Managed Care for Dually Eligible

On another discussion venue in which I participate, a very learned and esteemed physician colleague in the San Francisco area shared with our group a recent brief from the California Medical Association (CMA Alert) regarding that state’s pilot project to move dually eligible individuals in Los Angeles, Orange, San Diego and San Mateo counties into a managed care plan.

Under the Medi-Cal 1115 Waiver, California is pursuing four pilot projects to redesign care for dually eligible seniors.  Similar pilot projects are being pursued in a number of other states as part of a national effort under the direction of the Center for Medicare & Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation (CMMI).  Of significance for this post, it was noted in the CMA Alert that, “if dual eligibles (sic) wish to remain in fee-for-service Medicare, they will have to actively choose to do so.”

In other words, they will be assigned to the new managed care pilot project by default.  Given what is the reasonably perceived inability of this aging population to necessarily advocate for themselves, at issue is whether such default can be interpreted as a back door mandate.  Are these individuals being deprived of their right to choose their healthcare provider? And who, by right, assumes the responsibility of advocating on their behalf?

This is certainly a moral dilemma, and I can appreciate CMA physician members’ concerns.  We are a nation and society with deep roots and political sensibilities to individual rights.  We are also a society, however, that is facing a potential national calamity in being unable to provide basic housing, services and care for an aging population that cannot afford to pay for such necessities.  From that vantage, I think an effective argument can be made that the potential to infringe upon such rights is outweighed by the urgent need to proactively develop innovative public policy solutions to address the aging tsunami that is building every day.

But setting aside for the moment the issue of the means by which the dual eligible population is enrolled, according to a Kaiser Family Foundation research paper, when compared to the non-dual eligible population dually eligible individuals are more likely to have chronic care needs, have a higher incidence of ADL needs, and be more than twice as likely to be both in fair or poor health – and suffer from a cognitive or mental impairment. This is a population for which the right to choose their own doctor is often not high on their list of priorities. This is also the very population where coordination of services and care across community-based programs, acute care, post-acute/long-term care and behavioral health services has the most promise of being beneficial to the individual because of the huge communication gaps that now exist between those areas.

So we are looking at a frail elderly population that isn’t able to pay for their own care – and likely in need of a host of complimentary/supplementary assistance (housing, ADL assistance, private duty, medication management, behavioral health – addiction in this population is scarily on the rise).  I do not wish to be ignorant of those individuals’ rights – but we are standing on the beach looking into the abyss of the looming demographic tsunami and understanding before a lot of others that such tradeoffs will have to be made.  They will be made.  The only thing at issue is when and how.  Wouldn’t it be better to plan for the flooding after the age wave hits?

These are the types of critically important public policy issues that senior housing, aging services and PA/LTC organizations should be aware of – and have active participation in their advocacy – whatever your views.

So, what do you think?

  ~ Sparky