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Early Insights from One Care: Massachusetts’ Demonstration to Integrate Care and Align Financing for Dual Eligible Beneficiaries

Massachusetts was the first state to launch a 3-year capitated financial alignment demonstration to integrate care for beneficiaries who are dually eligible for Medicare and Medicaid – One Care – in October 2013. This report describes the early implementation of Massachusetts’ capitated demonstration.  Findings are based on interviews conducted with a diverse group of state leaders, including representatives from state agencies; medical, behavioral health, and social services providers; consumer advocates; and health plans, involved in the design and early implementation of the One Care program. The report also includes data drawn from various sources to provide context for the qualitative findings.

As of February 2015, One Care had enrolled 17,763 beneficiaries (or over 18 percent of the estimated 96,449 eligible state residents), about 63 percent of whom were automatically assigned to a health plan and enrolled into the program; 37 percent voluntarily chose to enroll on their own.

The Massachusetts’ demonstration includes the following features:

  • focuses on the non-elderly dual eligible population, an estimated 70 percent of whom have behavioral health service needs;
  • excludes beneficiaries who participate in Medicaid home and community-based waivers;
  • requires that participating health plans contract with Independent Living Long-Term Services and Supports (LTSS) coordinators from community organizations to work with participating beneficiaries;
  • offers expanded Medicaid state plan benefits, as well as diversionary behavioral health and community support services; and
  • contracts with organizations outside of any state government agency to provide independent ombudsman services for the demonstration.

Beneficiaries, the state, plans, and providers faced several challenges during the early implementation stage of the demonstration, such as:

  • delayed launch date due to planning challenges associated with implementing significant financial and delivery system changes for beneficiaries with complex health needs;
  • gaining robust health plan participation, as three of six health plans decided not to participate in the demonstration due to concerns about upfront costs to build the necessary care delivery infrastructure and develop a robust provider network within the constraints of the demonstration’s financial model;
  • passive enrollment-related issues including tracking down reliable contact information for new demonstration enrollees and confusion resulting from uncoordinated demonstration enrollment notices and Medicare Part D disenrollment notices;
  • addressing findings from initial health plan assessments that some beneficiaries needed to be placed in a higher rating category due to previously unmet or unrecognized needs;
  • implementation of the role of the LTSS coordinator, as this is a new function, and health plans have spent more time than anticipated locating new enrollees and performing initial assessments, leaving less time to focus on the LTSS coordinator’s role and service planning to date; and
  • building provider networks for plans with sufficient primary care, behavioral health, and LTSS capacity to meet the needs of the population.

Strengths of the implementation process that were identified included:

  • design and implementation of One Care was conducted in an open, participatory, and transparent manner; for example, the state publishes monthly enrollment reports, and holds public One Care meetings, initially monthly and now at least 3-4 times a year, where enrollment information and other updates are presented and discussed, and feedback is encouraged from all participants;
  • involvement and encouragement of robust stakeholder and beneficiary participation throughout the planning stages and implementation; for example, an Implementation Council, made up of beneficiary, provider and advocacy organization representatives was established early on and provides ongoing feedback; and
  • sufficient enrollment numbers were ensured through the passive enrollment process, which was helpful in reducing financial concerns of participating plans.

As the first capitated dual eligible financial alignment demonstration to be implemented in the country, Massachusetts’ early experience can provide important insights for other states as they move their demonstrations forward in the coming months, as the first reports from CMS’s formal evaluation are not expected to be released until 2016. It is important to note that this case study provides a very early look at the program.  Overall, stakeholder interviews conveyed a general sense of cautious optimism about the potential for the demonstration to transform care for the dual eligible population in Massachusetts. However, stakeholders also agreed that it was too early or that data were not yet available to assess key aspects of the demonstration, including whether the capitated rates and risk adjustment are adequate to support the long-term financial viability of the care delivery model, the amount and sources of savings, the demonstration’s impact on beneficiary health outcomes, and the appropriateness of the selected quality measures given the unique and complex needs of the beneficiary population. Consequently, it will be important to assess Massachusetts’ and other states’ demonstrations over time as more information becomes available.

Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.