How To Protect Seniors During Duals Conversion?

by David Gorn

TOPIC ALERT:

Yesterday's stakeholder meeting to help plan the duals conversion pilots was partially notable for what it was not.

It was not rancorous, it was not loud and the discussion went relatively smoothly for the Department of Health Care Services, compared with last week's grilling of DHCS over the smaller conversion of SPDs (seniors and persons with disabilities) to managed care.

"Hearing the issues here today is very important for us," Melanie Bella of CMS said at the end of the meeting. "A couple of things we said were non-negotiable here are stakeholder involvement, meaningful stakeholder involvement and consumer protections."

Protecting the level of medical care for dual eligibles (Californians eligible for both Medicare and Medi-Cal benefits) was the subject of yesterday's stakeholder meeting in San Francisco. It was the second of three planned meetings in December. The last one is scheduled Thursday in Los Angeles.

At the San Francisco meeting, DHCS deputy director Jane Ogle announced there will be a series of town hall meetings over the next couple of months to make sure dual eligible patients get their say.

"We'll have the town halls in January and February, and maybe into March," Ogle said.

The four pilot sites for the dual eligible demonstration project are expected to be chosen in mid- to late March, so those town-hall meetings are designed to solicit input before that decision is made.

The state is moving relatively slowly on the duals project, which involves about 1.1 million Californians who generally have multiple medical conditions, medications and providers. It's a population that has to be treated carefully, according to panelist Kevin Prindiville of the National Senior Citizens Law Center.

"This is an ambitious project," Prindiville said. "The scope is huge, it hasn’t been done outside of a few small places and projects at all. And it's not just a process of bringing Medi-Cal and Medicare together, but it's also bringing Medi-Cal together, because services right now are fragmented."

There's a difference between coming up with a plan for this conversion and the actual implementation of a plan because it's breaking new ground, he said. "The root of the challenge is to bring the medical and the social together, and our primary concern is that we lose the social in that equation," he said, adding that the transition could be jarring for seniors, many of them with dementia, who could have severe trouble switching providers or provider settings.

"What might be the greatest consumer protection is to take this process slowly -- adding authority slowly, expanding risk slowly as the project moves forward, and making sure the model works before serving too many people," Prindiville said.

Health consultant Peter Harbage, who is organizing the stakeholder outreach effort, said one of the big elements that still needs to be worked out is oversight.

"What is the criteria to evaluate whether a plan or demonstration site is properly including beneficiaries, with interaction and enough feedback with the actual client?" he asked. "This is the first time we've had a public conversation of that."

Panelists raised concerns about building in alternative methods of communication, such as audio or Braille, in part because so many dual eligibles are hearing- or vision-impaired.

"We have to do it right, not do it fast," panelist Janie Whiteford of the California In-Home Supportive Services Consumer Alliance said. "We need to think about what it means to have access. It needs to go better than the 1115 waiver has."

She was referring to the SPD conversion that is part of the 1115 federal Medicaid waiver. That SPD program has been operating for about eight months, and was the piñata at last Wednesday's joint Senate and Assembly health committee oversight hearing in which advocates, providers and health plans all voiced concerns about implementation glitches.

Prindiville expressed some concern at yesterday's meeting that the same thing might happen to the much larger duals conversion.

"One of the challenges is, it's easy to describe a care model that's good," Prindiville said. "But how do you make sure it is?"

Vladimir Yepishin
The Manage Care System has the triple great opportunities: 1. Increase the attention to the person as whole, not to his/her diseases or social problems; 2. Decrease the treatment mistakes. 3. Make the treatments cost effective.

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