Regardless of who pays for health care services, the U.S. health care system is in desperate need of dramatic change to make it the best it can be – affordable, sustainable and focused on outcomes – without leaving millions of Americans, mostly low-income or those with existing health conditions, uninsured. The good news is that reforms can bend the cost curve while improving health outcomes and achieving higher levels of consumer/patient satisfaction.
In its many pages of law and regulation, the Affordable Care Act (ACA) includes a number of initiatives to refocus health care delivery in the most efficient manner. From creating Accountable Care Organizations (ACO) that will be concentrate on quality not quantity to grant programs that provide seed money to create new models of health care delivery, the ACA incentivizes and provides flexibility for states to innovate.
One of those initiatives is focused on developing better ways to coordinate health care for the nation’s lowest-income and most chronically ill – people who are enrolled in both Medicare and Medicaid coverage. This is a critical area for innovation because this group often has complex and costly health care needs and traditionally accounts for a disproportionately high share of medical costs. Dual eligibles in Medicare account for 16 percent of enrollees but incur 27 percent of total spending; in Medicaid, 15 percent of individuals are dually-enrolled but account for 39 percent of program costs.
To address the issues associated with individuals who are dually eligible, the Centers for Medicaid and Medicare Services (CMS) just awarded up to $1 million in federal funding to each of 15 states – California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin – to develop better ways of coordinating care. States will use the funds to design strategies for implementing person-centered models that fully coordinate primary, acute, behavioral and long-term care services.
Last week, CMS also issued a proposed rule to make it easier for states to provide home and community-based services for persons covered by Medicaid. The rule would give states the flexibility to serve multiple groups in a single home- and community-based waiver demonstration project where currently individual waivers are required for each target group. The rule will allow individuals to participate in the design of their own array of services and supports, including such things as personal care and respite services for caregivers.
The goal of such waivers is to integrate people into the social mainstream by clarifying the definition of a home- and community-based care setting. Specifically, the rule disallows settings located on the campus of a facility that provides institutional treatment or custodial care or housing complexes designed expressly for persons with disabilities and allows these individuals to choose the least restrictive environment possible in which to live – like their own home. The proposed rule was published in the Federal Register on April 15, 2011 and will be open for public comment for 60 days.
