New research shows efforts to improve Medicare and Medicaid programs are working

RESEARCH TRIANGLE PARK, NC -- Efforts to improve care and reduce costs for Medicare and Medicaid patients are showing promise, according to new results reported in three issue briefs by RTI International.

The Centers for Medicare and Medicaid Services’ (CMS) Medicare-Medicaid Coordination Office and Center for Medicare and Medicaid Innovation (CMMI) are running demonstration projects in thirteen states as part of their Financial Alignment Initiative.

The initiative is working to develop coordinated care delivery models that integrate primary care, acute care, behavioral health, and long-term support services for Medicare-Medicaid enrollees to improve the quality of care, enhance the patient experience and reduce costs. The patients involved are low income and age 65 and over or under age 65 with disabilities. As a result, they frequently suffer from multiple ailments, including heart disease, diabetes, arthritis, or a serious mental illness; may be frail; and need frequent or long-term care.

“People with both Medicare and Medicaid often have complex medical and supportive service needs but may not know where to turn for help navigating the health care system, to access the care they need, or to improve their health,” said Edie Walsh, the director of the RTI evaluation of these demonstrations.

Walsh continued, “Care coordinators can fill this gap, working with Medicare-Medicaid patients to identify their health care needs, set health goals, and access resources to achieve the goals. The result can include more engaged patients, better health outcomes, and lower health care costs, for example, by helping people decrease their need for emergency room visits and hospitalization.” 

CMS contracted with RTI and its partners at the University of Southern Maine, the National Academy for State Health Policy, the Urban Institute, Actuarial Research Corporation, The Henne Group, the American Institutes for Research, and the Center for Health Care Strategies to:

• Monitor the implementation of demonstrations
• Evaluate the impact on the patient experience
• Monitor and evaluate the impact on the population overall
• Monitor and evaluate the impact on specific population subsets (e.g., those with mental illness and/or substance use disorders and long-term support services users)

These three RTI’s reviews of the demonstrations indicate the Financial Alignment Initiative is showing potential for meeting CMMI’s goals. Participating states largely have been able to overcome major design and operational challenges to implement new care coordination approaches.  Managed care plans in these states have hired and trained care coordinators who work with enrollees to assist them in better managing their care and health needs.

Enrollees in five states indicated in focus groups that they have noticed positive changes in the programs, including greater access to a broader and more flexible range of services.

One woman in Washington said during one focus group that she used to visit the emergency room three to four times a week for little things. “Since I started with (my care coordinator), over the last two years, I’ve been to the (emergency room) once in two years,” she said.

However, focus group participants noted challenges remain—including communication about patient benefits, rights, and protections; access to providers, pharmacies, and supplies; and concerns about the quality and accessibility of non-emergency medical transportation.

Lastly, demonstrations in Washington and Massachusetts showed progress in meeting the needs of racial and ethnic minority patients with complex health issues, such as multiple chronic diseases or persistent mental illness, and patients expressed satisfaction with the services provided by care coordinators. Spanish-speaking enrollees also indicated a preference for providers and materials in Spanish.

The demonstrations under the Financial Alignment Initiative are scheduled to continue for several more years, and RTI and its partners will continue to monitor and report on the impact of the initiatives.

To learn more about the projects, read the three issue briefs:

• Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans under the Financial Alignment Initiative
• Issue Brief: Special Populations Enrolled in Demonstrations under the Financial Alignment Initiative
• Beneficiary Experience: Early Findings from Focus Groups with Enrollees Participating in the Financial Alignment Initiative

Additional reports are also available on the CMS website.