Medicare Watch

Patient-Centered Care Means a Strong Patient Voice in ACOs

This week, the Medicare Rights Center, along with other members of the Campaign for Better Care (CBC), responded to a request from the Centers for Medicare & Medicaid Services (CMS) for comments on a proposed rule that governs the formation of Accountable Care Organizations (ACOs). The comments emphasize the importance of patient engagement and of the consumer protections that must be part of any model. For example, patients should be allowed to seek care outside of an ACO network of providers. Also, a notice must be provided to patients that defines ACOs and describes what patients should expect if they receive care from an ACO. According to the comments, the notice should also detail the financial relationships between physicians and other providers who participate in the model.

The comments focus on the importance of ensuring that patients have a meaningful voice in ACO administration and that patients, and when appropriate, caregivers and family members, be engaged in decisions about medical care. Furthermore, in addition to clinical measures, the comments state that patient satisfaction and experience must be built in to the quality measurements that will be used to examine ACO success.
 
An ACO is a group of health care providers who agree to be held accountable financially for providing high-quality care while lowering costs. The promise of ACOs is that providers will have greater incentives to coordinate care for patients across settings, improving the quality of care patients receive. By using techniques such as tracking patients’ adherence to post-hospitalization regimens and promoting prevention, providers should be able to avoid the need for more expensive acute care. If Medicare savings are achieved by health care providers who participate in an ACO, they will be able to share in those savings. Under the proposed rules, patients will be retroactively assigned to ACOs based on where they receive the plurality of their primary care. This will be determined based on claims submitted to Medicare by patients’ primary care physicians.

Read the Medicare Rights Center’s and the Campaign for Better Care’s comments on the ACO proposed rule.

Learn more about the Campaign for Better Care.

Understanding the Dual-Eligible Population

The high cost of providing care for dual eligibles, individuals with both Medicare and Medicaid who often have complex medical needs, has made the population the subject of many policy discussions at both the federal and state level. The Kaiser Family Foundation and the Alliance for Health Reform hosted a panel last week to provide an overview of this unique population and to review the ways in which federal and state governments are working to address dual eligibles’ needs. Several documents and fact sheets released in conjunction with the panel also highlight the characteristics of this population.

Nearly nine million people with Medicare are also enrolled in Medicaid, according to the Kaiser Family Foundation. While dual eligibles make up about 15 percent of the Medicaid population, they account for almost 40 percent of overall Medicaid spending. The Affordable Care Act (ACA) established the Medicare and Medicaid Coordination Office (MMCO) at the Centers for Medicare & Medicaid Services (CMS) to work with states and other stakeholders to improve coordination of care and coverage for dual eligibles. This includes helping states to develop different models that will ensure access to the care and services dual eligibles require, with the goal of improving the population’s overall health and preventing the need for more acute and expensive care. Such models include, but are not limited to, establishment of Special Needs Plans (SNPs), which are private plans specifically targeting dual eligibles, the use of the Program of All-Inclusive Care for the Elderly, also know as PACE, which is a fully integrated model that targets the most at-risk dual-eligible population, and new models such as Accountable Care Organizations (ACOs). 

Understanding the support and coverage that Medicaid provides for people with Medicare is also important in the context of the current federal deficit conversation, because dramatic cuts to Medicaid will impact people with Medicare by reducing access to affordable health care and to long-term care services and supports. Twenty-one percent of people with Medicare rely on Medicaid to provide supplemental coverage to Medicare and fill in gaps in Medicare coverage. Furthermore, Medicare does not cover long-term care supports and services and, as a result, some people with Medicare rely on Medicaid to access this type of care. In fact, 70 percent of Medicaid spending on dual elgibles in 2007 was spent on long-term care services. 

Watch Kaiser Family Foundation’s “A Primer on Dually Eligible Beneficiaries.” (Scroll to the bottom of the page for related documents.)

 

Medicare Reminder

If you have Medicare and Medicaid, you will usually get your drugs covered by the Medicare prescription drug benefit (Part D) and the Extra Help program. Extra Help is the federal program that pays for most of the costs of Medicare drug coverage. In some limited cases, Medicaid may cover drugs that Medicare does not cover.

In many states, Medicaid covers some drugs that are excluded from Medicare coverage by law. Drugs excluded from Medicare coverage by law that may be covered by your state’s Medicaid program include:

• Certain anti-anxiety drugs (barbiturates and benzodiazepines)
• Drugs for:
• Anorexia, weight loss or weight gain
• Fertility
• Cosmetic purposes or hair growth
• Relief of the symptoms of colds, like a cough and stuffy nose
• Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
• Non-prescription drugs (over-the-counter drugs)

In some states, Medicaid covers additional medications for people with Part D.

Learn more about Medicaid and Part D at www.MedicareInteractive.org.

Spotlight

Representatives from Medicare Rights attended the 17th Annual SHIP (State Health Insurance Assistance Program) Conference in Dallas this week. At the conference, Federal Policy Director Ilene Stein gave a presentation on coordination of benefits and enrollment in Part B. Many people who qualify for Medicare are confused about whether they need to enroll in Part B if they are still working, and about how Medicare works with their current insurance.

Learn more about whether you should enroll in Part B.