services — to keep seniors out of nursing homes. To do this well, a state must effectively manage the entire care for this population. But for the 9 million nationally who are on both Medicaid and Medicare, it is almost impossible to do so. This is because each program operates in its own silo with different rules, providers, and services, resulting in enormous fragmentation and added cost. And this cost is significant. Seniors in this circumstance — so-called ‘dual-eligibles’ — account for more than $200 billion in spending per year.

Enter Senior Care Options. Massa-chusetts and CMS entered into a novel experiment in 2004. For dual-eligible seniors, Medicare and Medicaid both provide funding to Senior Care Options organizations, which are responsible for managing all care. The organizations provide care that best meets the needs of individuals without separate funding sources and rules to fragment care. Care is fully coordinated, and patients and their families are actively involved in decisions about their health.

The program has had impressive results. Enrollment in this state now tops 11,000 and has increased each year. (Senior Care Options is not available in all regions of the state, and as a voluntary program does not cover all those eligible.) One recent survey found that customer satisfaction was generally very high. Another showed that those in these organizations entered nursing homes at a rate that was 25% lower than those not in the program.

Senior Care Options teaches that seamless coordination of care is critical to success. Yet, the arcane design of Medicaid and Medicare presents major obstacles. As a result, very few other states have successfully replicated this model, and the care for most dual-eligibles remains largely unintegrated.

As Congress considers a new public plan, shouldn’t we better align the public plans that already exist? The Obama administration can reorganize CMS so that it focuses as much on the unique needs of populations as it does on the rules of payment. CMS should create a program integration unit devoted exclusively to breaking down silos between the two programs and working with states to eliminate barriers to seamless care for dual-eligibles. Doing so will go a long way to reducing costs — and free up resources for more far-reaching reform.

Douglas S. Brown is senior vice president and general counsel of UMass Memorial Health Care in Worcester and a former state Medicaid director.

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