Serving Low-Income Seniors: Lessons and the Impact of COVID-19
November 6, 2020
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The ongoing COVID-19 pandemic has had a disproportionately negative impact on both low-income communities and seniors in the U.S. As the acute effects of COVID-19 are continuously felt, and we enter a challenging winter season for health, it is important to consider how best to serve the nation’s most vulnerable populations. As many as 7.2 million adults aged 65 or older live in poverty as measured using the Supplemental Poverty Measure (SPM), making accessing and paying for health care and services more difficult. Furthermore, roughly half of individuals turning 65 require long-term services and supports (LTSS), yet coverage gaps exist in paying for this type of care. The challenges of coordinating, delivering, and paying for this population’s care and the need for coordinated actions to improve quality of life and health outcomes will persist long after election week.
This briefing overviewed the complex ecosystem of federal, state, and private programs that coexist to integrate medical, LTSS, and social services for low-income seniors. Panelists also highlighted how the COVID-19 pandemic response has only made these efforts more complicated and present potential policy solutions, especially state-federal and public-private partnerships, to best serve this complex population.
Speakers:
- Katherine Hayes, J.D., Director of Health Policy, Bipartisan Policy Center
- Lynda Flowers, J.D., MSN, R.N., Senior Strategy Policy Advisor, Public Policy Institute, AARP
- Elizabeth Wood, MPAP, Health Researcher, Mathematica
- Sarah J. Dash, MPH, President and CEO, Alliance for Health Policy (moderator)
Presentation: Presentation
Event Resources
Key Resources
Additional Resources
Experts
Speakers
Lynda Flowers
AARP
Senior Strategy Policy Advisor, Public Policy Institute
lflowers@aarp.org
Katherine Hayes
Bipartisan Policy Center
Director of Health Policy
khayes@bipartisanpolicy.org
Elizabeth Wood
Mathematica, Health Researcher
ewood@mathematica-mpr.com
Experts and Analysts
Cindy Mann
Manatt, Phelps & Phillips, LLP
Partner
cmann@manatt.com
Vincent Mor
Brown University School of Public Health
Florence Pirce Grant Professor of Community Health
Vincent_Mor@brown.edu
Michelle Herman Soper
Center for Health Care Strategies, Inc.
Director, Integrated Care
msoper@chcs.org
Government
Nina Ashford
Medicare-Medicaid Coordination Office at Centers for Medicare & Medicaid Services
Deputy Director of Program Alignment
Nina.Ashford@cms.hhs.gov
Marc Steinberg
Medicare-Medicaid Coordination Office at Centers for Medicare & Medicaid Services
Technical Director
Marc.Steinberg@cms.hhs.gov
Stakeholders
Melanie Bella
Cityblock Health
Chief of New Business and Policy
melanie@cityblock.com
Leslie Fried
National Council on Aging, Senior Director
Center for Benefit Access
leslie.fried@ncoa.org
Sachin Jain
SCAN Health Plan
President and CEO
SJain@scanhealthplan.com
Anne Montgomery
Altarum, Deputy Director
Program to Improve Eldercare
anne.montgomery@altarum.org
Transcript
(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)
0:06
Hello, everybody. Thank you for joining today’s webinar on Serving Low-Income Seniors: Lessons and the Impact of COVID-19.
0:12
I’m Sarah …, president and CEO of the Alliance for Health Policy. For those who are not familiar with the Alliance, welcome, We are a non partisan resource for the policy community dedicated to advancing knowledge and understanding of health policy issues.
0:27
Today’s a momentous day for our country and as we all wait for the results of the election, we’re thrilled to have you join us today, because no matter what the outcome that the fate of low-income seniors and dual eligibles, as we will talk about today, remains very, very important policy challenge. The Alliance for Health Policy gratefully acknowledges the support of Arnold Ventures or supporting today’s webinar, and we’re really pleased to partner with them on this. So, I’m going to now turn it over to REL Mirror, Vice President of Healthcare Centers to provide some brief opening remarks before we get started.
1:04
Arielle.
1:07
Thank you, Sarah.
1:09
Welcome, everyone. I’m Arielle. I’m here and I’m the vice president of a complex care program at Arnold Ventures.
1:16
You might be familiar with Arnold Ventures and our approach to philanthropy. But our investments in the face are relatively new. So I wanted to take a moment just to share about why we are doing this work.
1:29
Adventurous, healthcare work is motivated by a deep concern about the affordability of healthcare in this country.
1:37
We have a system that burdens individuals and families and overstretch a state and federal budgets.
1:43
Spending is high, and outcomes are often poor, especially for low-income folks and people of color.
1:50
Nowhere are the poor outcomes and high spending so staggering as among the low-income seniors who are dually eligible for Medicare and Medicaid.
2:00
These individuals rely on both Medicare and Medicaid to cover their needed services, and to afford their premiums and cautionary.
2:09
And when I say needed services, I mean a broad spectrum of needs, right, to manage their chronic conditions to care for them when they are ill or recover from injury, often to attend to basic needs, like cooking or living safely in their own homes.
2:25
We have a system that we have in place to address those needs are fragmented and flawed, And in the time an already strained systems cracks are further exposed.
2:38
That’s why our team at REL ventures and is investing in a re-orientation of our state and federal policies to move from a fragmented system to one that favors person centered, seamless, efficient, and effective care.
2:54
To do this, we’re funding research, policy analysis, and policy development, and technical assistance to support these changes.
3:01
The work isn’t easy, it’s a complicated set of issues and policies to wade through. So we really appreciate the Alliance’s efforts to bring you today’s webinar, and so grateful to our terrific panelists. And we look forward to the discussion.
3:20
Great. Thank you so much, Arielle, and let me now just go over a couple of quick technical notes, and then I’ll introduce our panelists. So, we want you to all be active participants, so please, do get your questions ready. And here is how you do it. You will see a dashboard on the right-hand side of your web browser with a speech bubble icon that has a little question mark on it. You can use that to ask any questions that you have for the panelists, or if you are experiencing any technical issues. You can also join our conversation today on Twitter at the hashtag I’ll have live, and follow us at all health policy. Finally, check out our website, all health policy dot org for background materials, and a recording of today’s webinar, which will be made available there soon.
4:03
And now I am so pleased to introduce today’s expert panelists, and I’m going to introduce, going to invite them to turn on their cameras. First, I am joined by Catherine Hayes, Director of Health Policy at the Bipartisan Policy Center. Prior to joining BPC, Catherine was an Associate Research Professor at the George Washington University School of Public Health, where she taught courses in Federal Advocacy, policymaking, and the federal budget process. She holds a Juris Doctor from the American University Washington College of Law.
4:32
Next, we’ll hear from Elizabeth one Health Researcher at Mathematica.
4:37
Elisabeth’s Work is focused on providing technical assistance to state Medicaid and Medicaid Managed Care programs, Medicare and Medicaid integration, and quality oversight.
4:47
Prior to joining Mathematica, Elizabeth Lead, the state of New Jersey is Fully Integrated Dual Dual Eligibles Special Needs Plan. She holds a master of public affairs and policy from the Edward J Blaustein School of Planning and Public Policy at Rutgers, the State University of New Jersey.
5:04
And finally, I am so pleased to be joined by Linda Flowers the Senior Strategy Policy Advisor for the Public Policy Institute at AARP. Linda’s work at PPI focuses on Medicaid dual eligibility and dual eligible demonstration projects, as well as other public health and healthcare topics. Before joining AARP, Linda held senior policy positions with the National Academy for State Health Policy and the Medical Assistance Administration of the Government of the District of Columbia. Our panelists are going to open with a few minutes of remarks, and then we will turn to questions from the audience. So, again, feel free to keep the questions coming in, and we’ll collect them and address as many as we can during today’s broadcast.
5:45
Catharine, let’s start with you.
5:48
Great. Thank you very much. I appreciate the opportunity to participate in today’s event.
5:54
I’m going to just give you a quick rundown of what I’m going to cover.
5:57
First, the characteristics of low-income older Americans, including dual eligible individuals, the respective roles of the Medicare and the Medicaid programs for these people, the key attributes of successful care models in treating these individuals. And then laying out a few of the policy barriers that are there, I hope, later, in our discussion, as part of the Q&A, to talk about some of VPCs recommendations in these areas.
6:25
So first, low-income seniors face significant challenges. And coven 19 has only exacerbated these problems.
6:33
They’re high risk individuals, many living in congregate settings, and are exposed to coven. And some of the stories that we’ve seen have been heartbreaking.
6:44
In addition, while poverty, rates for older Americans have been on a downward trend over the last decade, about 9% of older Americans are living in poverty today and for the most vulnerable those over age 80, that percentage. And it’s older women, mostly living alone. The poverty rate is over 18%.
7:08
While research on the health status of Medicare, Medicaid beneficiaries are mostly available in 20 16, BPC commissioned a study and found that those with incomes just over the poverty level, have characteristics that are very similar to those who are full benefit dual eligible individuals. The average full benefit dual individual has six or more chronic conditions.
7:34
And has double spending is double for the average Medicare beneficiary, and they have twice the number of hospital admissions.
7:44
For low-income Seniors, Medicare covers clinical health services, inpatient and outpatient services, professional office visits, and, in certain circumstances, home health, and short-term skilled nursing. It also covers lab X ray and prescription drugs for those who choose to enroll in the Medicare Prescription Drug Program.
8:07
Medicare beneficiaries qualify for Medicaid if they have low incomes are aged blind, or have deficits in activities of daily living, such as bathing or dressing for Medicare beneficiaries.
8:21
Medicaid, Medicaid can you can split their Medicaid benefits really into two different populations.
8:29
As I mentioned, full benefit dual eligibles for that group.
8:33
Medicaid covers all clinical health services that are not covered by Medicare provided they’re offered under the Medicaid state plan.
8:41
And non clinical benefits, such as targeted case management services, transportation in some cases, And they may also if they meet the criteria qualify for either nursing home care or home and community based care.
8:57
For partial benefit dual eligibles, which, as I mentioned, look very much like full benefit dual eligibles when it comes to the number of chronic conditions they have and the cost of serving and the costs incurred by the Medicare program.
9:12
They are individuals. These are partial benefit dual eligibles with whose incomes are slightly over poverty.
9:19
And Medicaid may cover Medicare premiums, co-pays and deductibles, but not the full Medicaid benefits, and coverage of premiums, co-pays and deductibles is tiered based on your income.
9:32
They don’t receive the full range of Medicare benefits, Medicaid benefits, and certainly not things, the social services and supports that are offered through the program.
9:43
Studies have shown that those with multiple chronic conditions thrive in care models that have targeted individuals with interventions likely to benefit from evidence based treatment.
9:59
So, for example, these things include engaging patients and their caregivers in the development of care plans and transitions from hospitals.
10:10
two, skilled nursing, and back into the home.
10:13
These successful care models provide preventive benefits, home visits, and regular follow ups.
10:20
They employ specialty trait specially trained care managers, and use a team based approach to care.
10:27
Finally, being able to connect patients with providers of social services and supports is critical to the success of treating high risk individuals and dual eligibles. The social services and supports are things like Meals on Wheels, Pest control, and minor home modifications.
10:49
So what are the barriers? Why aren’t these folks receiving services?
10:54
Now, um, if you look at coverage, Medicare coverage, particularly Medicare fee for service, um, either doesn’t cover a lot of these services.
11:05
And by that, I mean, some of the social services, the chronic care management, and the team based care models in some respects, either doesn’t cover that, or the reimbursement is such that it just does not encourage providers to engage in this kind of practice.
11:23
Particularly for dual eligible individuals, it’s important to integrate Medicare and Medicaid services. And what do I mean by integration of care?
11:32
It means that they are within a single, they have a single benefit package. Instead of having to navigate between Medicare benefits and Medicaid benefits.
11:44
It means they have a single plan or group of providers. They have a single point of contact in order to reach out to folks if they need help.
11:56
And the plan or provider organization should have responsibility for a full range of benefits.
12:03
And most troubling, I think, are the trends, although they’re reversing a little bit, or the trends in sort of carving out certain Medicaid services so that, in extreme cases, Emetic, a dual eligible beneficiary, could have, could be participating in several plans. They could be in a Medicare Advantage plan or Medicare fee for service.
12:25
They can be in a Medicaid managed long-term care plan. They can be in a Medicaid behavioral health plan. They may have a separate dental plan, and then they’re planned for just traditional Medicaid benefits.
12:38
So it is quite difficult for a lot of these individuals and their caregivers to navigate this process, which makes it so important that we continue the trend that began back.
12:52
Well, actually, it began back in the early 19 nineties with pace and and then demonstrations and a number of other programs to move forward.
13:06
And more recently, through the Center for Medicare and Medicaid Innovation and Medicare Medicaid co-ordination Office for the Financial Alignment Initiative and some of those integrated programs, which Elizabeth will talk about later.
13:21
If done, well, the studies have shown that integration can both improve patient outcomes and lower costs, including emergency department visits, hospital admissions and re-admissions.
13:34
It’s important to note, however, that these savings are going to require that they are going to be over the long term and they’re going to require significant upfront investments.
13:47
And BPC, as I’ve mentioned, has made recommendations in a number of various, first changes in Medicare Advantage, supplemental benefits, special supplemental benefits for the chronically ill.
13:58
In follow up to the passage of the Bipartisan Budget Act, Full integration of care for dual eligibles, which I’m happy to talk about as part of the Q and A, and then most recently BPC back in the summer.
14:14
Issued recommendations related to the cost effective, coverage of cost effective, non medical services for patients with multiple chronic conditions.
14:25
Who are in accountable care organizations, medical homes, or receiving chronic care management services? So, what I mean by that is that we are trying to push the envelope a little bit and figure out a way to cover some of these social services and supports outside of Medicare Advantage, particularly given that in many areas of the country, Medicare Advantage plans, particularly rural areas, aren’t readily available. So, with that, I’ll turn it back over. Thank you very much.
14:56
Great. Thank you so much, Catherine, and now pleased to invite Elizabeth Wood.
15:09
Elizabeth, I think you’re muted.
15:12
Thank you, Kathy, And thank you to the Alliance for Health Policy. It’s an honor to be on the panel today.
15:21
I’m going to cover a really high level overview of the structure, and the types of integration major integration platforms available today are dually eligible individuals.
15:33
And while I will just take a little moment at the top, while this panel is really focused on the needs of low income older adults, it’s important to note that about 40% of dually eligible individuals are under the age of 65.
15:46
And have physical, cognitive, and, or developmental disabilities. And in some cases, many cases, a mental health or substance use need along with that.
15:56
So it’s important to bear in mind that we have both of these populations out there. Only 10 to 15% of the younger dually eligible individuals are long-term care facilities, though, with kind of a nod to the pandemic.
16:13
Julie, eligible individuals are a diverse population in terms of their demographics and the next slide, please.
16:21
And the benefits that they receive.
16:24
On this slide, you’ll see a couple of breakdowns that are really related to the structure of the programs.
16:34
Integrated programs tend to be organized or long demographic characteristics tied to Medicaid eligibility categories and associated funding streams. And this kinda contributes to some of that fragmentation that Catherine referred to.
16:49
two of the most common breakdowns are along age and full versus partial benefit status.
16:55
So see there’s a smaller proportion that are the younger under 65 joules.
17:01
And then the larger chunk that are over 65 and then similarly you have some people who’ve received a little bit of support for Medicare and some people who receive the full package of Medicare and Medicaid that make up the lion’s share.
17:15
So, next slide please.
17:20
OK, so a little bit more on full benefit and partial benefit, dual eligibility.
17:25
Full benefit dual duly eligible individuals receive help from Medicaid to pay for Medicare costs as well as any Medicaid benefits available under state plans and waiver programs that they qualify for.
17:38
Partial benefit dual eligible individuals receive help from Medicaid for Medicare costs, but they’re not receiving the full package of Medicaid benefit at the state level, though there are many In that partially eligible category that are at risk of needing full Medicaid benefits in the future.
17:56
This chart is probably a little bit hard to read at home, but we included it here for reference, since this will be available after the presentation, as it provides detailed information on the different types of dual eligible individuals that may exist in each State, and the types of coverage that each group is entitled to. Next slide, please.
18:17
OK, so, just a little bit on the, uh, the models, the major models of integrated care that are available in the state markets today.
18:26
The first step is the capitated models is the Managed Care model.
18:32
Now I’ll speak briefly about how states use these to co-ordinate care for Dually Eligible Individuals.
18:39
There are three main capitated program models: the program of all Inclusive Care for the Elderly or known as pace. The Capitated Financial Alignment Demonstration Models, also known as … or Medicare Medicaid plans, and the Integrated Dual Eligibles Special Needs Plans or ….
18:56
And there’s an especially integrated version of the DSM model called the fully integrated dual eligible special needs plan that we’ll want to make note of.
19:07
In each of these programs, managed care entities attempts to improve care utilization and beneficiary experience in the delivery of Medicare and Medicaid services and paste programs. All Medicare and Medicaid services, including long term services and supports, are covered by the pay site.
19:21
It’s more of a brick and mortar arrangement plus insurance, rather than an insurance company trying to cover all services.
19:30
In the case of the financial alignment initiative demonstrations, the plans are called Medicare Medicaid plans.
19:36
and they offer a comprehensive single benefit package under a three-way contract with the state CMS and that health plan.
19:45
In the case of integrated DCPs, the integrated plan is typically made up of one, a decent path covering Medicare benefits and Medicaid managed care plan covering Medicaid benefits. And that could be long-term services and supports. It could be a comprehensive package, It could be behavioral health, they vary somewhat, but it’s a Medicaid managed care plan.
20:10
In the least integrated D step models, those one could be owned by different parent companies further contributing to fragmentation.
20:18
In the most integrated decent models, one parent company owns both hubs and integrates through back end processes internally. And that really contributes to reducing the fragmentation, putting a little bit of grout in the cracks in the system, if you will.
20:35
All right. So next slide.
20:40
This slide is, uh, all about the spectrum of integration.
20:46
And this was developed by the Integrated Care Resource Center, so I’m borrowing on their their work here. It’s run by Mathematica and the Center for Health Care Strategies on behalf of the CMS Medicare Medicaid co-ordination Office.
21:00
As you can see on the spectrum, the least integrated model on the left, oh, and the one that forms the comparison group for demonstrations and evaluations of integrated models is fee for service Medicaid, combined with fee for service Medicare.
21:13
The most integrated and best studied versions of, um, managed integrated care, or the pace programs, and the financial alignment initiative demonstrations, which represent the gold standards of integration. Those are in those green columns on the right.
21:29
In between, are several different levels of, integrate, a decent program, when Medicare and Medicaid enrollment is completely aligned.
21:38
Medicaid payment is capitated to the D SNP from the state, or its affiliated Medicaid plan, there a couple of ways that states pay into the decent model.
21:48
And, Care is highly coordinated.
21:50
Decent models start to approach the level of integration available in an MMP model in terms of integration, beneficiary experience, and administration. Next slide.
22:05
Alright, and now, um, we would be remiss if we didn’t give a nod to the managed fee for service models.
22:12
While Capitated Models are the most popular, and they do allow for fuller integration on financial, administrative, and clinical domains, states that don’t wish to use a Managed Care model, or perhaps they can, some states are not allowed to do have a variety of options under fee for service to improve co-ordination of care for dual eligibles.
22:36
Examples of such models include the fee for service demonstrations and there’s a financial alignment initiative, the model that is currently used by Washington segment, and has had great reviews, and some, in some ways, the primary care case management models and health homes.
22:52
All right, next slide.
22:56
This map shows which states currently have a capitated financial alignment initiative, and to which states currently have integrated decent models.
23:04
Note that it does not show which states have peace programs within these models, state approaches to eligibility benefits vary.
23:11
For example, while some programs like New Jersey cover all ages and all levels of care.
23:18
So it’s pretty comprehensive.
23:21
Other states choose to break it up according to some of those demographics I mentioned earlier.
23:26
So they stratify by by age or by level of care. Minnesota and Massachusetts, for example, offer one integrated program for individuals under 65 and another for those over 65.
23:36
And in other cases, level of care need is domain eligibility factor in all cases outside of pace. The demands on state administrative resources tend to increase with the level of integration. So that’s a major factor in their decision making about how, when and whether to pursue more integrated models for their, for their home dolls.
23:55
Uh, so, it, the resource demand increases, also, with the degree of enrollment alike alignment, and the scope of Medicaid benefits offered. So, next slide.
24:13
So, how’s it all going?
24:15
There are some evaluations available and to help us all digest all of those evaluations to date. Mark Pack prepared a helpful overview of available evaluations of the three main integrated models, the ones that I covered today.
24:31
They did that in August 2020, which I summarized on this slide. There’s still a lot to learn about decent models and RK evaluations of the demonstrations have not been able to assess impact on Medicaid spending it.
24:44
So, that’s an area where results are still pending, but we do have some promising results, especially in terms of major clinical outcomes that are tracked in several metrics.
24:55
For example, hospitalizations decrease across the board across the models.
25:00
Emergency Department use Changes were mixed. Admission to nursing facilities for long term care.
25:08
Nursing facility re-admissions, and mortality decreased in some major decent model studied in California and Massachusetts.
25:16
Their care co-ordination may support better health outcomes, but the results are mixed and appear to vary based on whether beneficiaries were made aware, whether there was good communication to beneficiaries.
25:26
So, communication within these models is a really key component of that sparkling that helps put this integrated system together.
25:33
It’s nuttall, it’s not all backend systems, a lot of it comes down to the humans that act on behalf of beneficiaries in that integrated system.
25:42
And then we have just submitted outstanding challenges, especially around identifying cost savings, although, there, there are some mixed mixed results, some promising results, and administrative challenges remain in in paring Medicare and Medicaid Services within government agencies.
26:03
So more research is needed. There are a couple of links down at the bottom of this slide.
26:11
And, um, I will, I will turn it back over to Linda.
26:18
Great, Thanks, Elizabeth. That was, that was a great overview. And, by the way, I thought in your slide on, on how Medicaid supports kind of, the partial tools with the, with the financial supports.
26:28
Worth mentioning the acronyms of slim bees and queen bees, Which, for those who are maybe newer to this space, may here. And that was, that was all included in that slide, so thanks so much for that terrific overview. And now, Linda flower is great to see you, Linda.
26:47
Come on. I am glad to be here. Thanks for having us.
26:51
It’s a pleasure.
26:52
Thank you to you and your team for all the support you’ve given us. It’s been really great.
26:57
And I’d also want to, before I start, I’d like to thank my colleague, Clare Noel Miller, for all the support she’s given to me for the producing the data as well as help with by analyzing the slides.
27:09
So, with that, I’m going to shift the focus a little bit to to focus on the determinants of health that impact those who are enrolled in health plans.
27:20
Next slide, please.
27:22
So, before I started just a little bit about the Public Policy Institute, we are the Public Policy Institute. And we work really hard to promote the development of sound creative policies to address common needs for economic security, health care, and quality of life.
27:38
Next slide, please.
27:40
So, first I want to talk a little bit about the covert 19 experience of dual eligible Medicare beneficiaries.
27:47
So, next slide, please.
27:49
You can see here in this slide that the code of corona virus has disproportionately impacted dual eligibles.
27:56
So not only with exponentially more cases than non dual Medicare beneficiaries, but also many, many more hospitalizations, then then than non dual Medicare beneficiaries.
28:11
Next slide, please.
28:13
Then, of course, it layering on top of that is the disparate impact that culvert 19 has had on Black and Hispanic duels relative to other dual eligibles.
28:24
So you can see here that the black and Hispanic experience in terms of Koby 19 by race and ethnicity is even higher.
28:35
Next slide, please.
28:37
So, what are, what accounts are, what are its accounting for these outcomes.
28:41
Some of the things that are driving, we think this disproportionately or that don’t have disproportionately higher needs for social supports, which we, which we all recognize, they lack certain basic need, for example, access to nutritious foods which weaken their immune systems, thereby putting them at higher risk for illness from covert 19.
29:02
And then, they tend to have much, many more underlying health conditions, as, I think, one of our previous speakers mentioned. And that also puts them at risk higher risk for illness and bad outcomes from COVID-19.
29:15
Next slide, please.
29:18
So, when we talk about determinants of health, I think there’s been a lot of focus on the social determinants of health.
29:24
And I’m here today to talk about the importance of looking at all determinants of health.
29:30
So, I’d like to put that clinical piece back in.
29:33
So, What are the determinants of health outcomes?
29:36
Many millions of tools are enrolled in.
29:41
Millions of dually eligible Medicare beneficiaries are enrolled in Managed Care and have significant clinical and social needs.
29:49
They also experienced social, economic, and environmental stress related factors that contribute to their poor health outcomes.
29:56
And then clinical care is comprised of access and quality, and that accounts for 20% of their health outcomes. And we need to take what’s going on inside of that.
30:07
It’s well, take into consideration.
30:10
Next slide, please.
30:13
So there is variability in plan ability to address the social determinants of health among duels.
30:19
There are some plans that are strained by the costs associated in addressing social determinants of health. And they’re limited rebate dollars to be able to afford to address them. And then there are some plans to think about the unpredictable return on investment and if that isn’t going to be profitable for us to really make these long term investments in social determinants.
30:40
Thus, these plans tend to prefer to focus on providing services that attract new members like dental and vision services. And, in addition, some of the plans lack the robust community contexts that are really needed to adequately address the determinants of health.
30:56
Next slide, please.
30:59
So, in terms of other plans that are better at high, high performing plants that are addressing social so social determinants of health, they view this as a critical part of their social mission.
31:11
They are high performing plants that attend to the clinical and social needs of their enrollees.
31:16
And, a key characteristic of these plans is that they establish robust community partnerships that allow them to address housing, food, and other transportation and other needs. And they also remain flexible as they reach out to address the needs.
31:31
Next slide, please.
31:34
So, let’s turn now to addressing social needs among El Bulli Eligibles in Managed Care.
31:40
Some emerging trends here.
31:44
Yeah.
31:47
I’m just going to try to.
31:52
Sorry. I was trying to get rid of this little box in the corner, so I can see my slides more completely, but I am unable to do that, so I apologize for that. So, I wanted to talk about two Medicare models.
32:04
Today, They are emerging, they have emerging important, in terms of being able to address social needs of Medicaid, of dual eligible Medicare beneficiaries, and the emergency merging importance of partnering with community.
32:19
So these two models are the community based Care Transition Model that was sponsored by CMS and that mod that experiment has been completed.
32:30
And then there’s the CMS Innovations Accountable Care Communities Model, the Accountable Health Communities model, which is still in progress.
32:38
Next slide, please.
32:42
So, the Community Based Care Transitions Program tested models for improving care transitions, from hospital to other settings.
32:51
And with the goal of reducing hospital re-admissions, among fee for service, high risk fee for service Medicare beneficiaries.
32:58
Mind you, these were not all duals, but they were high risk Medicare beneficiaries, and the goal was to reduce hospitalizations in the fee for service population.
33:09
And so while the majority of community based organizations use the coalmines model for interventions as their formal model, they were flexible and adaptable, adaptable, and met were able to meet the unique needs of clients, so they were able to go outside of the model, if need be, to meet the needs of the clients.
33:28
They also collect located staff within the hospital settings, And that was really helpful for them in generating the ability to apply to develop stable and strong relationships with their hospital partners.
33:42
And finally, they connect the CBOs, connected high risk beneficiaries to needed social and clinical services.
33:48
So, even though the focus here was just transitioning high risk people from hospitals, there also had to be that social service connection in order to make that a reality.
33:59
Next slide, please.
34:01
So, now we have the accountable health Community model, which uses bridge organizations to forge collaborations between clinicians and the community. So, in fact, in effect, you have this organization, this community based organization, that’s working with the providers and with the community to bring everything together.
34:21
So in this model, which is ongoing, they’re screening of the the community based organizations are screening community dwelling tools to identify their unmet need, their unmet social needs.
34:32
There are also increasing awareness of community services among the dually eligible population.
34:38
It providing navigation services to help this community assess where in the community they can find the social services they need, and to access them.
34:47
Then they’re encouraging alignment between clinical and community services to ensure that the community, the dual community, is getting the services they need and the community based services they need.
34:59
Next slide, please.
35:02
So common, I wanted to pull out some of the common characteristics among these models.
35:06
Because while the first model has not been taken, CMS did not adopt the first model, the transition model.
35:17
Primarily because they said it didn’t show surveying savings to Medicare, it’s important to look at some of the characteristics of these models.
35:26
What can we pull out of them in order to maybe move some of the need to address social determinants of health into the community? Are certain things working or certain things not working?
35:38
So some of the common characteristics were that these models were community centric.
35:43
They form strong and mutually beneficial relationships between institutions and community based organizations.
35:49
They were driven by data, but not constrained by data. So what if they encountered something that the data didn’t take into consideration?
35:56
But there, I think for them, we’re telling them this is a need that needs to be met.
36:01
That name was met.
36:03
They will not. They were also model driven, but not model constrained.
36:07
And they had the flexibility and ability to adapt to unforeseen needs.
36:11
And then they were able to develop a community work, community based workforce, and had strategic workforce placement. And I think this is important not only for developing trust among duels in the people that they interface with, but also for workforce development within impoverished communities. So, in a sense, that will be a twofer.
36:31
Next slide, please.
36:35
So using the best of all worlds to address social determinants of health, health plan should play an important, but not singular role, in addressing the social needs of duels.
36:44
So, it’s important to look at other models, and extract the best ideas, and continue to mine this rich opportunity to move this, the move, the ability to meet the social needs out into the communities in which people live.
36:57
There’s also involvement of communities in which tools live may help create trust among medical and non medical interventions, which is a really important thing, and it really does drive health outcomes across the board.
37:09
Providers should be willing to form strong partnerships with CBOs.
37:13
And we saw in that we saw in the transition of care, the transition model bad, oftentimes, the hospital providers were not willing to form those partnerships.
37:25
They were busy with other things, and it worked best when the community based organizations were able to co locate a community partner in the institutional setting.
37:35
So it’s sort of sort of force that partnership. So that was useful information. And then we need to put more effort into hearing directly from the duals of the service focus groups.
37:46
Community based participatory research methods, and other things about what’s working for them. And, as we always say, nothing about us without us. So, we need to do things for tools and with tools.
37:59
Next slide, please.
38:03
So, let’s look at that other 20% of healthcare, which is access and quality.
38:07
That’s the part that goes on within the clinical setting, and not in the social setting, And how does that come into bear? So, next slide, please.
38:16
So in addition to ensuring clinical competency, health plans have to make the 20% more robust, 20% of care, more robust by continually educating their providers about the special needs of duals and promoting non biased care delivery, equity. And trust building among their provider network providers.
38:36
And within their organizations. Next slide, please.
38:41
So what can plants do? Here’s some examples.
38:44
Providers need to Managed Care organizations.
38:48
Organizations need to ensure that their providers are trained in trust building, cultural competency, cultural humility, language access. one of the things I noted in one of the …
39:00
reports was that, I think it was people who have Chinese, Chinese people that were just enrolling from the, some of the integrated, integrated plans.
39:10
And one could posit that maybe one of the reasons for that was either, there were no in language providers or enough of them in the network to provide enough services. Or there was lack of language access. So you can see how critical this is to driving integration and driving, having people want to stay.
39:28
improve improving provider discipline participation in interdisciplinary care planning.
39:34
That was another thing that came out of the evaluations, was that it was very difficult to get the primary care providers to participate in the care planning process, unless you, we’re missing a really critical piece of what goes into care planning.
39:47
So we need a lot more education for providers to understand the importance of their participation in this process, particularly as it relates to managing at risk and populations, then ensuring that dual status does not affect access to providers.
40:04
And some of the, one of the reports I read there was an issue around that, where when the provider could see the codes for where they were going to bill for that particular patient, suddenly there was no appointment, et cetera, et cetera.
40:15
So, we have to make sure that we create this access and opportunities to get robust care on the clinical side, as well as addressing the social need.
40:27
Next slide, please.
40:33
Next slide.
40:34
Can you hear me?
40:37
Next slide, please.
40:39
So, as concluding thoughts here is, it’s critical to ensure that the social needs of those are assessed and addressed to improve their health outcomes.
40:49
But it’s also important to look at successful community based strategies to help meet the needs of doors in collaboration with plants, rather than making it the sole responsibility of plants.
41:01
Then, finally, it’s important for plans to look inward to ensure that providers are addressing the critical issues that can influence care outcomes, like building trust, eliminating bias, and being willing to address the needs of individuals with low income.
41:17
And with that, I’ll just end and look forward to questions.
41:21
Thank you.
41:22
Hey, thank you so much, Linda. That’s, that’s terrific, and so, while the others are getting their videos up for the Q and A, and please audience, feel free to chat your questions in the Q&A. Linda, I want to ask you that that was such a great overview.
41:36
And I’m wondering, know, given the impact of …, we’ve heard so much about social isolation, and the additional challenges on, you know, seniors and people with complex care needs. We’ve heard so much about, of course, the economic challenges and the budget challenges. And, you know, just given, you know, given the importance, as you set of community partnerships, and of really, like, you know, as I kind of heard, you say, really, meeting.
42:07
Why don’t come seniors? dually eligible? Beneficiaries? Like, really, where they are?
42:11
Can you share a little bit about what are the increased challenges with coven?
42:15
And how do we sort of begin to think about moving forward from them.
42:21
Well, I think in terms of social isolation, some of the research that we’ve done internally at AARP, has shown that there has been a sharp increase in feelings of loneliness and isolation among older adults, including those during the covert 19 experience, including probably some of us, as well. So, it’s important to think about, you know, strategies that we can use to meet those needs. I know that our foundation, our AARP Foundation, has a quite a web based platform called Connect to Effect.
42:52
And that’s a web based platform where people can go on and assess themselves and see if they’re socially isolated and do some things about it and we have suggestions on there.
43:02
I’d also recommend to paper from the Commonwealth that talks about what is going on in other countries, particularly your European countries around addressing disparities.
43:14
And one of the things that paper points out that I think holds a lot of promise is it’s a system called comp.
43:21
And it’s for people who are not tech savvy and don’t know, older adults who don’t know how to use the internet, etcetera. It’s just like a little television box. You turn it on.
43:30
But your daughter who lives in another state has the app and can push conversations to you, push pictures to you, and so this technology is being used widely in Europe right now to help we reduce isolation.
43:45
But I think we have to get a lot more creative because, as we know, as people become lower and lower in that income scale, they have less access to the internet, less access to broadband, less access to the tools that they need to, to use web based technologies.
44:02
So, in terms of addressing their needs, often it’s that home care provider, that’s the social person, or that food provider who is the social person.
44:11
So, I think it’s an all hands on deck approach.
44:16
Thanks, Linda. And, you know, you get such great examples of things that health plans can do.
44:21
And, and what, I, you know, bridging to sort of some of, that the evaluation that we heard from, Elizabeth, I know it sounds like, know, some of those can really help to enhance the experience of their members, and, you know, in working hand in hand with with the community providers. And we, we have a great question from the audience. And I don’t know who, who might be able to answer this, that. The question is whether there’s anything on the horizon, in terms of pharmacy support from the plans and and Charlotte Notes, that she’s a Community Health Worker, for, Pharmacy does, everything you’ve talked about being needed.
45:00
When did you have any insights into that, the pharmacy component, Or maybe Elizabeth or Katherine?
45:07
So, go ahead, Catherine.
45:09
I can speak to it from my personal experience, which is one of the services, my mother is a dual eligible individual and is, yeah, has every chronic disease that there is. And one of the services that are available through she is enrolled in a Managed Care Plan for long-term services and supports in a separate Medicare Advantage Plan for her Medicare benefits.
45:36
But one of the benefits that we could request is to have them come in and help organize her meds, and put them together, have them.
45:44
And some of the plans will actually come in and break them off, you know, into, well, some of them do it at the pharmacy level, but others will come in and organize them as if it’s not available at the pharmacy.
45:56
We have not chosen to do that.
45:59
My husband’s a pharmacist. So. Comes in handy. And, Catherine, I think that’s interesting here.
46:07
You’re such a, you know, deep expert on, on so many health policy issues, and, you know, No.
46:15
I wonder if if, you know, if you don’t mind maybe, like sharing a little bit around.
46:22
How have those challenges been for you and sort of caring for for a parent and, and like what? does that tell you then about people who may be?
46:31
You know, don’t like have decades of experience following these policy issues.
46:35
That is amazing, and I’m glad you asked that. My husband and I have both worked in health policy for 35 years.
46:45
Both of us know Medicare. Both of this new Medicaid.
46:48
I have worked in duals policy for 20 years, and my mother, we got a note from that, or letter from the state Medicaid agency. That my mother was being dropped from the Medicaid plan, because I did not fill out the redetermination Paperwork, correct. Well, he said, you know, we ended up having to hire both of us are lawyers.
47:14
We ended up having to hire a lawyer in Virginia to appeal the redetermination decision. So that’s one issue.
47:23
A second issue that I’ve heard this story from so many people, but my mom fell and broke her hip about a year ago. So, it was on Christmas morning.
47:34
In 20 90, yeah, July 29, 2018. Sorry. It’s all a blur.
47:42
And she was in and out of the hospital, and skilled nursing, what was re-admitted to the hospital, because of an infection that she acquired in the skilled nursing facility.
47:55
And it was an antibiotic resistant infection.
47:59
And so, you know, it was, she had to have, basically have a second surgery and, you know, then was in skilled nursing for awhile.
48:09
And we got a phone call at about four o’clock on a Friday afternoon saying we’re discharging your mother tonight, and we need you to come pick her up.
48:18
And we had been visiting or regularly, I a bit in there earlier that day. I knew she could not get in and out of bed by herself.
48:27
And fortunately she lives with us.
48:30
So we were able to provide the caregiving support that she needed until we were able to find an agency that could come in And, of course, they couldn’t come in within the next couple of days.
48:42
We had to wait several days, so we were she, she couldn’t make it to the toilet and back, you know.
48:47
So, it was just an unbelievable situation, and we actually paid for that caregiver support for three months that it took us to get her qualified for Medicaid.
48:59
Wow.
49:02
It’s overwhelming, and I thank you for sharing that, and of course, Sorry, that, that, know, your mom, you all have been going through this and just just illustrates some of the challenges, Elizabeth. And I’m wondering, you know, you directed a program yourself and New Jersey as a policymaker. You know, you’ve run these things, you studied them. How, how do you balance, you know, this need for like?
49:30
Adjusting to these individual situations, and, as Linda kind of said earlier, like really listening and, and incorporating feedback with, with some of the other pressures, And we had a question from the audience around cost savings, and, you know, cost savings seem to be the main focus to stakeholders and determining value. Like, How, how do, how do the different programs kind of balance those tradeoffs? How do you think about that as a former official yourself?
50:01
That’s, that’s a really great question.
50:04
And from my my own former official perspective, I can’t speak for everybody, but what we tried to do? And what I tried to do is to put the, the beneficiary at the center of our decision making a undesigned at all times.
50:22
And to make decisions, kind of big and small process decisions during the day.
50:27
Like when we weren’t quite sure which way to go, when there’s that tension around, hey, we could do something nice or we could do something expensive, what would we choose to do? And we’ve really tried to err on the side of designing around the beneficiary, believing that in the long run that was going to build the right. So so minute because we’re going to build the right system if we really design around something we try to think of.
50:50
It’s like organized flexibility so that no matter who you are as a dual eligible because it’s such a heterogeneous population, um, the system melds together, Medicare and Medicaid and any other supports that are available in that environment, melded together around you and your specific needs.
51:09
So if it’s a mental health condition that takes you to dual status, that’s what we want you to feel the closest collaboration between Medicare and Medicaid on if it’s a developmental disability, If it’s a severe chronic condition, or if you are just trying to keep your finances together in the community, you’re an elderly woman.
51:30
And we want to serve each one of those individuals in the best possible way.
51:35
It’s, It is very difficult to do it at the state level.
51:41
And I think the things that get in the way, or resources, competition with other implementation priorities, And so it really like comes down to support technical assistance.
51:53
Any kind of support the states can get in knowledge, and even finances can make a big difference in helping them support the organized flexibility that, I think Linda spoke to how all these other pieces have to work together with community services.
52:12
Without support for that kind of flexibility, what the system’s natural immune response to requests for changes is to say no.
52:21
And so if we, if we can support yeses with policymaking, it would make a big difference.
52:28
I hope that answers the question, but, yeah, I’d like to jump in here, if you don’t mind, Cordell. Thanks. I agree with you.
52:38
And I think that we have to realize that dual eligibles have been living entrenched lives in poverty and poverty and racism over a long period of time.
52:50
And, you know, five years of trying to undo a lifetime of, you know, poverty, or poverty and racism, or both.
52:57
Is that realistic?
52:59
And, so, we know I don’t know where this five year came from, but it needs to be rethought.
53:05
And we need to think about incrementally. Are we hitting some marks? Are we doing better on reducing food security? Maybe we haven’t saved money.
53:12
We haven’t done the whole thing on half the leases yet, have we done some have we do we have some markers that we could use instead?
53:20
The other thing, too, is, you know, a lot of these demos, they’re saying, they may or may not have reduced hospitalizations. We don’t really know the impact of observational status on those outcomes. So there’s a lot that needs to be considered reconsidered.
53:40
In terms of how long does it take to undo a lifetime of being disadvantaged?
53:46
And should it just be, can we think of other ways to measure progress?
53:51
Not to say, we don’t want to save money, but along the way, can we make progress?
53:57
Yeah, I was just gonna say that it’s a, it’s a, it’s a, it’s a really great point. You make about the arbitrariness of five years in in New Jersey. When we were trying to stand up the fully integrated product, it took us three years just to figure out, really, and smooth out.
54:17
The enrollment issues that sort of pulled all the other system pieces together, to make a tight integration, and you just don’t know. five years is such a short time. And it’s like, let’s invest the time that’s needed rather than sort of an arbitrary amount and then, sort of, throw up our hands. If it’s not where we are.
54:35
Like you said, it, it’s taken a long time to get here, and so many of these services were designed to exclude, rather than include from the get go. So, that’s That’s a great point. And, Catherine, you, you’ve You’ve been on the federal budget. I know you’re you, you want to chime in. And just in the interest of time, you know, I’d love for you to elaborate on it and maybe you can share a little bit kind of from the policymaking perspective like, Why is there this pressure to sort of put these time windows on? And, you know, you have through BPC, some policy recommendations. I’m wondering if you can, you know, kind of elaborate a little bit from that perspective as well.
55:13
Sure. You know, I think, first of all, I agree completely that five years is completely arbitrary, even mature state states that have been doing this for a long, long time.
55:24
Need the time to get systems up and running and to Yeah, no work with No, so arbitrarily saying you have to save money, first of all.
55:35
I think we should take it out of the Center for Medicare and Medicaid innovation, because those are the limits. I mean, you know, certainly, the states get the resources to do that. But because of the requirements around CMMI, which is great.
55:49
You know, a great program, don’t be wrong. It has given us the ability to do demonstrations.
55:55
But I think it’s time for us to move this out, and really make some long term recommendations for dual eligibles and to recognize two things. I think first, we’re not gonna save money in the short-term. We do need to make upfront investments. If you think about what happened in Massachusetts, which has been doing this for years, they moved to the under 65 population and found that it was a very different population.
56:20
You know, they had behavioral health and substance abuse issues and homelessness issues that were not as prevalent among seniors.
56:27
And so they literally, in some areas had to build clinics for behavioral health and substance abuse to get people in for treatment and they had to form partnerships with homeless providers in order to find a lot of the individuals. So for these reasons, I agree completely that five years doesn’t work.
56:46
I recognize that policymakers are going to want to see in stage two, are going to want to see a return on investment. And so one of the things that I think we can do at the Federal Policy at the Federal level is, provide more upfront resources and technical assistance to states to help them solve these problems. before you know a clock an arbitrary clock starts.
57:09
Rami. Yeah, that’s great. And there were, there’s, there’s two questions from the audience I want to kind of combine. And just, they may go to a little bit of that upfront resource question. So, I’ll send it to Elizabeth, first. You might have thoughts on it.
57:24
You know, one is kind of, why are Medicaid eligibility form so complex?
57:28
And is it budget driven, or is it just like not well thought through or is it just a reaction to this, sort of, know, I love the wayside ability. It’s kinda like the, the immunity to change or something like that on to that effect. And then, kind of, and, Linda, maybe I’ll ask you this one is, is there a sort of a one stop shop, or a social worker discharge planner can refer dual eligible patients to see if there’s extra supports available for them? Like, are there some best practices on that front? So, Elizabeth, I’ll ask you, sir, that question. And, does it go to some of that, like upfront resource?
58:02
No, um, question?
58:06
Yes, some of it is, it takes a lot of resources to overcome the complexity that’s built into Medicaid.
58:14
There are some, I think there are some states that have tried to do more of that, sort of.
58:21
An almost like an app to get through the up the eligibility, but it’s, it really is hard to bring those down to a simple level and still maintain the program integrity accountability that states have. So, I’ll leave it there.
58:36
But, yeah, it’s the complexity of the program, in a lot of cases, It’s a big challenge. Lindo, what do you think about sort of this question around, like discharge planning in particular? You know, how does that go to some of the points you raised around community based organizations?
58:52
What was the question, Sarah? But the question was kind of weather. Yeah, the question from our audience is whether there are. is there a one stop shop or a social worker or a discharge planner can refer?
59:03
You know, at the ALJ often I think that it’s variable by state but I would say that generally it’s really tough to get in one space the expert on snap, the deep expertise, and deep expertise on Medicaid, the deep expertise on housing.
59:23
I think that is really something that we should be aspiring for, for every state. I think that’s a huge resource.
59:29
If you can send people to one place, and I think we haven’t spent the time and resources, we need to try to bring that kind of education, I think there’s a lot more that can be done to develop that, that level of expertise. So, there could be one stop shopping.
59:45
That’s great.
59:46
And, Catherine, I want to start, asked the final the final questions, since we only have, sadly, Just a couple minutes left here.
59:54
How can policymakers support these efforts, which have been no decades in the making, and, and, you know, or are still, you know, clearly.
1:00:05
Clearly, there’s still much to work on, like, what are some of the key recommendations that you would have?
1:00:11
Yeah. I, you know, first of all, I’d urge you to go to our website and take a look at the report and see the long list of recommendations.
1:00:17
But I think the primary takeaway from our report is that without some sort of forcing mechanism for state to require them to integrate care for dual eligibles. It’s not going to happen.
1:00:29
And in the short term, we need to provide the technical assistance. We need to provide financial resources. We need to better co-ordinate federal agencies and state agencies to make this happen, but, at the end of the day, you need to require states to do it, or, or, it won’t happen.
1:00:45
And just to add on to that, Sarah, I think when you’re thinking about requiring, you also have to figure out what’s going on inside that environment that drives the sick, sick, or duels to opt out.
1:00:58
And because we have to address that issue as well, it’s obvious that, on some level, they don’t feel that they’re going to get their needs met within that system.
1:01:07
So we need to learn and better understand more about that as well.
1:01:11
Yeah, Thank you. That’s great. Elizabeth. Any any final thoughts on that?
1:01:18
And network availability for the doctors where they have established relationships feel like a life or death, no tie to the health care system.
1:01:27
And if that feels threatened to join managed Care, then you know, that’s very scary, and it’s understandable. So I totally agree.
1:01:36
Great. Thank you. Well, really, you know, a tremendous amount of phenomenal information that you all have shared today. And and great insights, both on just the lay of the land and how we’ve been trying for decades to really integrate these really complex systems for dual eligibles, understanding the needs of low-income seniors, the impacts on health disparities, particularly exacerbated, by Coburn, and just some phenomenal evidence based information that you all have presented on this day. So we thank you, Linda Flowers, Catherine Hayes, and Elizabeth would, thanks to Arnold Ventures for your partnership on this. Thanks to all of you for watching.
1:02:18
I know, we’re all going to quickly go back to Twitter or whatever news source. We’ve been wanting bated breath. Please, check out. Check out the Alliance for Health Policy website for additional information background resources. We’ll make sure to share that report that Catherine mentioned, and for all of the slides and a recording of this, which will be made available there soon. Thank you so much again. And have a wonderful afternoon.