Managed care plans have long been part of the landscape of commercial health benefits and over the past decade have moved into Medicaid and Medicare programs. Now they are poised to conquer the dual-eligible world.
It's that conquest that has raised concerns from a prominent U.S. senator who last week posed the question the industry has been trying to answer since the 1980s: Do managed care plans merely manage costs or do they also ensure better care in the process?
Sen. John Rockefeller has asked Kathleen Sebelius, the secretary of the U.S. Department of Health and Human Services, to suspend the pilot program for dual-eligibles operated by the Centers for Medicare & Medicaid Services. Rockefeller believes that the assumption of savings for the multiple state programs will force managed care plans into shortcuts in order to meet financial targets.
Rockefeller, who is asking for an answer from Sebelius by July 20, also is upset that some dual-eligible members or those dually eligible for Medicaid and Medicare benefits are being automatically enrolled in managed care plans rather than making an active choice.
The senator is backtracking after basically starting the ball rolling he inserted the dual-eligible pilot program language into the huge 2010 Affordable Care Act. Recently, CMS has doled out grants to at least 15 states, including California, which has one of the most ambitious dual-eligibles overhauls in the country. California has rolled out contracts with managed care plans Health Net, Molina Healthcare and several local plans to enroll dual-eligible members in four counties. In those four California counties alone, there could be 500,000 new members entering the managed care universe.
The scale of the programs is one reason Rockefeller is concerned. He estimates that as many as a third of the 9 million fully dual-eligibles in the country could soon be in the pilots, and the intent was for it to only serve 2 million.
Aside from the fact that it's a rare ACA-related program that's actually exceeding enrollment projections (think the paltry enrollment in high-risk pools), my bets are that Sebelius won't be swayed by Rockefeller's concerns.
For one thing, states are under tremendous pressure to manage this costly group of citizens. For a second, who's to say that the care the states have been providing would be much better than what the managed care plans may deliver? At least in a managed care plan, duals are guaranteed to have access to a network of providers. Many physicians do not take fee-for-service Medicaid patients and others limit their Medicare case load.
Clearly, the world of prior authorization and denials is scary when it comes to the sickest and poorest Americans. But we may all have to stomach a little cost cutting and coordination to avoid having the whole system explode.
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