Improving care for dual eligibles could lower rehospitalizations, study finds

McKnight’s Long Term care

June 18, 2012


 More focused treatment of common illnesses among dually eligible Medicare and Medicaid beneficiaries could cut costs and lower hospital readmissions, researchers found.

In analyzing data from 958,837 hospitalizations of residents of Medicare and Medicaid-covered nursing facilities and Medicaid home- and community-based services waiver programs in 2005, investigators found that 39% of admissions might have been avoided with more effective care.

Conditions including pneumonia, congestive heart failure, urinary tract infection, dehydration and chronic obstructive pulmonary disease or asthma were to blame for three-quarters of these admissions, researchers noted.

Interventions that improve long-term care settings and expand home and community-based service programs, “will require additional investments by state Medicaid programs to yield savings or Medicare policies that provide an incentive to reduce hospitalizations,” Edith Walsh, Ph.D., lead author of the study, said.

The study was published in the May issue of the Journal of the American Geriatrics Society.

Medicaid Regulations No Match for Rural Roads


The dispute between an Eastern Kentucky hospital chain and private Medicaid operators has lawyers arguing distance versus drive time. Under state regulations, a private Medicaid operator cannot sign up a patient unless it has a doctor or hospital within 60 miles of that patient’s home. But that distance is measured as the crow flies and the state doesn’t take into account narrow and winding Appalachian roads. For many patients, it may be faster to visit a doctor that’s 70 miles away than it is to visit one that’s 50 miles away.That’s prompted the Appalachian Regional Healthcare hospital chain to argue against the 60-mile rule.

ARH says it has hospitals that are easier to get to for Eastern Kentucky patients, therefore no private operator could have a proper healthcare network without a contract with ARH. The state and private operators disagree.

“I think they do realize there is an issue there it’s just a question of how’s that’s been interpreted,” says Anne Hadreas with the Kentucky Equal Justice Center.

State regulations also say providers within a one-hour drive are in a patient’s network, but Hardreas says that isn’t often enforced.

“It definitely puts more of a burden on the consumer and we’re talking about Medicaid patients here who are by definition are low income and it means that they will have to travel farther to get the same amount of care,” she says.

Millions still go without insurance if law passes

Millions still go without insurance if law passes

By TOM MURPHY, AP Business Writer – 4 hours ago 

One of the biggest misconceptions about President Obama’s health care overhaul isn’t who the law will cover, but rather who it won’t.

If it survives Supreme court scrutiny, the landmark overhaul will expand coverage to about 30 million uninsured people, according to government figures. But an estimated 26 million U.S. residents will remain without coverage — a population that’s roughly the size of Texas and includes illegal immigrants and those who can’t afford to pay out-of-pocket for health insurance.

“Many people think that this health care law is going to cover everyone, and it’s not,” says Nicole Lamoureux, executive director of the Alexandria, Va.-based National Association of Free & Charitable Clinics, which represents about 1,200 clinics nationally.

To be sure, it’s estimated that the Affordable Care Act would greatly increase the number of insured Americans. The law has a provision that requires most Americans to be insured or face a tax penalty. It also calls for an expansion of Medicaid, a government-funded program that covers the health care costs of low-income and disabled Americans. Additionally, starting in 2014, there will be tax credits to help middle-class Americans buy coverage.

The Supreme Court is expected to hand down a decision this month on whether to uphold the law completely or strike down parts or all of it. If it survives, about 93 percent of all non-elderly, legal U.S. residents will be covered by 2016. That’s up from 82 percent this year.

Still, millions of illegal immigrants won’t qualify for coverage. This population will account for roughly 26 percent of those who will remain uninsured, according to Urban Institute, a nonpartisan think tank.

And many legal U.S. residents will go without insurance, too. About 36 percent of the population that remains uninsured will qualify for Medicaid but won’t sign up for various reasons. Others likely will make too much money to qualify for assistance but be unable to afford coverage.

Here’s a look at some of the groups that will likely remain uninsured if the law survives:


More than 11 million unauthorized immigrants live in the United States, according to the Pew Hispanic Center, a nonpartisan research center. That amounts to nearly 4 percent of the total population. But there are no provisions that address illegal immigrants in the health care law.

They won’t be able to sign up for Medicaid. They won’t be eligible for the tax credits to help buy coverage. And they won’t be able to use online marketplaces that the government will set up in order for people to get coverage in a process that’s similar to buying plane tickets on travel web sites. Those online exchanges, much like the tax credits, will require proof of citizenship.

“They will still need to find alternative ways to seek care because nothing in the law really expands coverage and affordable coverage options for undocumented immigrants,” says Sonal Ambegaokar, a health policy attorney with the National Immigration Law Center in Los Angeles.

The topic is a politically divisive issue. On one side, there are people who say that the government should provide health care for all U.S. residents — legal or not. The other side contends that doing so could take valuable resources away from U.S. citizens.

“Because of the limited supply of health care, we’re almost in a sociological triage,” says Bob Dane, spokesman for the Federation for American Immigration Reform, a national group that calls for stricter immigration laws. “It begs the question, ‘Who do we serve, who do we serve first and who is not entitled?'”

Researchers have found that immigrants tend to use the health care system less than legal residents. Illegal immigrants, in particular, tend to avoid using the health care system until they have to, favoring home remedies first or making cash payments to providers when they need care. That population also is younger, so it generally has fewer health care needs, says Timothy Waidmann, a researcher with Urban Institute.

The think tank, using federal government survey data, estimates that illegal immigrants accounted for an estimated $18 billion of the $1.4 trillion spent on health care in the United States in 2007. That adds up to less than 2 percent of total spending.

Some say excluding illegal immigrants from the overhaul will keep some legal residents uninsured, too. Ambegaokar, the Los Angeles attorney, points to parents who are illegal immigrants but have children who are legal citizens because they were born in the United States.

If the parents are not eligible, they may not know that their kids qualify. And in other instances, if one child is legal and the other is not, the parents may decide not to sign up either to avoid playing favorites.

“The goal is to enroll everybody who is eligible,” Ambegaokar says. “But when you make systems complicated and require proof of ID, you’re going to inevitably keep out people who should be in.”


Medicaid, which currently covers more than 60 million people, is expected to add about 17 million more people to its program by 2016 if the law is upheld, according to the nonpartisan Congressional Budget Office, which researches budgetary issues for Congress.

But people are still expected to fall through the cracks. That’s because the requirements and process for signing up for Medicaid can be confusing. And while the overhaul aims to make the process easier, it won’t smooth out all the wrinkles.

The problem? Many people don’t realize that they qualify for coverage. And that likely will still be the case, albeit to a lesser extent, after Medicaid expands.

Coverage depends on how someone’s income stacks up to federal poverty guidelines, which can be obscure to the average person. Plus, because income can fluctuate, someone could qualify one year but not the next.

“Regardless of how much outreach you do … you’re never going to get perfect enrollment,” Matthew Buettgens, another Urban Institute researcher, says.

Staying enrolled can be another hurdle. Medicaid recipients have to re-enroll, sometimes more than once a year. They can be dropped if they miss deadlines, submit incomplete forms or if paperwork doesn’t catch up with them after they move — something poor families tend to do more frequently than the average American household.

Leeanna Herman learned this when an unexpected $300 doctor bill arrived in the mail. The Bakersfield, Calif., resident was pregnant and unemployed and didn’t know her government-funded health coverage had lapsed.

“I was freaking out,” says Herman, 23, who went a month without coverage because she missed the deadline to re-enroll. “How do you expect me to pay that?'”

Experts say online applications and electronic verification of income levels and other things will make this process easier. But deadlines will still matter and some people don’t have easy access to the Internet. And there will still be some people who simply won’t enroll.

“There will always be that segment that says, ‘Aw, the heck with it, I will just wait until I get sick and go to the ER,'” says Stephen Schilling, CEO of Clinica Sierra Vista, a nonprofit that has a network of 27 community health centers in California.

Schilling expects to still see a lot of uninsured patients at the nonprofit group’s health centers even if the law is upheld. The center sits in an agricultural area in California’s San Joaquin Valley, populated with migrant workers and saddled with an unemployment rate of around 15 percent.

It cares for about 60,000 uninsured people annually, thanks in part to grants and a sliding fee scale for patients based on their family size and income. Schilling says he still expects between 20,000 and 40,000 uninsured patients if the overhaul is implemented.


The overhaul calls for tax credits to help middle-class Americans buy coverage. But some people who make too much money to qualify for the tax credits may have a hard time finding an affordable option for private health insurance

The subsidies can pay a large chunk of the insurance bill. For instance, a 40-year-old person who makes $50,000 in 2014 and needs coverage for a family of four might receive a government tax credit of more than $8,000.

That would cover more than 70 percent of the premium, or the cost of coverage, according to a subsidy calculator on the nonprofit Kaiser Family Foundation’s website. Of course, that estimate depends on the type of coverage the person choses, where they live and whether they can get coverage through work.

But the tax credits will go to people with incomes up to 400 percent of the federal poverty level, or $44,680 for an individual this year. People just above that level may have a hard time finding affordable health insurance.

Angela Agnew Laws worries that she might remain uninsured like she has been for the past eight years even if the health care law is upheld.

Laws, who lives in Leesburg, Va., runs a small business that cleans and maintains commercial buildings. She hopes her income will climb to about $60,000 by 2014, which would be too high for tax credit help.

A plan that offers more than just basic protection against big medical expenses could cost as much as $10,000 annually for Laws. She could find less extensive coverage for a lower premium, but that may only save about $1,000.

Laws, 58, figures that she’ll remain uninsured if she can’t find an affordable coverage option that fits a monthly budget already crammed with payments of $1,203 for rent $530 toward her car.

“It’s a scary prospect for me,” she says.

Other states provide perspectives on move to managed care

People from across the country share their views on Medicaid changes

Moise Brutus is a 22-year-old Florida Medicaid beneficiary who became a triple-amputee as the result of a motorcycle crash in 2010. Brutus hadn’t had any experience with Medicaid or other government programs until after the wreck, which left him unable to work or afford private health coverage.

By Mike Shields

Monday, June 18, 2012

TOPEKA — Kansas is part of a new wave of states moving to expand managed care to higher numbers of their Medicaid patients.

Gov. Sam Brownback’s KanCare plan, unveiled in November, would begin moving virtually all the state’s 380,000 Medicaid enrollees into managed care plans on Jan. 1.

Nationally, the first wave into Medicaid managed care began in the early 1990s. By 2008, more than 70 percent of Medicaid beneficiaries nationwide were enrolled, largely as the result of state or local government mandates.

There are fewer studies than one might expect of the effectiveness of Medicaid managed care, experts say. And those that have been done have shown mostly mixed results with respect to health outcomes and cost savings. A working paper released in July 2011 by the nonpartisan National Bureau of Economic Research apparently was the first study to examine Medicaid managed care costs over an extended period from all 50 states.

The authors reported that the 13 years of data they reviewed suggested “shifting Medicaid recipients into managed care plans did not reduce Medicaid spending in the typical state.”

Despite the uncertain or uneven results reported by researchers, states have forged ahead with managed care.


KHI News Service reporters interviewed people involved in Medicaid managed care from Florida, Texas, Kentucky, Georgia, Indiana and Washington, D.C.

Generally left out of the first wave of managed care plans were Medicaid recipients who were elderly or disabled and required long-term services. They tend to be the most needy and thus most costly beneficiaries, and the new wave of expansions, including KanCare, would bring more of them into the plans.

State officials, here and elsewhere, have concluded or hope that including them in managed care will offer new opportunities for savings or at least assure more predictable costs.

KHI News Service reporters have been closely following developments surrounding the KanCare plan. As part of our reporting over the past few months, we have interviewed dozens of people involved in various ways with Medicaid managed care expansions across the nation.

What follows are various perspectives gleaned from some of those interviews.

Jump to:

Florida perspective

Texas perspective

National perspective

Georgia perspective

Kentucky perspective

Indiana perspective

A Florida perspective

Moise Brutus is a 22-year-old Miami, Fla., man who became a triple-amputee as the result of a motorcycle crash in 2010.

Brutus said he was working as an assistant manager at an auto dealership before the accident and didn’t have any experience with Medicaid or other government programs until after the wreck, which left him unable to work or afford private health coverage.

KanCare waiver public forums

Two public meetings are scheduled to take comment on the administration’s proposed Section 1115 Medicaid waiver application:

• 2 p.m. June 18 at Hughes Metropolitan Complex at Wichita State University in Wichita, and

• 3 p.m. June 20 at Memorial Hall Auditorium in Topeka.

Read more on the Medicaid waiver application.

After a few months on Medicaid, while he was still in the early stages of recovery, the state of Florida sent him a letter saying he needed to enroll in a managed care plan. He ignored the letter and subsequently was “auto assigned” by the state to a plan run by WellCare.

Florida incrementally has been moving more of its Medicaid beneficiaries into managed care, and 85 percent of them are expected to be in managed care plans by 2014.

Brutus said WellCare assigned him a case manager. He spurned her initial efforts to contact him by telephone because he was experiencing profound depression that led him to consider suicide after he had sought “stump revision” surgery through traditional Medicaid and was denied.

“I was lost,” he said. “At that point I was still in a lot of pain physically and emotionally.”

Ultimately, his mother responded to the case manager’s calls and the woman was able to connect with Brutus.

“She took it on herself — kind of like she was on a mission to save the world,” Brutus said of the case manager. “She got me in touch with the doctors I needed, got me the medication I needed, because some of the medications I was taking Medicaid didn’t cover. So, she pretty much had to get me an override so I could get the medications, and I went in and did the stump revision. WellCare took care of that.”

He said the case manager also arranged for him to get an additional month of physical rehabilitation sessions.

“To sort of make a long story short, I’m not on any medication at all. I’m walking. They took care of all my prosthetics, my rehab, teaching me how to walk. They got me a new bionic hand. I’m actually the first person to get that approved from Medicaid,” Brutus said.

“I can honestly say I wouldn’t be here if it wasn’t for WellCare and (the case manager). They’re not perfect, but they certainly have helped me a lot. Now, I’m going back to school and I’m pretty much done with rehab. I’m doing some occupational therapy and I’m walking on my own with no assistive device,” he said.

WellCare experiences

“Would I actually recommend (Medicaid managed care) to anyone? From my experience I would, but speaking logically I’m sure not every story has as happy an ending as mine,” Brutus said.

In June 2011, Brutus was among those who testified at a public hearing on Florida’s Medicaid managed care makeover. His comments for this article were from a March 21 telephone interview with KHI News Service.

A WellCare employee helped arrange the interview.

“A lady actually called me (from WellCare prior to the interview) and spoke with me and she pretty much told me to just tell it how it is, that if I feel like I don’t agree with something to definitely let you know,” he said.

WellCare scored better with Brutus than it did with the state of New York, which recently informed the company it had six months to improve performance or face being cut out of its state contract. States rarely have revoked or threatened to revoke a managed care company’s contract for failing to perform, according to a Bloomberg Government study that reported New York adheres to stricter standards than most states.

Jack Maurer, WellCare’s vice president of corporate communications, said the company had responded to the New York assessment by hiring more staff and making other changes.

“The company has been working diligently to meet the (New York) performance standards and, based on recent improved results, hopes to meet these expectations at the next measurement date,” he said.


Anne Dunkelberg of the Center for Public Policy Priorities.

A Texas perspective

Anne Dunkelberg is an associate director with the Center for Public Policy Priorities and has studied managed care’s impact on Medicaid in Texas.

In December 2011, federal officials approved the state’s request to expand fixed-cost managed care to Medicaid beneficiaries in 174 rural Texas counties. The five-year demonstration project, approved through a so-called Section 1115 waiver, is expected to expand the Medicaid managed care population in the state to include about 940,000 people.

The waiver allowed Texas to require people who are dually eligible for Medicaid and Medicare to enroll in a managed care plan. The waiver also provided a pool of federal funding to reward hospitals for improving access to care and the outcomes for Medicaid clients and the uninsured.

“The challenge with judging managed care is that when you’ve seen one state’s Medicaid program, you’ve seen one state’s Medicaid program,” Dunkelberg said. “They’re all different, and every state’s health care market is different – dramatically different.”

One of the overarching benefits of managed care nationwide, Dunkelberg said, has been the introduction of measurable outcomes and the notion of linking payments to performance.

But it’s also become clear, she said, that some states are willing to settle for less than others.

Kansas officials have said they expect to have more than 200 performance standards in place once the KanCare contracts are signed, including about a dozen “pay-for-performance” measures for which companies would be paid or penalized, depending on whether they meet them.

Kansans shouldn’t expect KanCare to be free of controversy or heated criticism, Dunkelberg said.

“Murphy’s Law is in full effect when you’re talking about a managed care rollout,” she said. “The things that can go wrong will go wrong.”

Dunkelberg said she thought it was a little unusual that all five KanCare bidders were for-profit insurance companies. State officials have said they plan to choose three from the five for contracts.

“I’m surprised there aren’t any nonprofits in the mix,” she said. “In Texas we have a significant number of nonprofits in Medicaid. It’s always a good idea to have a range of nonprofits and for-profits so you can compare performance and customer satisfaction.”

A 2011 study by the Commonwealth Fund found that publicly traded, for-profit managed care companies tend to score lower on quality-of-care measures than nonprofit plans.

Finding out how managed care companies have performed in other states is not as easy as it may sound, Dunkelberg said.

“There really isn’t a reliable place to get a sense of how a company performs,” she said. “State agencies and advocacy groups have a tendency to rely on Google clips when it comes to finding out whether ‘State Contractor X’ has been sued or fined. That’s probably not the best way for any of us to get our information, and I don’t think it helps a state be as prudent a purchaser as it should be.

“We need a national clearinghouse of information,” Dunkelberg said.


Chris Flavelle of Bloomberg Government.

A national perspective

Christopher Flavelle is a health care policy analyst for Bloomberg Government, a commercial analyst group in Washington, D.C., and has co-authored three recent reports in a series examining Medicaid managed care in the five states with the largest populations.

“Some states have primarily for-profit managed care, some have primarily nonprofit managed care and some have a mix,” he said. “There seems to be a pattern – and my research isn’t the only body of work showing this – that for-profit seems to be lower performance on health outcomes.”

He said New York alone had a system where poor performance by a managed care organization would trigger sanctions. In New York, he said, plans that fail to meet six performance criteria are put on probation. If they don’t improve, they risk losing the contract.

He said New York also helped assure better outcomes by encouraging “a large number of plans” to compete within the state.

“Some states, like Illinois, have a small number of plans (two) and if one doesn’t perform well, it leaves the state no choice. New York is the other kind of approach. If one isn’t doing well, they can remove that plan from the program.

“Connecticut is one smallish state I’m familiar with,” Flavelle said, “and they recently moved their system from risk-based (capitated or fixed-cost) managed care system with two or three plans to a self-insured program. They use insurance companies to administer the system, but it’s not risk-based. I think it’s possible that other states will be looking at Connecticut to see if they can save money with that approach. Connecticut’s argument was that the companies were taking too much profit.”

Flavelle said a common rationale for states that move to more managed care is to stem the growing cost of Medicaid.

“That’s a sentiment that you hear a lot of, and we took a direct look at it,” he said. “It’s like everything else in this business … you have to be careful how you look at the numbers. If you look at nominal numbers, the governors are right. But if you control for inflation and enrollment growth, the cost per resident actually isn’t going up so fast … it’s actually kind of flat over the last 10 years. So it doesn’t look like cost pressure alone is driving the expansions.”

He said policy decisions for the most part were driving the growth in Medicaid managed care.

“A point I wanted to make in the first study is that I think this is a choice that isn’t out of the hands of policymakers,” he said. “If you assume that costs are out of control, that leaves policymakers no choice. But that’s not the case.

“It’s an active choice. Policymakers can say in the future, ‘If this isn’t working for us, we can try something else.’”

Though managed care has been used in state Medicaid programs increasingly during the past 20 years, Flavelle said it wasn’t clear yet whether it was reducing costs or producing healthier beneficiaries.

U.S. Sen. Chuck Grassley, R-Iowa, “has made this point that he would like to see there be more consistent data on Medicaid and Medicaid managed care,” Flavelle said. “One of the problems of tracking it is there are 50 state programs and they’re all a little bit different.

“Research is always fraught with some type of shortcomings. But even with the constraints as we try to measure this thing, I think it’s fair to ask: Shouldn’t we see some clear evidence of cost savings? I expected to find more clear evidence going into this that Medicaid managed care works. None of the five states I looked at had obvious evidence of that.

“I’ve seen some studies arguing for the cost savings,” he said. “But the ones I’ve seen have tended to be industry-funded. I wish there was more evidence.

“I think whatever happens with the Supreme Court and the health care overhaul, this Medicaid managed care push is going to keep on going. I think it’s going to be one of the most important health issues of the next 10 years.”

A Georgia perspective

Georgia officials, like their Kansas counterparts, are considering a redesign of that state’s Medicaid managed care system with an eye toward expanding it to include more enrollees, namely the elderly and disabled who depend on long-term services.

Currently, like Kansas, Georgia Medicaid has managed care for low-income children and pregnant women. A consultant’s report released in January encouraged the state to expand managed care, and state officials plan to seek contracts in the fall with roll-out of the expansion scheduled for early 2014.

Cindy Zeldin is executive director of the consumer advocacy group Georgians for a Healthy Future. She said the state’s experience with managed care to date has been “somewhat mixed,” noting that some gaps in the state’s health care delivery system have not been filled.

Much of the discussion by public officials had focused on how to squeeze more money out of the system, she said.

“A lot of groups that work with vulnerable populations have a lot of concerns about the way things have worked with managed care,” she said. “But there’s also a recognition that, across the nation, this is the direction that things are headed. So the focus has become, ‘OK, if this is the way we’re heading, how do we make it work as best we can?’”


Jodi Mitchell of Kentucky Voices for Health.

A Kentucky perspective

Kentucky switched to Medicaid managed care statewide late last year.

The transition “hasn’t been smooth,” said Jodi Mitchell, executive director at Kentucky Voices for Health, a consumer advocacy group.

“The more time you take (to implement it), the better,” she said. “Either you take the time to learn from what’s gone on in other states or you’re going to have a lot of confusion.”

Mitchell said consumer and health advocates in Kentucky have struggled to make the system more responsive to people’s needs.

“We tried to put forward legislation that would hold the MCOs to the same patient protections that are in private insurance plans – things like mental health parity, prompt payment, network adequacy,” she said. “The MCOs came out and said it would add costs, and that the contracts would have to be opened up for review. The Legislature wasn’t willing to do that.”

An Indiana perspective

In Indiana, David Roos, executive director at Covering Kids and Families of Indiana, said the state’s managed care companies have “had their ups and downs” in running the state’s Medicaid programs for children, pregnant women and indigent adults.

Early on, the state had contracts with five managed care companies. Today, Roos said, it contracts with three, and lawmakers have “made it clear they’re willing to live with two.”

One of the companies, Centene, has bid on the KanCare contract.

“It’s a huge company,” Roos said of Centene, noting that, generally speaking, it has been responsive to advocates’ concerns. “Let’s put it this way: Nobody’s a novice.”

Still, he said, managed care has proven to be a “tough market” that has caused some “very good people (in the industry) to get burned out.”