The time is ripe to reconsider an integrated ACO model for dually eligible patients, many of whom need nursing home care. Integration could happen via mandated relationships between Medicare ACOs and state Medicaid agencies, especially for plans serving a high number of dual-eligible beneficiaries.
Such a strategy could help the Centers for Medicare and Medicaid Services (CMS) achieve its goal with ACO REACH, in which a subset of providers would be designated as high-need ACOs that serve dual eligibles, according to an article published in Health Affairs.
Other strategies to promote more integrated Medicare ACOs would include models which support up-front investment and allow provider groups to reinvest savings over time, in turn unlocking barriers to participation.
But, the agency would need to monitor for cost shifting to Medicaid – an ACO may appear to generate savings by shifting costs to Medicaid without reducing total health care spending, authors said.
José Figueroa and Jessica Phelan, both with the Harvard T.H. Chan School of Public Health; Eric Roberts with the Perelman School of Medicine; and Kenton Johnston with the Washington University School of Medicine co-authored the Health Affairs article.
There’s already a decade of progress in Medicare ACOs, authors said. Continuing down this path would push beyond the limitations of current managed care integrated models and better align with provider incentives.
Integrated Medicaid accountability through ACOs is a “long-overdue” step for a population that falls through the cracks too often, authors said. The other care plan commonly used for dual eligible patients – dual-eligible special needs plans (D-SNPs) – doesn’t guarantee care delivery will be well coordinated among providers.
ACOs, meanwhile, are structured around provider-led coordination of services, authors said.
“While D-SNPs have made progress in aligning incentives across the two programs, the evidence base on their ability to reduce avoidable, costly care remains limited compared to what has been demonstrated by ACOs in Medicare,” authors said in the article.
Currently, ACOs bear risk for dual-eligible beneficiaries’ Medicare Part A and B spending, but they’re not at risk for Medicaid spending. These misaligned financial incentives for dual eligibles may lead to inefficient spending and fragmented care across both programs, and cost-shifting between programs, authors said.
“An ACO might be incentivized to avoid Medicare-covered post acute skilled nursing facility care in favor of Medicaid-covered long-term care even if skilled nursing care was more appropriate,” authors said in the article. “Similarly, ACOs might skimp on providing post acute home health care services if they anticipate that Medicaid home- and community-based services (HCBS) may assume the burden.”
And, ACOs lack the tools and incentives to coordinate Medicare-funded care with Medicaid-funded long-term services – this includes nursing home care.
ACOs that share risk for both Medicare and Medicaid expenditures would alleviate conflicting incentives, according to the article.
“Integrated accountability would encourage providers to make care decisions that optimize the true needs and outcomes of patients across both programs, rather than selectively avoiding costs borne by Medicare alone,” authors said.
But nearly half of states don’t have managed Medicaid, which poses a major barrier for dual eligibles participating in highly integrated care plans. And so, there’s a need to explore alternative models of care integration that don’t rely on the managed care frameworks, authors said.
Washington could be a good pilot state for an integrated ACO; the state has seen success in reducing health care spending and institutional long-term nursing facility care despite not having managed Medicaid, according to the article.
Companies featured in this article:
Centers for Medicare & Medicaid Services, CMS, Health Affairs
