Financial Alignment Demonstrations for Dual Eligible Beneficiaries: A Look at CMS’s Evaluation Plan

Enrollment in the new state demonstrations to integrate care and align financing for beneficiaries dually eligible for Medicare and Medicaid is underway, and there is considerable interest in the demonstration evaluation plans among federal and state policymakers, beneficiaries, and other stakeholders.  The demonstrations are being implemented under new authority, Section 1115A of the Social Security Act, which was added by the Affordable Care Act and authorizes the Health and Human Services Secretary to expand the duration and scope of demonstration models, including nationwide, that are expected to reduce program spending without reducing care quality or improve patient care without increasing spending.  This issue brief describes the Centers for Medicare and Medicaid Services’ plan to evaluate the demonstrations, via its contract with RTI International.

• The evaluation will include both qualitative and quantitative methods.  Qualitative information will be based on site visits, including interviews with state staff; beneficiary focus groups; and stakeholder interviews.  Quantitative information will be based on implementation tracking data reported by states and analysis of claims, encounter, quality, utilization, and cost data.  Each state’s demonstration will have a comparison group of similar beneficiaries unaffected by the demonstration.  The evaluation will not include a beneficiary survey.
• The evaluation will profile each state’s care delivery system prior to the demonstration, identify key elements that the state’s demonstration intends to change, and measure the effects of any changes.  It will describe major demonstration design features in each state and compare those features across demonstration states.  Other areas of focus in the evaluation include beneficiary experience, utilization and access to care, quality of care, costs, subpopulations and health disparities.
• The evaluation results will be reported at regular intervals.  The evaluation plan calls for state-specific initial (based on the first six months of implementation), quarterly, annual, and final reports, as well as an aggregate final evaluation report.  While the law requires the evaluation results to be publicly available, the evaluation plan does not specify which of these reports will be released publicly or when.

The evaluation plan acknowledges that the analysis may be limited by the quality and availability of claims and encounter data.  As the evaluation progresses, it will be important for timely results and reports to be publicly available to promote broad discussion of the demonstrations’ successes and challenges.