Elizabeth Newman

In case you were wondering how the largest pilot program for managing dual eligibles is going in California, the short answer is “Not great.”

Kaiser Health News reported recently that beneficiaries have received stacks of paperwork they don’t understand, almost half of those targeted for enrollment are opting out and the Los Angeles County Medical Association has filed a lawsuit to try to block the demonstration program.

Part of the problem is marketing and communication. The state’s beneficiaries are confused by packets of information promoting “new choices,” which is generally Human Resources-speak for something that sounds good, but is actually terrible. The state health care services department received close to 50,000 calls in September, Kaiser reported.

It is all a blow to those hoping the pilot can give insight into managing beneficiaries who are Medicaid and Medicare eligible. Nationally, there are 9 million dual-eligible Americans. Dual-eligible beneficiaries are 21% of the Medicare population, but take up 31% of total Medicare costs, and are 15% of the Medicaid population, but account for 39% of total Medicaid costs, according to the Kaiser Family Foundation. They tend to have chronic illnesses that aren’t managed well, and many low-income, sick seniors often end up in your facility with a host of issues.

For California, which has more than a million dual eligibles, there’s real money at stake: Kaiser reports officials believe the state may save $300 million in fiscal year 2014-2015 through the program. Apart from that, everyone realizes dual eligibles should be getting better care. There is no reason for them to bounce between healthcare providers, navigate two government systems and receive treatment in a siloed environment.

The state project means beneficiaries have one health plan and a case manager, and the government pays a set monthly rate to a managed care plan instead of paying physicians or a SNF per visit. This all makes sense, and California appears to be trying to address its problems, with telephone town halls, a call center and expansion of outreach.

Meanwhile, back at the long-term care ranch, some nursing homes are whispering to beneficiaries to opt out, which the Centers for Medicare & Medicaid Services criticized recently. At least one long-term care leader pushed back, citing a lack of guidance from the agency.

What do we take away from all of this news, knowing that managed care is going to be an increasing part of the fabric of long-term care? To start, much like companies or facilities have MDS coordinators, many are rightly looking to hire someone who can oversee the minutiae of managed care contracts on a full-time basis. Second, a Kaiser Family Foundation brief listed that there were certain success indicators for care coordination programs that worked. One was telephone contact between nurse care coordinators and patients. The other was a relationship with primary care physicians – this cannot be undervalued given the physician resistance in California. Specific for nursing home dual eligibles, capitated programs such as Evercare appear to have the largest success in helping nursing home residents avoid hospitalizations.

Managed care may not be on anyone’s wish list for 2015. But what we can learn from the troubles in California is partially based on what you already know: Communication, education and direct management are what can increase resident care, help keep seniors out of the hospital and reduce costs.

Elizabeth Newman is the Senior Editor at McKnight’s.