California House Democrats Sign Letter Criticizing Dual Eligible Initiative
June 14, 2013 02:08 PM
On June 4, fourteen House Democrats from California wrote a letter to Marilyn Tavenner, Administrator of the Centers for Medicare & Medicaid Services (CMS), criticizing the state’s recently approved Memorandum of Understanding (MOU) with CMS to coordinate care for dual eligibles (the Demonstration). The effort was led by Rep. Linda Sanchez, and co-signed by House Energy and Commerce ranking member Henry A. Waxman. Primarily, the letter’s arguments involved issues of the Demonstration’s timeframe and scope, network adequacy and readiness, and savings rate calculations. The Demonstration has been delayed several times, and is currently set to start by January 2014 at the earliest.
Timeframe and Scope
While appreciating the fact that the Demonstration delays implementation in Los Angeles County, the letter criticized that statewide, “the timeframe and scope are not conducive to a seamless transition [from fee-for-service (FFS) to managed care] for beneficiaries.” Citing provider and beneficiary groups, the House members stated that providers are not prepared to absorb the approximately 250,000 duals into the Demonstration. They also questioned their ability to timely educate beneficiaries, caretakers, and providers on the Demonstration. Finally, the letter stated that the moving of 875,000 children from the California Healthy Families Program to MediCal and the rollout of the Affordable Care Act in California generally makes it extremely challenging to also adopt the Demonstration if the latter is not delayed.
Network Adequacy and Readiness
The letter also mentioned that both providers and beneficiaries are concerned about network adequacy and readiness. House members mentioned one organization, HealthNet, who dropped a large provider from its network shortly after signing on to the Demonstration in LA County. The letter complained of insufficient networks generally, and advocated that CMS closely monitor the Demonstration’s networks to make sure they are adequately established and that providers are sufficiently educated to address the needs of the dual eligible population.
While recognizing the “limited continuity of care for patients with pre-existing physician relationships,” the letter questioned the capacity of the Demonstration to give each beneficiary a needs assessment within a year of implementation. The letter called for CMS to mandate that states have concrete plans for assessments, and for CMS to ensure that there are enough providers to conduct the assessments. The letter questions the ability of plans to conduct care management without sufficient needs assessments.
Savings Rate Calculations
The letter, echoing provider and patient concerns, called the savings rate calculations in the Demonstration “overly ambitious and arbitrary” that “will simply encourage plans to pare down care, rather than providing beneficiaries with the complete array of services that they will need.” The letter also expressed concern with that the drive for savings will negatively impact quality of care, and criticizes the lack of information available regarding rate calculation.
To see a press release issued by Rep. Linda Sanchez’s office, along with the full letter to Ms. Tavenner, click here. To see the Council’s analysis of the Demonstration in California, click here.
While there are currently six states including California that have signed on to the Demonstration, many others have been dropping or delaying implementation. Concerns of timeliness and scope, network adequacy and readiness, and savings rate calculations have caused stakeholders attempt to mitigate implementation in California.
That said, home health providers can still look to the Demonstration as an opportunity to increased clinical coordination among the dual eligible population. In addition, the Demonstration will give home health providers rebalancing opportunities, as a stronger emphasis is placed on community based systems over institutional settings. Home health providers are encouraged to keep abreast of Demonstration developments on CMS’ website, and to contact the Council with any questions or concerns.