California finds the road to reform is rocky for vulnerable ‘dual eligible’ patients

More than 9 million health care consumers in the United States are eligible for both Medicare and Medicaid. This group, often referred to as “dual eligibles” or “duals,” includes both low-income seniors with multiple chronic conditions and young people with significant disabilities. Duals are among the poorest and sickest of health care consumers and account for a disproportionate share of health care utilization and spending.

The Affordable Care Act of 2010 established the Center for Medicare and Medicaid Innovation (CMMI), which was charged with testing new ways of paying for and delivering care to those who receive both Medicare and Medicaid benefits. Currently, there are 1.5 million duals in 12 states who are eligible to enroll in CMMI demonstration projects, and more than 450,000 reside in California.

In 2014, California launched a three-year demonstration program for duals called Cal MediConnect, a managed care plan in which participating health plans are responsible for the delivery and coordination of all medical, behavioral health, and other long-term services and benefits. The managed care health plans are paid a monthly fee per enrollee in exchange for providing a package of Medicare and Medi-Cal (i.e., California’s Medicaid program) services.

Most would agree with the goals of MediConnect: to better coordinate benefits and services, improve the quality of care, and reduce overall costs. Historically, the delivery of care to this patient population with complex needs has been disjointed, with little or no communication between providers. This often results in duplication or gaps in patient services. The integration of behavioral health, support services and medical care under MediConnect represents a major shift in the practice and delivery of health care, so this is a brave new world for providers and consumers alike.