[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
------ DU
AL ELIGIBLES: UNDERSTANDING THIS VULNERABLE POPULATION AND HOW TO
IMPROVE THEIR CARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
----------
JUNE 21, 2011
----------
Serial No. 112-64
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
DUAL ELIGIBLES: UNDERSTANDING THIS VULNERABLE POPULATION AND HOW TO
IMPROVE THEIR CARE
U.S. GOVERNMENT PRINTING OFFICE
71-402 WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC
area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC
20402-0001
COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas HENRY A. WAXMAN, California
Chairman Emeritus Ranking Member
CLIFF STEARNS, Florida JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois EDWARD J. MARKEY, Massachusetts.
JOSEPH R. PITTS, Pennsylvania EDOLPHUS TOWNS, New York
MARY BONO MACK, California FRANK PALLONE, Jr., New Jersey
GREG WALDEN, Oregon BOBBY L. RUSH, Illinois
LEE TERRY, Nebraska ANNA G. ESHOO, California
MIKE ROGERS, Michigan ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina GENE GREEN, Texas
Vice Chairman DIANA DeGETTE, Colorado
JOHN SULLIVAN, Oklahoma LOIS CAPPS, California
TIM MURPHY, Pennsylvania MICHAEL F. DOYLE, Pennsylvania
MICHAEL C. BURGESS, Texas JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee CHARLES A. GONZALEZ, Texas
BRIAN P. BILBRAY, California JAY INSLEE, Washington
CHARLES F. BASS, New Hampshire TAMMY BALDWIN, Wisconsin
PHIL GINGREY, Georgia MIKE ROSS, Arkansas
STEVE SCALISE, Louisiana ANTHONY D. WEINER, New York
ROBERT E. LATTA, Ohio JIM MATHESON, Utah
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi JOHN BARROW, Georgia
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BILL CASSIDY, Louisiana DONNA M. CHRISTENSEN, Virgin
BRETT GUTHRIE, Kentucky Islands
PETE OLSON, Texas
DAVID B. McKINLEY, West Virginia
CORY GARDNER, Colorado
MIKE POMPEO, Kansas
ADAM KINZINGER, Illinois
H. MORGAN GRIFFITH, Virginia
7_____
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois EDOLPHUS TOWNS, New York
MIKE ROGERS, Michigan ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee CHARLES A. GONZALEZ, Texas
PHIL GINGREY, Georgia TAMMY BALDWIN, Wisconsin
ROBERT E. LATTA, Ohio MIKE ROSS, Arkansas
CATHY McMORRIS RODGERS, Washington ANTHONY D. WEINER, New York
LEONARD LANCE, New Jersey HENRY A. WAXMAN, California (ex
BILL CASSIDY, Louisiana officio)
BRETT GUTHRIE, Kentucky
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)
(ii)
C O N T E N T S
----------
Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement............................................... 3
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 5
Prepared statement........................................... 7
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 11
Prepared statement........................................... 12
Hon. Bill Cassidy, a Representative in Congress from the State of
Louisiana, opening statement................................... 14
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, opening statement............................... 14
Prepared statement........................................... 17
Hon. Joe Barton, a Representative in Congress from the State of
Texas, prepared statement...................................... 188
Hon. Leonard Lance, a Representative in Congress from the State
of New Jersey, prepared statement.............................. 190
Hon. John D. Dingell, a Representative in Congress from the State
of Michigan, prepared statement................................ 191
Witnesses
Melanie Bella, Director, Federal Coordinated Health Care Office,
Centers for Medicare and Medicaid Services..................... 24
Prepared statement........................................... 26
Answers to submitted questions............................... 192
Robert Egge, Vice President of Public Policy, Alzheimer's
Association.................................................... 74
Prepared statement........................................... 76
Answers to submitted questions............................... 196
Billy Millwee, Associate Commissioner for Medicaid/CHIP, Texas
Health and Human Services Commission........................... 92
Prepared statement........................................... 93
Denise Levis Hewson, Director of Clinical Programs and Quality
Improvement, Community Care Center of North Carolina........... 99
Prepared statement........................................... 101
Answers to submitted questions............................... 199
Shawn Bloom, President and Chief Executive Officer, National PACE
Association.................................................... 131
Prepared statement........................................... 133
Answers to submitted questions............................... 325
Submitted Material
``Better Medicaid coordination would cut costs, help the most
seriously ill,'' Washington Post article by Ezra Klein
published June 16, 2011, submitted by Mr. Burgess.............. 53
Letter, dated March 1, 2011, from Kathleen Sebelius, Secretary,
Health and Human Services, to Hon. John Boehner, submitted by
Mr. Pallone.................................................... 60
Statement, undated, of Mary Kay Henry, International President,
Service Employees International Union, submitted by Mr. Pallone 66
DUAL ELIGIBLES: UNDERSTANDING THIS VULNERABLE POPULATION AND HOW TO
IMPROVE THEIR CARE
----------
TUESDAY, JUNE 21, 2011
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 2:04 p.m., in
room 2322 of the Rayburn House Office Building, Hon. Joe Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Burgess, Whitfield,
Shimkus, Latta, Lance, Cassidy, Guthrie, Upton (ex officio),
Pallone, Christensen, Markey, and Waxman (ex officio).
Staff present: Howard Cohen, Chief Health Counsel; Andy
Duberstein, Special Assistant to Chairman Upton; Paul Edattel,
Professional Staff Member, Health; Julie Goon, Health Policy
Advisor; Kirby Howard, Legislative Clerk; Debbee Keller, Press
Secretary; Peter Kielty, Senior Legislative Analyst; Ryan Long,
Chief Counsel, Health; Carly McWilliams, Legislative Clerk;
Jeff Mortier, Professional Staff Member; Katie Novaria,
Legislative Clerk; John O'Shea, Professional Staff Member,
Health; Monica Popp, Professional Staff Member, Health; Andrew
Powaleny, Press Assistant; Heidi Stirrup, Health Policy
Coordinator; Lyn Walker, Coordinator, Admin/Human Resources;
Tom Wilbur, Staff Assistant; Alli Corr, Democratic Policy
Analyst; Tim Gronniger, Democratic Senior Professional Staff
Member; Purvee Kempf, Democratic Senior Counsel; and Karen
Nelson, Democratic Deputy Committee Staff Director for Health.
Mr. Pitts. The subcommittee will come to order. The chair
recognizes himself for 5 minutes for an opening statement.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Dual eligibles, those individuals who are eligible for both
the Medicare and Medicaid programs, are one of our sickest,
poorest, most costly and most vulnerable populations. If we are
to simultaneously improve and lower the cost of their care, we
must do a better job at integrating Medicare and Medicaid
benefits and services.
Dual eligibles are unique. While more than half of dual
eligibles live below the poverty line, only 8 percent of
Medicare-only beneficiaries have incomes below the poverty
line. Nineteen percent of dual eligibles live in an
institutional setting, while only 3 percent of Medicare-
eligible-only individuals live in such a setting. They are also
more likely to be hospitalized, to go to emergency rooms, and
to require long-term care than other Medicare beneficiaries.
According to the Centers for Medicare and Medicaid
Services, more than 9 million people fall into the dual-
eligible category. Forty-three percent of them have at least
one mental or cognitive impairment, while 60 percent have
multiple chronic conditions.
According to the Kaiser Family Foundation, dual eligibles,
who make up only 15 percent of Medicaid enrollment, consume 39
percent of total Medicaid spending. Additionally, in 2005, the
Medicare and Medicaid programs spent an average of $20,000 per
dual eligible, almost five times greater than the average
amount spent on other Medicare beneficiaries.
These individuals, who have fewer resources and more
complicated health care needs, face the added struggle of
trying to navigate both Medicare and Medicaid. Medicare covers
their basic acute health care services and prescription drugs,
and Medicaid fills in the gaps. Medicaid generally pays the
Medicare Part B premium and the cost sharing for Medicare
services. For some, Medicaid also covers various benefits not
covered by Medicare, including long-term care supports and
services, dental care, eyeglasses, and other benefits.
Each State determines its own eligibility standards and
which benefits will be provided to Medicaid beneficiaries. So,
we are able to watch various States experiment with different
models and designs to better align the care of dual eligibles.
Currently, 15 states have been selected to receive funding,
data and technical assistance from CMS to develop a more
coordinated model of care for dual eligibles.
We can improve the quality of care that dual eligibles
receive. We can make their care more efficient and easier for
them to navigate. We can do all this while lowering costs to
both the federal government and the beneficiary.
I look forward to hearing from our witnesses today about
which models are being tried in the States and what we have
learned so far.
[The prepared statement of Mr. Pitts follows:]
[GRAPHIC] [TIFF OMITTED] 72402.001
[GRAPHIC] [TIFF OMITTED] 72402.002
Mr. Pitts. At this time I will yield the remaining time to
the vice chairman, Dr. Burgess.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Thank you, Mr. Chairman.
In no other area is the lack of coordination at the federal
level more apparent than when we deal with people who are
dually eligible for Medicare and Medicaid. Studies of the
population make it clear that Medicaid is actually 56 separate
programs administered by the States and territories in the
context of duals. It sometimes becomes a game of hot potato.
Data suggest that duals are sicker when they are
hospitalized, that their costs are almost 10 percent greater,
and they have more episodes of avoidable hospitalization. It is
a symptom of no one being held accountable for their care.
Certainly, better alignment of Medicare and Medicaid is needed.
Now, unfortunately, ACOs, accountable care organizations,
that may have provided a model and a good place to start, it
seems that once again the bureaucracy has killed any such hope
for that happening. The rule that was produced on ACOs was
virtually unintelligible and most large groups that thought
themselves to be ACOs have now moved away from this.
You want to drive cost savings with better care. This is a
problem that really we could solve. Fifteen percent of Medicaid
enrollees are duals and they account for almost 40 percent of
the program's spending. The old Willie Sutton law, you rob
banks because that is where the money is, clearly it should
apply here. And these patients are fully covered by Medicare
and the entire Medicare benefits package and still they are
five times costlier. These are patients that are defined. We
know where they are. We know who they are. We know when they
are accessing care and why they are accessing it, and yet for
some reason we lack the fundamental amount of consistency for
coordinating their benefits.
I rarely find myself agreeing with Ezra Klein and the
Washington Post, but I did last week when he talked about the
fact that this was an idea whose time has come. What I don't
understand is why it takes an entirely new federal agency when
CMS has had broad waiver authority and demonstration authority
for years to take care of this problem.
I will yield back the balance of my time.
Mr. Pitts. The chair thanks the gentleman and recognizes
the ranking member of the subcommittee, Mr. Pallone, for 5
minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
I really welcome today's hearing on a critical issue: the
coordinating and improving of health care of those dually
eligible for Medicare and Medicaid programs, otherwise known as
dual eligibles, and I appreciate my colleagues for working with
us in preparing this hearing and look forward to our
discussion. This is an area of our health care system that I
think has potential for effective change.
The reality is that dual eligibles are a vulnerable
population. Their care is both costly and frequently
uncoordinated, which is resulting in poor outcomes in many
cases. In total, there are 9.2 million Americans who rely on
both Medicare and Medicaid. Meanwhile, they are significantly
poorer and tend to have extensive health care needs. Overall,
they are also more likely to suffer from chronic conditions
such as heart disease, pulmonary disease, diabetes and
Alzheimer's disease, and as such, their care is complicated and
too often they are not receiving the patient-centered care they
need and that they deserve.
In addition, dual eligibles represent less than 20 percent
of the Medicare and Medicaid programs but bear the
responsibility for a significant amount of the programs'
expenses. In fact, in 2007, they comprised only 15 percent of
enrollees but represented 39 percent of Medicaid spending and
their medical costs were more than six times higher than non-
disabled adults in Medicaid. Meanwhile, in Medicare, they
represent 16 percent of enrollees and 27 percent of
expenditures. Compared to all other Medicare enrollees, the
health costs are nearly five times as great.
These are powerful numbers that demonstrate if we can
improve care coordination and make life better for these
individuals, there is also an opportunity for savings. That is
why, in passing the Affordable Care Act, we created the Federal
Coordinated Health Care Office at the Department of Health and
Human Services, otherwise known as the Medicare-Medicaid
Coordination Office. Its mission is to gain some much-needed
efficiency within the system for this group of beneficiaries.
I must admit, the timing of the coordinated office, as well
as today's hearing, couldn't be better. Congress and this
committee are increasingly concerned about the rising cost of
Medicare health care coverage for the 45 million elderly and
disabled Americans and Medicaid's 55 million poor patients. So
what better place to explore, understand and address than the
sickest and most expensive populations to cover. But we mustn't
set a price tag on their care nor should we shape policy with
the goal of only saving money.
It is clear we have some real big challenges, yet some real
big opportunities in providing care for dual eligibles. So I
look forward to hearing from our expert panel today, and I
would specifically like to welcome Ms. Melanie Bella, the head
of the new coordinated office. I know that she has a long
history of aiming to restructure the services of dual
eligibles, so I look forward to hearing about her innovative
work.
I also look forward to hearing about the successful efforts
represented here today by the different panelists. I hope we
can hear some new ways Congress can be helpful in addressing
what has been a longstanding problem facing our health care
system.
And I yield back, Mr. Chairman. Thank you.
[The prepared statement of Mr. Pallone follows:]
[GRAPHIC] [TIFF OMITTED] 72402.003
[GRAPHIC] [TIFF OMITTED] 72402.004
[GRAPHIC] [TIFF OMITTED] 72402.005
[GRAPHIC] [TIFF OMITTED] 72402.006
Mr. Pitts. The chair thanks the gentleman and recognizes
the full committee chairman, Mr. Upton, for 5 minutes.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman.
According to CMS, more than 9 million Americans qualify for
both Medicare and Medicaid, including at least 257,000 in
Michigan.
I want to thank our two panels this afternoon for agreeing
to share their expertise in serving this vulnerable population,
often referred to as dual eligibles. We look forward to hearing
your perspective on the health care needs and the barriers that
currently prevent them from properly navigating the health care
system.
This hearing is important for two key reasons. First, we
must better understand the distinctive behavioral and physical
health care complexities associated with the dual-eligible
population. And second, we need to better understand what is
currently being done to help these individuals navigate the
health care system. By the end of the hearing, we should be
able to identify what initiatives exist to effectively
integrate care for dual-eligible populations, what coordination
models are working, what prevents these effective models from
expanding, and building on the positive efforts already
underway, we must also look for ways to modernize the current
structure so these individuals are ensured access to quality
health care with less red tape.
Most Americans have uniform coverage that guides them
through the complex health care system, but for the dual
eligible, that process is more complicated because they have to
navigate the waters of two different entitlement programs that
offer different benefits and cover different services and
providers. Because of that segmented structure, we have come to
learn that dual eligibles have difficulty identifying where to
access good, quality care. Not surprisingly, they frequently
end up in the ER, which is harmful to both patients and
taxpayers, who end up with the costly bill for preventable
hospitalizations.
Again, we welcome you, and I yield the balance of my time
to Dr. Cassidy.
[The prepared statement of Mr. Upton follows:]
[GRAPHIC] [TIFF OMITTED] 72402.007
[GRAPHIC] [TIFF OMITTED] 72402.008
OPENING STATEMENT OF HON. BILL CASSIDY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF LOUISIANA
Mr. Cassidy. Thank you, Chairman Pitts.
Medicare and Medicaid are important programs that are
unfortunately unsustainable in their current form. Medicare,
per the actuaries who run the program, is going bankrupt in 10
years hastened by $500 billion extracted from it by Obamacare.
Medicaid is bankrupting States, and this was before the
Obamacare mandates that usurp States' rights.
Now, as a doctor who teaches, who still teaches and treats
the uninsured in a public hospital, though, my primary concern
is patient welfare, and fortunately, there is an opportunity
for improvement. As we know, dual eligibles oftentimes have
poor outcomes. Now, Republican have proposed freeing States
from the rigid Medicaid rules, which make it difficult to
coordinate benefits between Medicaid and Medicare. We have also
put forward a plan to save Medicare from bankruptcy, to
preserve Medicare as it has been known for those who are on it,
and to preserve it for those who will be on it. Now, saving
Medicare from bankruptcy is important for all Americans, all
senior citizens, but particularly for dual eligibles.
Now, unfortunately, under the current situation, Medicare
provides incentives to treat patients in one way and it
provides Medicare incentives to treat patients in another way,
and these dueling incentives oftentimes lead to poor patient
outcomes. This is the problem of large bureaucracies trying to
dictate what happens to a patient in the patients' exam room.
We can do better.
So despite the fact that Medicare and Medicaid spend
disproportionate amounts upon dual-eligible patients, again,
their outcomes are poor, and this is actually the most
important issue. Now, we should note that we shouldn't take the
policy of do nothing for short-term political gain and kick
this issue of Medicare's fiscal solvency as an issue down the
road. We have got to address it now.
I am very interested in the perspectives presented here
today. I have had the pleasure to speak with Ms. Bella. She is
knowledgeable. I just look forward to it. Similarly, the
perspective of the PACE providers and the States. I will say
the Office of Dual Eligibles, I kind of like that. It is the
one provision of Obamacare I applaud. As we say in the South,
even a blind hog finds an acorn every now and then.
I yield back.
Mr. Pitts. The chair thanks the gentleman and recognizes
the ranking member of the full committee, Mr. Waxman, for 5
minutes for an opening statement.
OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mr. Waxman. Thank you very much, Mr. Chairman.
As observers of this hearing will note that by and large
whether you are a Democrat or a Republican, we care about this
issue and this is a hearing where we have collaborated in
providing panels that will give us the best information on how
we can address the problems that are unique to the people who
are dual eligibles, or both on Medicare and Medicaid.
This has been a major issue facing both programs. By
design, these individuals should have access to the best of
these programs, the best that each one has to offer, but too
often they struggle, fall between the cracks and cycle in and
out of nursing homes, hospitals, specialty care without
receiving the coordinated patient-focused care they deserve.
Dual eligibles are not a homogenous group but they can be
considered as several subgroups. Some, such as Medicare
beneficiaries who are eligible for Medicare by virtue of their
age and for Medicaid because they have low income, can be in
their mid 60s and may not differ significantly from other
Medicare beneficiaries in their need for care. Others, however,
such as adults under 65 with developmental disabilities such as
cerebral palsy or intellectual disabilities, require
significantly more care and resources to live their lives.
Older Medicare beneficiaries with cognitive impairments such as
Alzheimer's are another significant and very frail subgroup, a
group we are going to hear about today.
Many of these individuals may require nursing home level of
care or home-based support services allowing them to live
outside of an institution. A disabled person under the age of
65 costs Medicare and Medicaid between $23,000 and $84,000 in
2005 depending on whether he or she needed nursing home stay.
This is very expensive but not getting this care is worse,
resulting in eroding health, trips to the emergency room,
suffering for the patient and his or her family, and
astronomical costs for the patient and the taxpayer. These
costs present both a challenge and an opportunity to develop
and implement reforms that over time will simultaneously
improve care while reducing costs.
There is a Medicare Payment Advisory Commission and the
Medicaid and the child health program have their commissions as
well, and all these commissions have described how a lack of
coordination between Medicare and Medicaid can create harmful
and wasteful outcomes and misaligned incentives. For example, a
nursing facility may find it profitable to transfer a complex
patient to a hospital even if the facility is capable of
managing that patient because of different payment rates and
benefit rules in each program.
We have heard in this committee many times over the years
about problems generated by pure fee-for-service medicine that
provides no coordination of benefits. For dually eligible
beneficiaries, those problems are multiplied because of their
intensive care needs.
We face a lot of challenges in improving care for dual
eligibles and reducing costs to the taxpayer but it is
important to recognize that we shouldn't rush into new programs
for purely a budgetary focus. We should not assign a price tag
to this population and then design the policy around it.
As we will hear today, the best and most successful efforts
to integrate care for the duals has been local and it has been
focused on a small group of beneficiaries. These programs have
been built around intensive interventions by nurses,
physicians, social workers, therapists and others. But these
interventions can be difficult to scale up to a large
population, and I think we need to be wary about grand promises
regarding this decades-old problem.
I want to mention that one of the results of the Affordable
Care Act, which some people call Obamacare, was to extend the
Medicare trust fund, and in fact, it was extended over 12
years. Another thing to recognize is that whatever cuts some of
our colleagues objected to in the Affordable Care Act, they
took all of those cuts and went way beyond it in their Medicare
proposal, which they would transform into a whole different
system.
We have opportunities to save money we are spending on dual
eligibles by examining the drug rebates in Part D where we pay
a higher price for the dual eligibles than we used to pay in
the past. Providing better coordinated care and saving money
are not mutually exclusive goals and for the dual eligibles,
this may be the key to improved quality of care.
Thank you, Mr. Chairman, for calling this hearing.
[The prepared statement of Mr. Waxman follows:]
[GRAPHIC] [TIFF OMITTED] 72402.009
[GRAPHIC] [TIFF OMITTED] 72402.010
[GRAPHIC] [TIFF OMITTED] 72402.011
[GRAPHIC] [TIFF OMITTED] 72402.012
[GRAPHIC] [TIFF OMITTED] 72402.013
[GRAPHIC] [TIFF OMITTED] 72402.014
[GRAPHIC] [TIFF OMITTED] 72402.015
Mr. Pitts. The chair thanks the gentleman.
We have two panels today, and I would like to ask panel one
to take her seat at the witness table. I want to thank all the
witnesses for agreeing to appear before the committee. On panel
one, we welcome Melanie Bella, who is the Director of the
Medicare and Medicaid Coordination Office at the Centers for
Medicare and Medicaid Services. Your written testimony will be
made part of the record. We would ask that you please summarize
your opening statement in 5 minutes and then we will go to
questions and answers. Welcome.
STATEMENT OF MELANIE BELLA, DIRECTOR, FEDERAL COORDINATED
HEALTH CARE OFFICE, CENTERS FOR MEDICARE AND MEDICAID SERVICES
Ms. Bella. Good afternoon, Chairman Pitts, Ranking Member
Pallone, Chairman Upton, Ranking Member Waxman and members of
the subcommittee. Thank you for the invitation to participate
in this discussion today. My name is Melanie Bella, and I am
the Director of the Federal Coordinated Health Care Office at
the Centers for Medicare and Medicaid Services.
This office, which we are referring to as the Medicare and
Medicaid Coordination Office, to better explain our mission,
was created by the Affordable Care Act and our single focus is
the topic of the hearing today.
Medicare and Medicaid enrollees, also referred to as dual
eligibles, are a heterogeneous group. They include low-income
seniors, individuals with disabilities as well as those with
serious and persistent mental illness. Some individuals start
on Medicaid and age into Medicare. Other individuals start on
Medicare and have a functional or a financial decline that
makes them Medicaid eligible. Either way, these individuals
have very complex care needs. Three out of five have multiple
chronic conditions and two out of five have at least one mental
or cognitive impairment. Not surprisingly, given their higher-
than-average health care needs, the cost of providing care for
these individuals is significant. Together, Medicare and
Medicaid spend roughly $300 billion a year to provide care to
this population.
Our office is working across Medicare and Medicaid with
States, providers and other stakeholders on a number of key
initiatives to ensure better health, better care and lower
costs through improvement for Medicare and Medicaid enrollees.
Specifically, our efforts are focused in three main areas. The
first is program alignment, the second is data and analytics,
and the third is models and demonstrations. I will highlight a
few of those efforts today starting with program alignment.
Better coordination begins with program alignment.
Currently, Medicare and Medicaid enrollees must navigate two
completely separate systems, Medicare for coverage of basic
acute-care services and drugs, and Medicaid for coverage of
supplemental benefits such as long-care care supports and
services. Medicaid also provides help with Medicare premiums
and cost sharing. Although both programs provide important
benefits, they operate as separate systems with different
administrative procedures, statutory provisions and payment
policies. One of the first objectives of our office was to
catalog all of the places where Medicaid and Medicare literally
bump up against each other. This creates barriers to effective
care, and though internal and external consultation and
outreach, we use that opportunity to identify places where we
can improve alignment between the two programs. We have
published a list of these alignment opportunities in the
Federal Register, specifically to invite public comment. This
alignment initiative will allow us both to identify barriers to
high-quality cost-effective care as well as prioritize areas
for improvement.
Another key objective of this new office is to engage our
State partners. Improving quality and cost of care for Medicare
and Medicaid enrollees relies on effective partnership with
States because we share the responsibility to provide care and
to finance that care for this population. Our office has
recently announced two key initiatives that support our State
partners in improving care coordination for Medicare and
Medicaid enrollees. One of these initiatives was the
establishment of a new process for States to access Medicare
data for care coordination purposes. Lack of timely Medicare
data, particularly Part D data, has been a key barrier for
States in expanding care management efforts for their dual
population. These data provide States with a powerful new tool
to support their efforts to improve care for some of their most
complex and costly beneficiaries.
The second initiative done in partnership with the Center
for Medicaid and Medicare Innovation is the State
demonstrations to integrate for dual-eligible individuals under
which 15 States were competitively selected to design new
approaches to better coordinate care for Medicare and Medicaid
enrollees. Through these design contracts, CMS is providing
funding to selected States to support their efforts to design
person-centered approaches to coordinate care across primary,
acute, behavioral health and long-term supports and services.
The goal of this initiative is to identify and validate new
care delivery and payment models that can be tested and then
replicated in other States. Importantly, though, our office
serves as a resource to all States and is available to provide
technical assistance to any State interested in working to
improve quality and reduce costs for its Medicare and Medicaid
enrollees.
In closing, a high priority for our office is to
significantly increase the number of Medicare and Medicaid
enrollees that have access to seamless, coordinated care. We
will get there by eliminating barriers to integration,
partnering with States, providers and other stakeholders and
developing new delivery system and payment models. We expect
that improved care coordination and quality outcomes for this
complex population will result in better care at reduced cost
for both the Federal Government and States. Thank you very
much.
[The prepared statement of Ms. Bella follows:]
[GRAPHIC] [TIFF OMITTED] 72402.016
[GRAPHIC] [TIFF OMITTED] 72402.017
[GRAPHIC] [TIFF OMITTED] 72402.018
[GRAPHIC] [TIFF OMITTED] 72402.019
[GRAPHIC] [TIFF OMITTED] 72402.020
[GRAPHIC] [TIFF OMITTED] 72402.021
[GRAPHIC] [TIFF OMITTED] 72402.022
[GRAPHIC] [TIFF OMITTED] 72402.023
[GRAPHIC] [TIFF OMITTED] 72402.024
[GRAPHIC] [TIFF OMITTED] 72402.025
[GRAPHIC] [TIFF OMITTED] 72402.026
[GRAPHIC] [TIFF OMITTED] 72402.027
Mr. Pitts. Thank you. I want to thank you for your opening
statement. I will now begin the questioning and recognize
myself for 5 minutes for that purpose.
Director Bella, in a 2010 paper entitled ``Options for
Integrating Care for Dual-Eligible Beneficiaries,'' you wrote:
``The goals should be clear: to provide beneficiaries with the
right care at the right time in the right places and to give
States and other stakeholders the flexibility they need to
design and test accountable models of integrated care.'' Is it
fair to say that you still believe the current system does not
provide States the sufficient flexibility or incentives
necessary to integrate care for duals?
Ms. Bella. As I mentioned in my testimony, States are
critical partners for us and so we have to recognize the
variation in the States and understand where the States are in
being able to develop models to improve care for this
population. When I think of flexibility for this population, I
don't think of it in the context of being able to cut benefits
or services. I think about it in terms of we have a population
with very complex needs and we have to be able to adapt to
those needs, and by adapting to those needs, it allows us to
provide more cost-effective care than might otherwise be
available in the traditional Medicare and Medicaid systems when
they are fragmented and not integrated. And so we see potential
for integrated and coordinated systems to be able to take a
holistic look at an individual, understand what that individual
needs and make sure that we are getting those needs met in the
most cost-effective way.
Mr. Pitts. What feedback have you received from States, in
your current capacity, about their interest and willingness to
further integrate care for duals?
Ms. Bella. It is a great question. Everyone knows States
are financially strapped right now, now more than ever before,
and they recognize a tremendous opportunity to improve quality,
and by improving quality, help control costs with this
population. I have seen more motivation in States than ever
before to really understand the needs of this population and to
develop integrated and seamless systems of care. Again, that
improved quality, and by improving quality will lead to reduced
cost over time.
Mr. Pitts. As you know, there are various opinions on how
dual eligibles should be enrolled in integrated care models or
in coordinated care programs. Do you believe that mandatory
enrollment with an opt-out policy would increase enrollment?
Ms. Bella. Certainly, enrollment is a significant issue,
and first and foremost I should say that the commitment of our
office is really to establish beneficiary protections so that
the programs we are creating are ones that are better than what
are available to beneficiaries today.
In thinking about enrollment, enrollment is one of many
issues where we have to be open to exploring options to
understanding what is keeping people out of integrated systems
today, and again, this is one of the issues on the list that we
are committed to exploring with our State partners.
Mr. Pitts. Your office recently announced the availability
of Medicare data on duals for States to access on a project
basis. Why do believe the availability of this data was so
important for States, and what else can CMS do to improve the
availability of real-time Medicare data for States and
providers?
Ms. Bella. Well, I have a personal interest in this. I am a
former Medicaid director, and when Part D happened and Medicaid
agencies lost access to pharmacy data, it was like tying their
hand behind their back because a critical tool was taken away
to understand how to provide better care to these
beneficiaries. So by giving States these data, we support their
efforts to identify high-risk individuals to provide the data
to primary care providers and care managers who are developing
care plans to understand opportunities to prevent
hospitalizations, for example, or to reduce medication errors
or medications that are going to have adverse effects with each
other. We believe that putting the data out there for States
that we have will get them exactly where they need to be. It is
timely. It covers Medicare A, B and D, and it is done in a way
that allows us to protect the important privacy and
confidentiality safeguards yet still give this critical tool to
States who are trying to design programs to improve quality.
Mr. Pitts. I think I have time for one more question.
Realizing the Medicaid expansions in PPACA do not directly
apply to dual eligibles, do you believe implementation of the
expansions could have a woodworking effect on the overall
system that could increase the number of woodworking dual
eligibles?
Ms. Bella. We have not done--the Office of the Actuary has
not done as detailed estimates on this as in other populations
but our early examination of the issue does not lead us to
believe that there will be a woodwork effect for dual eligibles
under the expansion.
Mr. Pitts. Thank you.
The chair recognizes the ranking member, Mr. Pallone, for 5
minutes for questions.
Mr. Pallone. Thank you, Mr. Chairman. I was going to ask
unanimous consent for Ms. Christensen to sit in on today's
hearing, Mr. Chairman.
Mr. Pitts. Without objection, so ordered.
Mr. Pallone. Thank you, Mr. Chairman.
I wanted to try to ask you three questions and try to get
in three questions here, Ms. Bella. My first relates to
budgetary concerns. As you heard in my opening statement, I am
always concerned that decisions about dual eligibles are based
on budget concerns. I am not suggesting that that is true for
you but I always worry that that is a big factor or maybe
disproportionate to what it actually should be. And as we said,
you know, it is a very complicated group. There are patients
like people with developmental disabilities who may be well
under 65 but you also have duals who are people with cognitive
impairments like Alzheimer's diseases at advanced stages, so
because they are not the type of patients that insurance
companies are rushing to sign up for, you know, that is another
concern I have. It is a very expensive population. So I think
we have to be creative and assertive in our attempts to improve
care for duals but we also need to be realistic in our goals
and understand that it may be costly and budgetary expedience
should not drive our treatment of the sickest and the frailest
of our citizens.
So my question is, first question, can you tell us about
how you and your office are thinking about the dual eligibles
as groups? Are you looking at them by what kinds of diseases
that they might have or by the basis for eligibility for the
programs, and of course, you know, my concern is that it is not
budgetary driven.
Ms. Bella. You are exactly right. It is a very diverse
group. There are a few different ways that you can think about
slicing and dicing the population, and I think that is one of
the advantages to having this office is we are really going to
drill down and look at subset analysis of the population. One
of the ways we are looking is at the highest level over and
under 65 to understand the different care needs of those groups
and, for example, when the under-65 population with
disabilities, the presence or absence of mental illness, I like
to call it a game changer. It significantly changes the
utilization, the picture. On the corollary, the over 65s, the
same thing can be said for Alzheimer's and dementia, and you
will hear more about that today. So we are looking at those
levels and we are teasing out the subsets.
In addition, there is also ways of looking at the
population, understanding if their needs are more acute-care
driven so folks who have five, six, seven or eight physical
comorbidities or if they are long-term care driven, so these
are folks who have needs that are more supportive services and
those types of needs and the long-term care, some of those
individuals are in nursing homes and some of them are in the
community, so that further distinguishes how we have to think
about subsetting the population. Now, we tend not to think
about it by conditions or by eligibility groups. We tend to
look for care opportunities. So regardless of what the profile
is in many ways what needs to happen for these patients is an
assessment of their needs is the availability of a care team,
supports to get them the most cost-effective services they need
in whichever setting they need them.
So coming back to your question, those are examples of ways
we are looking at subsetting the population, and then using
that information to drive our decisions about what types of
care models, what types of care needs, what types of payment
and measurement systems we would have in place.
Mr. Pallone. Now I am going to try to get two more things
in. You mentioned the nursing home population. More than half
of all nursing facility residents are dual eligibles. In 2007,
more than 70 percent of Medicaid expenditures for dual
eligibles were for long-term care. What can be done to improve
the care and quality for people in nursing homes and what are
States proposing that would help these individuals? Obviously I
would prefer that they not be in nursing homes. Are there ways
to improve care in nursing homes or get them out of nursing
homes altogether so they don't have to stay in the nursing
homes?
Ms. Bella. The answer to that is yes, there are ways to
improve the care, and there are several States, many States
that are looking at rebalancing efforts. I think you will hear
about some initiatives in North Carolina in particular to
target those folks in nursing homes, but a couple of examples.
We can really focus on avoidable hospitalizations of nursing
home residents, and I will give you some examples. Urinary
tract infection, pressure ulcers, dehydration, fall prevention,
those are all things that are avoidable and they are
preventable, and by targeting interventions and clinical
resources on site, we can improve the quality of care, reduce
hospital transfers and presumably help toward the cost-
effectiveness change as well.
Mr. Pallone. My third question is, I know that, you know,
they worry about passing the buck, in other words, is the
State--who is responsible for their care, the State, the plan,
you know, their insurance plan, and a lot of times there is
passing of the buck in terms of who takes care of them, who
follows up, how to enforce their rights and fulfill their
medical needs. Who is truly accountable at the end of the day
for ensuring that the needs of duals are met and that quality
care is provided? Is it the plan, the State, the Federal
Government, and do you see it as part of your office's mission
to clarify that to make the pathway easier? In other words, can
you play a role in all this so that the buck doesn't get
passed?
I know I am out of time, Mr. Chairman. Maybe she can be
quick in her answer.
Ms. Bella. I will be quick. States and feds are
accountable. We share responsibility. Our office is absolutely
accountable, and I think the reason that was created was to
streamline care and to help make sure that we do keep the
systems together and improve accountability for the program
overall.
Mr. Pallone. So you try to coordinate between these?
Ms. Bella. Yes.
Mr. Pallone. Thank you.
Mr. Pitts. The chair thanks the gentleman and recognizes
the full committee chairman, Mr. Upton, for 5 minutes for
questions.
Mr. Upton. Thank you, Mr. Chairman.
I appreciate your testimony. In your testimony, of course,
you said the total annual spending for their care is estimated
at $300 billion annually, and that the 9 million Medicare/
Medicaid enrollees accounted for approximately $120 billion in
combined Medicaid, federal and State spending in 2007, almost
twice as much as Medicaid spent on all 29 million children that
it covered in that year. Now, in responding to Mr. Pallone, you
talked about some savings you may see in terms of targeting
certain innovations. What other ideas to eliminate barriers do
you think we might be able to achieve to actually see some real
savings in the program? What innovations should we think about
here?
Ms. Bella. Sure. I appreciate the question. Unfortunately,
there is no silver bullet, and the savings tend to happen over
time. However, if you think about--I think where we think holds
the most promise is understanding how do we create systems that
are accountable and coordinated for the 9 million dual
eligibles. There are, by our count, around 100,000 people that
are in fully integrated programs, and by fully integrated, I
mean, there is an accountability for both Medicaid and
Medicare. So the opportunity is large for the rest of the dual-
eligible population, and absent that coordination and
integration, we are not as aligned and efficient and effective
as we could be. And so great opportunity exists to look at
delivery system and payment reform models that understand how
to create a way to take care of the totality of a beneficiary's
needs and how to ensure that the incentives are aligned for
doing so.
Mr. Upton. Well, can we actually come up with some nuts and
bolts to see not only the innovations but then lead directly to
some savings, and if so, what would the savings be either as a
percentage or real dollars?
Ms. Bella. So as was mentioned, one of the first things we
did is to engage States in a partnership to work with us in an
innovation center to design new fully integrated models. So we
have 15 States. That is exactly what we are doing. We are
working with them to design the nuts and bolts of what this
would take. We are in the design phase so we don't have savings
estimates for you at this point. Certainly we can expect that
there are opportunities, as I mentioned, in some of the
avoidable hospitalizations, but we also have seen in programs
in the States that do have them oftentimes there is an increase
before you see a decrease because there is a lot of pent-up
demand, there is care management that is occurring, there is
new services that are taking place in order to reduce other
services now or down the road. So it needs to balance out, but
what we will be working on getting some concrete estimates over
time by working with our States on the models that they would
like to do.
Mr. Upton. So as you are looking at those 15 States, how
long will it take for them to complete the work that they are
doing and you can actually look at some accountability in terms
of what they have done?
Ms. Bella. The way we structured this demonstration
initiative right now is that it is a 12-month design period. It
doesn't mean that States that can't submit a proposal earlier.
Mr. Upton. Which started when?
Ms. Bella. April.
Mr. Upton. April?
Ms. Bella. It started in April. Several States are
interested in putting something forward earlier, and as I
mentioned, all States are able to put proposals together, we
are just working with these 15 to receive funding, so States
aren't--like I said, they can come in sooner with ideas. We
designed this, because this isn't a typical CMS demonstration
where we are prescriptive about what we want to see because
that hasn't worked for us with the States so far, so we need to
work with the States to design what is going to be most
effective for each of them. However, this is a complex
population and we have to do this in a way that makes sure that
we are addressing significant issues around beneficiary
safeguards, provider participation, financial incentives
correctly, and that is why we have designed it in a design
phase.
Mr. Upton. Thank you. I yield back.
Mr. Pitts. The chair thanks the gentleman and recognizes
the ranking member of the full committee, Mr. Waxman, for 5
minutes for questions.
Mr. Waxman. Thank you, Mr. Chairman.
There is an interaction between the issues we are talking
about today and the Medicare Advantage program is a complicated
one. Some Medicare Advantage special needs plans have been
around for a long time and built deep roots in their
communities. Others have less successful track records and of
course the program has for a long time been supported by large
subsidies provided by taxpayers and other beneficiaries. The
Affordable Care Act pared back many of the extra payments to
Medicare Advantage plans but not all of them and not
immediately. I was surprised to find that some States are
proposing to use Medicare Advantage benchmarks as the basis for
their proposed payments in the duals integration demonstration.
Ms. Bella, wouldn't the use of Medicare Advantage benchmarks
increase costs to the federal taxpayer if they were adopted for
duals integration demonstration?
Ms. Bella. We certainly think that--as I mentioned, our
goal is to get more beneficiaries served in integrated systems
and so in integrated systems there is an opportunity to achieve
savings. You are obviously pointing out what we all have seen
in terms of the differential and the MA rates, and I would just
come back to that the purpose of the innovation center is to
develop and identify delivery system and payment reforms that
improve quality and reduce cost, and so as we go forward with
these demonstrations, that is going to be our overriding
principle, so we will work with States to ensure that the
proposals they are putting in place do both of those things,
which would mean understanding how we would address the rate
issue in a way that would support improving quality but not add
cost to the system.
Mr. Waxman. Well, we want to highlight that issue to look
at carefully in your design of these proposals. There are
numerous cost savings with regard to the Medicaid program that
shift costs from the Federal Government to the State
governments instead of lowering cost. The intent of this
hearing and the mission of the Medicare and Medicaid
Coordination Office is to improve care for dual-eligible
individuals, thereby lowering health care costs in Medicaid and
Medicare, a better way of saving money than shifting
responsibility.
I want to ask about some of these contracts you have been
talking about in response to other questions. You recently
awarded to 15 States to design coordination care models. One
requirement you included was integrating care across primary,
acute, behavioral health and long-term support services. Can
you discuss the importance of integrating care across all these
benefits, the barriers to integrating care across all these
benefits and how prevalent such full integration is today?
Ms. Bella. Sure. The importance is to get at exactly what
you talked about, the opportunity to cost-shift, so we need to
mitigate or eliminate those opportunities, for example, if we
have acute care in one system and long-term care in another
system. But more importantly, if we are going to put together
systems of care that are better for real people that need them,
we have to provide a seamless way of them interacting with the
system rather than three different cards, three different
doctor networks, three different grievances and appeals, and I
say three because most of the duals are in separate Part D
plans so they are navigating Medicaid, Medicare and pharmacy
coverage. So that is the importance of putting everything
together in a way that is seamless to them.
The challenges are many. There are certainly always--
whenever you change a system, there are concerns. We have
concerns with capacity, with provider capacity, particularly in
the long-term supports and services side. We have carve-outs in
some States, particularly around behavioral health, so all
those issues that we need to address, but the opportunity is
great, and one of the reasons these States were selected was
because they are committed to providing full integration. As I
mentioned earlier in response to another question, we think
only about 100,000, maybe 120,000 folks have fully integrated
models. You will hear about one of those today with the PACE
program. But again, our goal is to create those types of
systems for significantly larger numbers of Medicare and
Medicaid enrollees.
Mr. Waxman. As you move forward in developing these new
systems for dual-eligible beneficiaries, I think it is critical
that you hear from the individuals and their family caregivers
and get their input into the process to ensure that any new
approaches are simple enough for these individuals and their
caregivers to navigate, protects the rights currently
guaranteed to beneficiaries in Medicare and Medicaid while also
meeting their health concerns. How will your office ensure that
we get these voices heard from the patients and the caregivers?
Ms. Bella. Well, first of all, we share your commitment and
your interest in doing that. We are very vigilant with the
States on the expectations in terms of stakeholder engagement.
We have gotten wonderful input from different consumer advocacy
organizations about how to ensure that is meaningful. We are
doing focus groups of real dual-eligible beneficiaries around
the country so hearing from the real people about what is
working and what is not working, why did some choose integrated
systems, why did others not, and so those types of
conversations really will be informing and driving our efforts.
Mr. Waxman. Thank you very much. Thank you, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman and recognizes
the subcommittee vice chairman, Dr. Burgess, for 5 minutes for
questions.
Mr. Burgess. Thank you, Mr. Chairman.
In the section of the Affordable Care Act that you
referenced that creates your office, there is paragraph E says
the Secretary shall as part of the budget submit to Congress an
annual reporting containing recommendations for legislation
that would improve care coordination and benefits for dual-
eligible individuals. When should we expect that report?
Ms. Bella. So our office was officially created December
30th through the Federal Register and so we missed really the
typical budget cycle. In February the Secretary submitted a
letter outlining the progress of the office to date, committing
to our priorities over the coming year, and now that we are
established we will get caught up on the regular cycle and
provide you that annual report as part of the annual budget
process as the mandate requires.
Mr. Burgess. So when should we expect to receive that
report?
Ms. Bella. Next year.
Mr. Burgess. Next year, January, next year----
Ms. Bella. Next year, February of 2012.
Mr. Burgess. It is just interesting, in the law that was
signed your office was created not later than March 1, 2010. It
is always interesting how something can be created 3 weeks
before the bill got signed into law.
Let me ask you a question. In January, Dr. Berwick was at
the Commonwealth Fund symposium that they put on every year,
and of course, he articulated this problem, and I think he was
a little more dramatic. He said 20 percent of the beneficiaries
are costing 80 percent of the money including blind and
disabled in that group as well. But that was a pretty startling
figure that he related. Now, another Member of Congress who was
there, and I can't take credit for this, it was actually a
Democrat who complained that American health care was so
complicated that he had to go out and hire a concierge
physician to manage his care between the two coasts on which he
lived, and so I asked Don Berwick, why wouldn't you have a
concierge doctor for a dual eligible. It seems like it would
make a lot more sense to pay a physician to manage these
conditions. I have got some figures from 2005 where it is
$26,000 a year that we spend on a Medicare/Medicaid dual-
eligible patient unless they have five or more conditions in
which case that cost doubles. It seems like there is some
significant efficiencies that could be gained here through the
integration of that care, whether you call it a retainer
physician, whether you call it integrated primary care, but
really putting the doctor and not the agency and not a home
health aide, putting the doctor in charge of that patient and
holding them accountable, of course, to perform its metrics
that you outlined, the alignment, the data and the models and
demonstrations. Why not do that?
Ms. Bella. I don't think these things are mutually
exclusive. I think there are opportunities depending on what is
driving a beneficiary's needs. Some of them are less medical.
They are non-medical and so in those cases it does make more
sense to have a care manager, a behavioral health specialist or
a home health aide.
Mr. Burgess. But why not have a physician in charge of all
of those facets of care?
Ms. Bella. There are certainly models that do that, and you
may hear a little bit about those on the second panel. There
are a lot of medical-home initiatives underway right now which
the primary purpose is to support the physician and provide
infrastructure support so that the physician is managing the
totality of the care and is accountable for the financing, so I
think there is a lot of promise for many of those models and
several States are exploring those very things.
Mr. Burgess. Well, forgive me for seeming impatient. I
think there is a lot more than a lot of promise. I think there
is a deliverable that could be obtained really in a much
shorter time frame than anything we have heard discussed here
this afternoon, and we are talking about enormous amounts of
money. We are talking about people's lives, people who are
medically fragile, whose care is of utmost criticality to them
and to their families, and I simply cannot understand why we
wouldn't move with greater dispatch. We are going to have to
wait another year for a report from your office. I mean, these
are things that should have been in the works for some time.
Ms. Bella. Certainly, developing new delivery system and
payment models is first and foremost on what we are doing. We
are happy to come over and do briefings at any time, and we
have done that repeatedly with several staffs. And the only
other thing I would say is, again, it is not that we are not
advancing physician-directed medical-home-type models but we
are also looking at different types of care models, some of
which are less expensive and perhaps better tied to a
beneficiary's needs, which again would I think advance what you
are charging us to today, which is control cost.
Mr. Burgess. Well, you do get what you pay for. You know,
the experience with the accountable care organization rules and
regs that came down is just so disappointing. So many people
had placed so much emphasis on this and so much importance, and
then to find the reg was absolutely unworkable, that clinics
who actually considered themselves accountable care
organizations said we can't do this, and I worry about the same
thing happening in this population where it is so critical that
we get it right.
Mr. Pitts. The chair thanks the gentleman and recognizes
the gentleman from Illinois, Mr. Shimkus, for 5 minutes for
questions.
Mr. Shimkus. Thank you, Mr. Chairman.
Welcome. We are glad to have you here. Realizing that the
Medicaid expansions in the health care law do not in totality
affect dual eligibles, do you believe that the expansion of
Medicaid--and I know you mentioned this woodworking aspect--do
you fear the woodworking aspect with the expansion of Medicaid
under the health care law?
Ms. Bella. We don't, no.
Mr. Shimkus. The latest MedPAC report included a chapter on
dual eligibles. In its report, the commission noted that a
single program design is not likely to be adopted in every
State. They added, there is no clear evidence about which
programs are most effective for every type of dual-eligible
beneficiary. Do you agree that a one-size-fits-all strategy for
improving the coordination and integration of care for duals is
a bad strategy?
Ms. Bella. We think it is very important that we recognize
that there are different delivery system designs in the States,
and if we are going to be effective, we have to work with
States to understand what systems are going to work best for a
given State, and honestly, for a population within that State.
Mr. Shimkus. And following up on that, do you believe that
mandatory enrollment with an opt-out policy would increase
enrollment?
Ms. Bella. As we discussed a little bit ago, enrollment is
obviously a significant issue. We don't have as many people in
these types of systems as we would like to today so it is one
that we are exploring to understand. It is one that we are
learning from in the focus groups as well to understand what it
is that is holding back enrollment, and that is one of the
things that is part of this design process in our work with
both States and stakeholders.
Mr. Shimkus. And part of the problem in obviously the
Medicaid, the dual eligibles, the Medicaid and Medicare, is
that the 50/50 share of Medicare and the ownership that the
State has versus Medicare, which is the federal program, and,
you know, the contention is or the fear that some States may
not be motivated to help solve this based upon depriving them
of the 50/50 share if Medicare is assuming more of a role, or a
role. Can you talk me through that and your experience in
talking with States and whether this might lend itself to a
sharing of Medicare as part of this debate of how you have
inclusive care?
Ms. Bella. Sure. Our work with States highlights that an
area that creates challenges is the misalignment of incentives
between the Federal Government and the States. The governors
have said that. NGA has said that. MedPAC has said that. This
Administration recognizes that. So that is part of our work
with States is to understand if we are going to get this right,
we have to look at how we align the incentives to create
systems of care that are better than we have today.
Mr. Shimkus. And I will just end on this, and again, I
appreciate your time and look forward to the second panel.
Illinois in particular is a struggling State, as many States
are, but we have a $12 billion debt. A lot of it is due to the
expansion of Medicaid without comparable increase in revenue by
the State and so it just was borrowed money and the like. Under
the health care law, which leads back to the first question, it
actually increased enrollment for Medicaid versus over the very
lucrative program the State has. That is why I would argue that
there should be a concern about more people coming out into the
arena based upon the expanded benefits, and I would hope that
you all would take a closer look at that because I do think
that is going to be additional liabilities for us that we are
not calculating in costs today.
Thank you, Mr. Chairman. I yield back.
Mr. Burgess. Would the gentleman yield?
Mr. Shimkus. I would yield to Dr. Burgess.
Mr. Burgess. Can I go back to the integrated care question
that I was talking about just a moment ago? So what is being
done right now as far as making families aware of the
availability of integrated type of care?
Ms. Bella. It depends on a given State and a given health
plan so there are opportunities to inform beneficiaries and
their caregivers of integrated care options either through
State efforts or through health plan efforts.
Mr. Burgess. Is anything being done to enroll people in
integrated care programs?
Ms. Bella. Certainly, but there are two different
enrollment processes, one for the Medicaid half of the person
and one for the Medicare half of the person.
Mr. Burgess. But the estimates I have are less than 2
percent of all of the dual eligibles are in some type of
integrated care program.
Ms. Bella. Correct.
Mr. Burgess. And yet the promise these types of programs
hold is high. Maybe you can get back to me with some additional
information on what is being done to foster that information.
Ms. Bella. I would be happy to do so.
Mr. Pitts. The chair thanks the gentleman and recognizes
the gentleman from Ohio, Mr. Latta, for 5 minutes for
questions.
Mr. Latta. Well, thanks very much, Director, for being with
us this afternoon. I appreciate your time.
Just a little background because I didn't see, where were
you director at?
Ms. Bella. Indiana.
Mr. Latta. And how long were you the director in Indiana?
Ms. Bella. From 2001 through 2005.
Mr. Latta. I always like to find out a little bit about a
person's background because sometimes it is good to see things
from the other side of the fence. I was in the State
legislature in Ohio for 11 years, and during that time we had
our go-arounds, especially with the cost of Medicaid going up,
what it is costing the State budget today, and so I am glad you
have that experience.
And not that I wasn't fascinated with all of your testimony
but something struck me on page 4. In the second paragraph when
you are talking about coordination of the offices, the one
thing that really caught my attention was the seamless care,
and I know that years ago when was in the legislature, I had
been a county commissioner for 6 years prior to that, we had an
individual in the county that we had a lot of problems trying
to get to the right service, to the right place, and I was very
proud of my home county in that we worked things out, and how
we termed it was ``seamless.'' And the reason I find that
interesting is that how is it that it has taken this long for
us to get to this point that after decades that we are finally
starting to talk about seamless and then also in your testimony
talking about the offices working to improve the collaboration
and the communication out there. And again, I think that goes
back that you have seen things from the other side of the fence
that, you know, for decades States have been on the receiving
end of things and the Federal Government is saying one thing
and the State is saying, well, how are we going to get this
done. So I will just ask you that.
Ms. Bella. Well, a few thoughts. I mean, when these
programs were created, I don't think it was ever envisioned
there would be 9 million people eligible for both and so they
work exactly as they were designed to work, which is completely
separately, and we haven't had the resources to date committed
and accountable for trying to put them together and create
seamless systems, and you all fixed that by creating this
office, and so I think it is a recognition. Oftentimes it seems
to be the most difficult fiscal times that drive some good
developments that could help real people and coordinate care,
and that perhaps is what we are seeing today is one of the
greatest advantages of having to realize where we need to focus
is on this population and so we now have a group of people that
is all we do, and so we are accountable for making that better
and working with our State partners to do so.
Mr. Latta. Let me ask this, if I may because, you know, I
hate to say it this way, but we do have some established
bureaucrats in this city that have been here for a while, and
in listening to your testimony and answering the questions to
other members with us today, you know, that you are talking
about doing focus groups around the country, that you are going
to be listening and that, you know, there is no one size that
fits all because, again, like the State of Ohio is completely
different than what is happening out in Idaho or you name it.
But I think it is going to take the direction from you as
someone that has seen it from the other side to really impose
upon these individuals down here that there is something that
occurs outside this beltway. I have folks back home ask me, I
don't care what it is about, they say don't they understand
what is going on back here, and it is very difficult to always
have to tell them no. And so we are going to be looking for
your guidance to make sure that these folks down here that have
been here for a while understand that they do have to take that
direction from you, that you are going to be listening, that
you are going to have these focus groups to find out what works
best.
So with that, Mr. Chairman, I appreciate the time and I
yield back.
Mr. Pitts. The chair thanks the gentleman and recognizes
the gentleman from Louisiana, Dr. Cassidy, for 5 minutes for
questions.
Mr. Cassidy. Thank you, Ms. Bella. I appreciated our phone
conversation a little while ago and I appreciate your testimony
today.
Now, I have been trying to figure out, you mentioned the
buckets of dual eligibles, and the partial duals versus the
full duals, the full duals with the wraparound, and I gather
the full duals may have custodial care paid for by Medicaid but
medical services paid for by Medicare, and the partials will
the deductible copay paid for by Medicaid. What percent of
patients who are duals are in each bucket, and what percent of
the expense of duals are in each bucket? Because clearly
wherever--and then what are the medical outcomes of each
bucket? Because clearly, if we have poor outcomes and higher
expense for that more expense and poor outcomes in a bucket,
that is where we should focus our attention, yet it seems as if
it should take two different approaches.
Ms. Bella. So the biggest bucket would be the full duals
who are receiving all Medicaid services and Medicare services--
--
Mr. Cassidy. Not to be rude, but just so I understand, so
really, in the full duals, there is not that much that Medicaid
is paying for for acute medical services, I gather; rather,
they are paying for the custodial care. Is that correct?
Ms. Bella. They are paying for largely the custodial care.
They wrap around and provide some things like behavioral health
services or home health, in cases where Medicare--it is
wraparound acute. It is the wraparound for the cost share for
the duals and then it is primarily the long-term care service
and support.
Mr. Cassidy. OK. So then if we can differentiate how much
the Medicaid dollar is going for custodial versus those medical
services which Medicare does not pay for, do you all have data
on that? Because I am gathering that most of the expense is in
custodial care which is relatively----
Ms. Bella. I would broaden it to call it long-term care
supports and services just because people tend to think of
custodial as an institutional base. So 70 percent of costs are
in the long-term care bucket, if you will, for those folks.
Mr. Cassidy. For the full duals?
Ms. Bella. Yes, but again, that is not just the custodial
care.
Mr. Cassidy. So then if you separate out--oK. Medicare and
Medicaid together, the duals are a higher percent relative to a
cohort, a non-disabled cohort?
Ms. Bella. Yes.
Mr. Cassidy. OK. So if you just look at the non-long-term-
care costs for those duals, how does that relate compared to a
cohort? Do you follow what I am saying?
Ms. Bella. So on primarily their Medicare expenditures?
Mr. Cassidy. Yes.
Ms. Bella. Yes, they are still higher across the board.
Mr. Cassidy. And is it as dramatic?
Ms. Bella. It is fairly dramatic. I mean, if you think
about they are qualifying people for both Medicaid and Medicare
so they have not just the medical needs but they have a lot of
psychosocial complexity.
Mr. Cassidy. Now, let me ask you, we are going to hear
about a PACE program, and I am very impressed with the concept
of PACE but it is clearly not going to scale. I would like your
perspective on why a program such as that is unable to go to
scale.
Ms. Bella. Well, PACE is designed for a very frail
population, so a couple of things: One is, PACE is for people
who are 55 or older and you need a nursing facility level of
care, so again, that is a very, very frail population.
Mr. Cassidy. But that must be your highest expense
population?
Ms. Bella. It is a high expense, although--yes, it is a
high expense.
Mr. Cassidy. And there must be a heck of a lot more than
20,000 people or 100,000 or whatever.
Ms. Bella. There are opportunities that Shawn will discuss,
and they have been thinking about to get something that is
available to more people in more States. It tends to be
resource-intensive to get some of the programs started but it
has very fundamental concepts that we want to replicate.
Mr. Cassidy. Well, I accept that, it has got great
concepts, and say this not to diss but rather to say--that is
disrespect--but rather just haven't gone to scale.
Ms. Bella. Yes. He is going to get into a lot more, but I
would be happy to have another conversation with you offline.
Mr. Cassidy. The ACO rules which are just, I mean, place
great faith in supercomputers to contact, to follow different
patient interactions, physician interactions I almost see as
counterproductive. Have you read the ACO rules and thought
about how they are going to apply to dual eligibles?
Ms. Bella. I have to be honest, I haven't read every single
page. I have read a majority and have been thinking about how
do you take that model for folks that have long-term care, not
just acute-care needs, and that have different funding streams,
both Medicare and Medicaid, and make sure that we are creating
a system that again doesn't provide opportunities----
Mr. Cassidy. I understand that is what your approach is but
what I have just gathered from you, most of the Medicaid
expense is actually on the long-term care aspect of it and the
ACO is going to be principally on the acute medical services.
In that way, the ACO still doesn't dictate or assign or
anything else, it just follows. I think you answered the
question. The following, it still seems like that is what we
have now. You are just merely following and paying a lot of
money for this coordinated care.
Ms. Bella. We are excited about the opportunity to work
with our States. Again, we are thinking about how do you adapt
more of a managed fee-for-service approach that has an
accountability like an ACO that brings in the long-term care
side for this population.
Mr. Cassidy. Thank you. I yield back.
Mr. Pitts. The chair thanks the gentleman and recognizes
the gentleman from Kentucky, Mr. Whitfield, 5 minutes for
questions.
Mr. Whitfield. Thank you, Mr. Chairman, and Ms. Bella,
thanks for being with us today.
When the Affordable Care Act was passed, the method used in
passing it created a lot of animosity, much of which is still
out there, and I am assuming that you were not even working at
CMS when it passed, but the method used, for example, when it
was on the House Floor, this bill was 2,500 pages, whatever it
was, we were not allowed to even offer one amendment. So I
contrast that sort of process to deal with a complicated health
care delivery system that has a lot of problems with what you
are doing in your coordination office in which you are giving
$1 million to 15 different States for the purpose of allowing
them to explore, be innovative and see if they can come up with
a system that works so it could be replicated in other States,
which I think is commendable. But that same suggestion has been
made for Medicaid regarding the grants to the States. A lot of
controversy in the Republican budget was, we will have a
capitated system for Medicaid.
My question would be, don't you think that there would be
some merit in working out a system so that individual States on
Medicaid could explore, be innovative? I know we are not
talking about dual eligibles per se but the Medicaid program.
Do you see any benefit by setting up a system that would work
like that?
Ms. Bella. We are really kind of singularly focused on
setting up coordinated and accountable system for dual
eligibles and making sure that there are beneficiary
protections, access to care and funds sufficient to provide
care in such a way that eventually helps with the cost
conundrum.
Mr. Whitfield. But at least you all are doing that with 15
States, so I think that is a good idea.
I would like to yield the balance of my time to Dr.
Burgess.
Mr. Burgess. Thank you, Mr. Whitfield.
If I could, let us just go back the fact that the spending
per dual eligible in 2005, $26,000, unless they had five or
more conditions in which case it doubled to $50,000. Obviously
more medical conditions are going to cost more but it seems
like that amount is greater in the dual-eligible realm than it
is for the comparable Medicare patient with five or more
chronic conditions. Is that a fair statement?
Ms. Bella. Across the board, dual eligibles rate higher
than Medicare-only beneficiaries, yes.
Mr. Burgess. So is that increasing cost only because of the
cost of long-term care or is there something else that is
entering into that? What accounts for that cost differential?
Ms. Bella. Well, this is a much more complex population and
so the needs that they have and the way those needs translate
into utilization of services is what drives cost. I mean,
across the board, again, this population is poorer, sicker,
more impaired than any other population.
Mr. Burgess. Correct, which is why my anxiety about not
having a knowledgeable medical person in charge of
orchestrating all aspects of that care, if you don't have that,
then you are going to get what you have got, and the last thing
we want is more of what you have got because we haven't got any
more to give to pay for what you have got. Do you follow me? I
mean, this is so critical that we have the knowledgeable
medical person in charge and responsible for that patient's
care. The elderly patient in the nursing home doesn't just get
a urinary tract infection, they get urosepsis, and they come
into the hospital and they die after five days of intensive
therapy. The outcome is just absolutely dreadful and it costs a
lot of money. Someone to be able to anticipate that and prevent
that is literally worth their weight in gold in that situation.
Is that not correct?
Ms. Bella. We are trying to create systems where there is
an accountable care team and an entity that is----
Mr. Burgess. You don't need a team, you need a person. You
need one person to be accountable. I am sorry, I am old school.
I am a doctor. In the old days, there was one person in charge
and accountable.
Mr. Chairman, against my better judgment, I am going to ask
that this Ezra Klein article from the Washington Post from June
16th be entered into the record. Only about half of it is
accurate but the part that is, is so accurate that I think it
is worth sharing with our colleagues and the general public.
Mr. Pitts. Without objection, so ordered.
Mr. Burgess. Thank you.
[The information follows:]
[GRAPHIC] [TIFF OMITTED] 72402.028
[GRAPHIC] [TIFF OMITTED] 72402.029
Mr. Pitts. The chair thanks the gentleman and recognizes
the gentlelady from the Virgin Islands, Dr. Christensen, for 5
minutes for questions.
Mrs. Christensen. Thank you, Mr. Chairman, and I thank you
and the ranking member for allowing me to sit in on this
important hearing, and I am particularly interested in being
here because in the dual-eligible population, somewhere around
40 percent of that population are minorities, and so I hope,
Director, that you are also working with the new Office of
Minority Health to look at that subpopulation as you plan this
coordination.
So the dual-eligible population disproportionately suffers
from racial, ethnic as well as geographic disparities, and
these are particularly pronounced in the end-stage renal
disease population. There has been a successful, I think,
completion of a 5-year coordinated care demonstration for end-
stage renal disease patients, and what are your thoughts about
expanding this demonstration to the dual-eligible population?
Is this something that your office can work with others to
implement?
Ms. Bella. Well, we are certainly interested in looking at
all demonstration opportunities that could be tailored to the
dual-eligible population for different subsets of the
population so it is certainly something that we can go back and
discuss further with our colleagues.
Mrs. Christensen. I think it might prove helpful,
especially since end-stage renal disease, I am sure, accounts
for a lot of the cost that Medicare puts out.
Also as a provider, like Dr. Burgess, and having worked
with AmeriHealth Mercy family of companies, which is one of our
country's largest Medicaid managed care plans to help
understand some of the challenges, I understand that under
current regulations, services provided to Medicaid health plan
enrollees by institutions are not counted in determining
payments to providers and this results in fragmented care
because states often choose not to enroll these populations
into Medicaid health plans or they carve out provider services
from the plan's benefit coverage. Are you familiar with this
problem and barrier to enrollment or expanding enrollment and
are there any plans to address this?
Ms. Bella. It is certainly something that we have heard
from some States and some plans, and again, kind of taking that
list of everything we have to begin to understand and figure
out how we are going to address greater opportunities to
promote alignment. That would be part of what we have on that
list.
Mrs. Christensen. Just one more question. Ms. Hewson from
Community Care of North Carolina in her testimony, one of the
things she notes is that programs targeting at-risk pre-duals
may, you know, be something to really start looking at, not
only for the care of those patients, better care of those
patients, but also for the larger budget impact. Is this
something that the office is working on?
Ms. Bella. Absolutely. There is a huge opportunity with the
pre-duals, particularly preventing their decline or their
spend-down of resources and being smart about how we can make
an investment on the front end and prevent migration into dual
status. So yes, it is something that we are looking at.
Mrs. Christensen. Thank you, Mr. Chairman.
Mr. Pitts. The chair thanks the gentlelady.
Mr. Pallone. Mr. Chairman, could I ask unanimous consent
that Mr. Markey be allowed to participate in the subcommittee
today?
Mr. Pitts. Without objection, so ordered. Do you want to
ask questions of this panel?
Mr. Markey. If you don't mind, Mr. Chairman.
Mr. Pitts. All right. The chair recognizes the gentleman
for 5 minutes for questions.
Mr. Markey. I thank you, Chairman Pitts and Ranking Member
Pallone, for holding this hearing, and I would like to thank
Melanie Bella for helping to lead the charge at CMS to improve
care for 9 million patients who by definition are the sickest,
poorest, costliest individuals covered by either Medicaid or
Medicare. The landmark health care law included language that I
authored to create a pilot program called Independence at Home
to address the unique needs of Medicare patients who have
multiple conditions including Alzheimer's, Parkinson's, et
cetera. Caring for these patients is disproportionately
expensive yet this population often receives substandard and
uncoordinated care that products conflicting diagnoses and
confusing courses of treatment. Further, many of these
individuals wish to remain at home rather than nursing homes or
hospitals and they could do so if they were given some help.
The Independence at Home program gets at the root of the
problem by creating teams of health care providers who will
work together to coordinate care for these patients and provide
primary care services at the patient's own home. If they
succeed in lowering costs beyond 5 percent, the providers will
share in the additional savings, so there is a stake in
lowering costs to the system.
It seems to me that Independence at Home could also help us
improve care for the patients who are eligible for both
Medicare and Medicaid by integrating health care services
provided by Medicare with long-term supports and services
provided by Medicaid. For years we have seen the success of
Independence at Home-style programs at more than 250 VA
locations and elsewhere throughout the country. The VA programs
have reduced nursing home care by 88 percent and reduced
overall costs by 24 percent on the highest cost, chronically
ill patients all while achieving record-high patient
satisfaction rates. ElderPAC, which has been operating this
style of program for the dual population, shows savings to the
Medicaid program of 23 percent over the past decade.
So let me as you this, Ms. Bella. In light of the fact that
the Independence at Home model has proven successful in
lowering costs and improving outcomes among some of the most
challenging Medicare patients. Don't you agree that your office
should look at expanding this model of patients that are
eligible for both Medicare and Medicaid?
Ms. Bella. Well, first of all, we thank you for your
leadership and support on this issue. We are very committed to
models that allow dual-eligible beneficiaries to stay at home
with supports. We are in discussion with our colleagues about
the Independence at Home demonstration. As you know, it is
still in development. It will be available the first of 2012
and we are looking for opportunities to make sure that it is in
the mix of models that could be considered for dual eligibles.
Mr. Markey. Is there in your experience a reason to believe
that this is a good way of looking at how we keep these
Alzheimer's and other patients at home longer and save the
system money because they don't have to go to nursing homes?
Ms. Bella. Certainly we are very interested in models that
allow individuals to stay in care preferences of their choice
and that are also cost-effective and so we do believe a model
like this holds promise. Again, we look forward to
understanding how we can adapt that in our work with States and
others as we develop new delivery system models.
Mr. Markey. And do you think that it makes some sense to
incentivize the health care providers that they make money if
they can figure out ways of saving money by keeping patients at
home? Do you think that that will incentivize them to think
anew about how to take care of these patients?
Ms. Bella. Well, we always want to make sure that there is
appropriate beneficiary safeguards in place and that people are
getting the services that they need, but opportunities where we
know that there are opportunities to align incentives, it
certainly is a direction that the agency has been heading in
terms of being able to do some performance-based outcomes
payments.
Mr. Markey. You know, I did that bill in conjunction with
the Alzheimer's Association. As you know, there are 5 million
Americans right now with Alzheimer's and 15 million baby
boomers are going to have Alzheimer's, so it is obviously
important that there be a plan that coordinates with families,
you know, who are the principal caregivers so that they can
have the maximum amount of help at home, because once they go
to a nursing home, it is $60,000, $70,000 a year on Medicaid,
you know, for those families, so this is just a program that
obviously meant to help keep them at home, save the system
money, make the families happier and the patient as well in a
setting where they would feel more comfortable, so we thank
you, and I would like to continue to work with you on
developing that program.
Ms. Bella. I would be happy to do so.
Mr. Pitts. The chair thanks the gentleman. That completes
round one of questions. We have one follow-up. Dr. Cassidy.
Mr. Cassidy. Ms. Bella, I should know this and I don't, and
I apologize, but you mentioned a couple times that mental
health issues are going to--you know, it is an independent
variable, it sounds like. You do a retrogression analysis and
it comes out mental health is a big issue. So a couple
questions. Is this related to addictive disorders or is it
related to, if you will, classical mental health issues, number
one, you know, paranoid schizophrenia, for example. Is the
issue that they are noncompliant with medical services and are
going in and out with poorly controlled comorbidities or is the
issue that they are going in and out with mental health
admissions? And clearly, it seems as if that would be something
that a wraparound managed care organization could theoretically
improve outcomes and strengthen stability of the programs'
finances. What is the track record of such programs?
Ms. Bella. Let me try to take your questions in order. So
the first, I mean, when we think about the folks that have
behavioral health issues, it is mental illness, it is also
substance use. There tends, as you know from treating patients,
there is a higher prevalence of substance use in folks who----
Mr. Cassidy. So that is a third category, if you will,
combined?
Ms. Bella. But you have the serious mental illness,
schizophrenia, bipolar, and then you have folks that have
depression and other symptoms. Clearly the utilization is
different for those populations. What drives part of the
trouble is there tends to be a disconnect in the physical and
behavioral health systems, as you know, and a real lack of
information sharing so that one half doesn't know what the
other half is doing with regard to this patient, and again, as
a practicing physician, you can understand why that would be so
detrimental because the effects of----
Mr. Cassidy. And again, that is why it just seems like
managed care would be custom made, that this is where it would
integrate and bring things together.
Ms. Bella. Certainly. I mean, there's been different--
States have tried different approaches. Some have given
responsibility for everything to a health plan. Some have
carved out behavioral health services to a health plan while
physical health services have stayed in fee-for-service or
sometimes physical health services have gone to yet another
health plan. So there tends to be different mechanisms States
have tried. There also have been a couple of really great
pilots, one in Pennsylvania, that it was within a fee-for-
service system but what they focused on was sharing information
and aligning incentives between the physical health and the
behavioral health world, and that made a huge difference.
Mr. Cassidy. That was not managed care, that was just--
there must have been some integration between the practice
groups.
Ms. Bella. There was management on the behavioral health
side and it was fee-for-service with PMPM overlay on the
physical health side but no structural or organizational
integration, if you will, and it all got down to really
understanding, making sure all people involved in that care had
a clear picture of what the beneficiary was getting on both
sides.
Mr. Cassidy. Now, they couldn't have been doing that with
Medicaid rates. They must have been paying Medicare rates to
providers, correct? Because that would be time-intensive to
transfer that.
Ms. Bella. It was time-intensive. They had some outside
support during the pilot phase but also they got smarter about
how they delivered care. They used other types of
practitioners. They did a lot with peer support specialists,
and the cost dynamic is different when you----
Mr. Cassidy. Do you have an analysis of that you could
share with us? Because I think it is very intriguing.
Ms. Bella. I am not sure that any final sort of journal-
ready analysis has been published but I would be happy to share
with you what has been done to date and certainly some
descriptive analysis and the metrics that they are using.
Mr. Cassidy. Sounds great. And my second question, which
was, since we went to the third, is the increased expense due
to multiple admissions for mental illnesses, for the paranoid
schizophrenic, for example, or is it noncompliance with medical
illnesses so it is bouncing in and out because their diabetes
is poorly controlled, for example?
Ms. Bella. It is hard to generalize. I mean, both, but
clearly two things that both could be improved with integrated,
coordinated and accountable systems.
Mr. Cassidy. Do you have any idea of the--that will be a
follow-up question at a later time, but I would be interested,
again, I trying to understand which of this is compressible,
long-term care is not as compressible, whereas perhaps this
would be. What percent of the increased expense is related to
this subgroup of populations, those with mental health and
physical health issues simultaneously?
Ms. Bella. We will call that our bucket analysis and we
will work on getting you some analysis in those different
categories across the board for the committee's consideration.
Mr. Cassidy. Thank you.
Mr. Pitts. The chair thanks the gentleman. We have a
follow-up questions from Dr. Christensen.
Mrs. Christensen. Just a very brief question. As you know,
the territories with Medicaid cap and not all of the help for
Medicare either really have struggled to provide services for
our dual eligibles so I just wanted to know if this process of
coordination, if your office also looks at this issue in the
U.S. territories.
Ms. Bella. Our office is intended to be a resource for the
States and the territories who are interested in improving
care, so yes, we are available to work with the territories,
absolutely.
Mr. Pitts. The chair thanks the gentlelady. That concludes
panel one. The chair thanks the Director for her excellent
testimony and yields to the ranking member for a unanimous
consent request.
Mr. Pallone. Thank you, Mr. Chairman. I would ask for
unanimous consent to submit for the record the first report
that Ms. Bella's office submitted to Congress as required by
the ACA that one member, I think Dr. Burgess, was asking about.
Mr. Pitts. Without objection, so ordered.
[The information follows:]
[GRAPHIC] [TIFF OMITTED] 72402.030
[GRAPHIC] [TIFF OMITTED] 72402.031
[GRAPHIC] [TIFF OMITTED] 72402.032
[GRAPHIC] [TIFF OMITTED] 72402.033
[GRAPHIC] [TIFF OMITTED] 72402.034
Mr. Pallone. And then I would ask unanimous consent to
enter the statement of Mary Kay Henry, who is the president of
SEIU, and I think you have both of these.
Mr. Pitts. Without objection, so ordered.
Mr. Pallone. Thank you.
[The information follows:]
[GRAPHIC] [TIFF OMITTED] 72402.035
[GRAPHIC] [TIFF OMITTED] 72402.036
[GRAPHIC] [TIFF OMITTED] 72402.037
[GRAPHIC] [TIFF OMITTED] 72402.038
[GRAPHIC] [TIFF OMITTED] 72402.039
[GRAPHIC] [TIFF OMITTED] 72402.040
[GRAPHIC] [TIFF OMITTED] 72402.041
[GRAPHIC] [TIFF OMITTED] 72402.042
Mr. Pitts. Thank you.
At this time I will ask the second panel to come forward,
and I will introduce them in the order of testimony. Robert
Egge is the Alzheimer's Association's Vice President of Public
Policy and Advocacy. Billy Millwee is the Associate
Commissioner for Medicaid and Children's Health Insurance
Program at the Texas Health and Human Services Commission.
Denise Levis Hewson is the Director of Clinical Programs and
Quality Improvement at Community Care of North Carolina. And
Shawn Bloom is the President and CEO of the National PACE
Association. Your written statements will be made part of the
record and we ask you to summarize each of your opening
statements in 5 minutes before the question-and-answer period.
At this point the chair recognizes Robert Egge.
STATEMENTS OF ROBERT EGGE, VICE PRESIDENT OF PUBLIC POLICY,
ALZHEIMER'S ASSOCIATION; BILLY MILLWEE, ASSOCIATE COMMISSIONER
FOR MEDICAID/CHIP, TEXAS HEALTH AND HUMAN SERVICES COMMISSION;
DENISE LEVIS HEWSON, DIRECTOR OF CLINICAL PROGRAMS AND QUALITY
IMPROVEMENT, COMMUNITY CARE OF NORTH CAROLINA; AND SHAWN BLOOM,
PRESIDENT AND CHIEF EXECUTIVE OFFICER, NATIONAL PACE
ASSOCIATION
STATEMENT OF ROBERT EGGE
Mr. Egge. Good afternoon, Chairman Pitts, Ranking Member
Pallone and distinguished members of the subcommittee. I am
Robert Egge, Vice President of Public Policy of the Alzheimer's
Association, and I thank you for the opportunity to appear here
today.
I want to begin by telling you about John and his wife
Emma. John and Emma are an elderly, low-income couple who
depend on both Medicare and Medicaid. John has Alzheimer's
disease and diabetes. John's physician has been consistently
attentive to his diabetes but not to his Alzheimer's. He has
given John good diabetes treatment plan, but because of John's
impairments due to his Alzheimer's, John has been increasingly
unable to comprehend or follow those instructions. So despite
his physician's efforts, John's diabetes and his overall health
has steadily deteriorated. For her part, Emma has been ill-
equipped to help John manage the demands of his dementia and
his diabetes because of her own health and the lack of
caregiver training and support that has been offered to her.
Because of all of this, John and Emma began taking frequent
trips to the hospital ER where John was regarded as a
noncompliant, difficult diabetic.
Most of the hospital staff did not seem to recognize John's
dementia and that his noncompliance with diabetes treatments
wasn't about John being obstinate or unmotivated but was due to
his inability to self-manage his care. Those that did recognize
the presence and the implications of his dementia were at a
loss for what to do about it. So John continued to show up at
the emergency room for diabetes-related conditions at ever more
frequent intervals. Each time he was sent home with discharge
orders often explained to him without Emma even present that he
had no hope of following. These ER episodes were disconnected
from his physician's care. John's hospitalizations increased,
his health deteriorated, claims to Medicare and Medicaid
mounted. Reluctantly, John and Emma decided he could no longer
live in his home but had to enter a Medicaid-funded nursing
home much sooner than either of them had hoped or expected.
As reported in the Alzheimer's Association's 2011
Alzheimer's disease facts and figures, there are an estimated
5.4 million Americans like John with Alzheimer's, currently a
terminal disease with no known means to prevent, stop or slow
its progression, and there are almost 15 million unpaid
caregivers, many like Emma, who help care for them. Those
millions of Americans with Alzheimer's form a disproportionate
share of the dual-eligible population. Sixty-one percent of
dual-eligible individuals are cognitively or mentally impaired.
Nearly one in every six dual eligibles has Alzheimer's disease
or other dementia. Alzheimer's and other dementias are also
extremely prevalent among dual eligibles in nursing homes where
59 percent of residents live with these conditions. Similarly,
at any point in time, about one-quarter of all hospital
patients age 65 and older have Alzheimer's or other dementias.
So this population of duals with Alzheimer's is large in
scale and it is also very large in cost. Medicare payments for
beneficiaries with Alzheimer's and other dementias are three
times greater than for comparable beneficiaries without these
conditions, and Medicaid payments are nine times higher. These
facts lead to the first of two points I want to conclude with
today.
Individuals with Alzheimer's that depend on Medicare and
Medicaid make up such a large, vulnerable and cost-intensive
share of the dual-eligible population that policymakers should
focus on these beneficiaries in pilots, demonstrations and
broader system reform efforts. Recognizing this group is
offering a leading opportunity to improve care while
controlling cost.
The other major point I wanted to close with is that
focusing on improving care for dual-eligible individuals with
Alzheimer's won't only deliver benefits for these millions of
Americans but will also have health benefits more generally.
Over the years, our growing awareness of the significance of
manageable chronic conditions like diabetes has led to an
important emphasis on prevention, self-management and patient-
centered care. Today, in a similar way, our growing awareness
of the widespread impact of cognitive impairments due to
Alzheimer's and other causes should draw much-needed attention
to themes such as reducing program complexity, the detection,
diagnosis and documentation of medical conditions like
Alzheimer's, and to putting in place care plans that recognize
not only an individual's cognitive abilities but fully
recognize and support the critical role of the unpaid family
caregiver.
The foundation of effective care is in diagnosis, care
planning and medical record documentation, principles contained
in Mr. Markey's bill, the Hope for Alzheimer's Act, which the
association strongly supports. Moreover, the insights
underpinning this bill apply across the dual-eligible and
Medicare populations.
So again, thank you. The Alzheimer's Association greatly
appreciates the opportunity to address these issues, and we
look forward to our continuing work with the subcommittee.
[The prepared statement of Mr. Egge follows:]
[GRAPHIC] [TIFF OMITTED] 72402.043
[GRAPHIC] [TIFF OMITTED] 72402.044
[GRAPHIC] [TIFF OMITTED] 72402.045
[GRAPHIC] [TIFF OMITTED] 72402.046
[GRAPHIC] [TIFF OMITTED] 72402.047
[GRAPHIC] [TIFF OMITTED] 72402.048
[GRAPHIC] [TIFF OMITTED] 72402.049
[GRAPHIC] [TIFF OMITTED] 72402.050
[GRAPHIC] [TIFF OMITTED] 72402.051
[GRAPHIC] [TIFF OMITTED] 72402.052
[GRAPHIC] [TIFF OMITTED] 72402.053
[GRAPHIC] [TIFF OMITTED] 72402.054
[GRAPHIC] [TIFF OMITTED] 72402.055
[GRAPHIC] [TIFF OMITTED] 72402.056
[GRAPHIC] [TIFF OMITTED] 72402.057
[GRAPHIC] [TIFF OMITTED] 72402.058
Mr. Pitts. The chair thanks the gentleman and recognizes
Mr. Millwee for 5 minutes.
STATEMENT OF BILLY MILLWEE
Mr. Millwee. Thank you, Mr. Chairman, members of the
committee. I would like to spend a few minutes speaking to you
about the STAR+PLUS program. The STAR+PLUS program is a
capitated managed care model that integrates acute and
community-based care services for the aged, blind and disabled
population in Texas. This includes the dual-eligible members.
A little bit about the Texas Medicaid population. There are
about 3.2 million people on Medicaid in Texas today. Of that
number, about 700,000 are classified as aged, blind and
disabled, and of that number, about 400,000 are duals. ABDs
represent about 25 percent of the Medicaid population but
approximately 58 percent of the total Medicaid cost.
Where does STAR+PLUS originate? STAR+PLUS originated in
1998 as a pilot in Harris County in Houston. It was created
largely to address concerns about cost, quality and access to
services for the aged, blind and disabled population, also the
subset we refer to as duals, and to address how we could better
integrate acute and long-term care for that population. The
program was started with about 58,000 people in 1998. Today,
STAR+PLUS now serves 42 Texas counties and 257,000 people. By
March 2012, the program will be expanded to serve another
370,000 people in Texas in 80 counties.
And here is how the program works at a very high level. It
is an integrated care delivery model in a capitated managed
care environment so we take acute care services and long-term
care services and bundle those together, deliver them to the
HMO. Central to that model is a primary care provider and a
service coordinator who really work with that patient to get
them the services that they need, whether those services are
acute care or long-term care. The service coordinator is
responsible for assessing that person's need and ensuring that
the needs are met, and by doing that, it provides that early
intervention so we keep people out of the hospital, out of the
emergency room and out of the nursing institutions.
Several studies to date by our external quality review
organization have shown the model is effective. We have
decreased inpatient services, hospitalizations about 22
percent, reduced ED visits by 15 percent, and, more
importantly, people who are involved in the program report a
high degree of satisfaction with the program. We are excited
about the opportunity now to work with CMS on how we can better
coordinate care and I look forward to working with Melanie
Bella in her program that she just started.
[The prepared statement of Mr. Millwee follows:]
[GRAPHIC] [TIFF OMITTED] 72402.059
[GRAPHIC] [TIFF OMITTED] 72402.060
[GRAPHIC] [TIFF OMITTED] 72402.061
[GRAPHIC] [TIFF OMITTED] 72402.062
[GRAPHIC] [TIFF OMITTED] 72402.063
[GRAPHIC] [TIFF OMITTED] 72402.064
Mr. Pitts. The chair thanks the gentleman and recognizes
Ms. Hewson for 5 minutes.
STATEMENT OF DENISE LEVIS HEWSON
Ms. Hewson. Good afternoon, Chairman Pitts and Ranking
Member Pallone and the other distinguished members of the
subcommittee. I am Denise Levis Hewson. I direct the clinical
and quality programs for Community Care of North Carolina, and
I appreciate the opportunity to tell you about our program. It
is a collaborative organization of regional networks of health
care providers, physicians, hospitals, health departments,
social service agencies and other community organizations. Each
network is a nonprofit organization and I work for the central
office that helps coordinate and provides supports to all of
the 14 networks.
We create medical homes matching each patient with a
primary care provider who leads an interdisciplinary team,
professionals who coordinate seamless medical services aimed at
producing better outcomes. Our challenge is not only to improve
the quality of care but to cut costs without changing benefits
and fees. As you start looking at changing the benefit package
and fee structures, oftentimes you are pushing the patient into
other delivery areas like the emergency room. You need engaged
providers to do this program and engaged patients to be
successful.
Sustainable savings come only from learning to deliver care
in a smarter and more coordinated way. We have been doing this
for 10 years. We started as a pilot in 1998 and we have been
adapting and refining this model, most recently really
targeting the highest costs and highest risk.
What is different about program is that it is led by
physicians who are charged with changing the face of health
care at the local community level. It is a bottom-up
governance. It is key to getting buy-in at the practice level.
We have begun to make some significant changes in local
delivery systems. It is built on a model where each patient has
a medical home. We have 1,400 medical homes across North
Carolina in our 14 networks that provide the infrastructure to
provide wraparound support to the medical homes. We have about
600 care managers. We have 30 medical directors, 14 network
directors, 18 clinical pharmacists and 10 local psychiatrists.
These are local people managing local patients and driving
improvements in their systems. The physicians are engaged
because they are part of the solution. They lead the local
teams. They decide how to collaborate best to get the best
results.
Efforts to improve care and save money are owned by those
who directly provide that care. Our care managers know their
patients. They know the community and the resources and that
varies greatly in some of our rural communities. Care managers
are the boots on the ground. They connect the dots between the
patient, the physician, the specialist, the hospital, home
health and other community resources. We believe that all
health care is local and that community support for individuals
with multiple chronic conditions can significantly improve
health outcomes.
One of the challenges in this program is defining the
impactable population. You have to have the information and
data to go after those patients and manage them and provide the
right support so that they can have better outcomes.
We serve over a million Medicaid recipients. We started as
a Medicaid program. Now we have about 80,000 duals that are
enrolled with our program. In addition, about 180,000 of those
are aged, blind, disabled so those represent fairly large,
significant high-cost patients. We get hospital data. Hospitals
and community providers are partners in this organization. To
manage these individuals, you have to follow them across
different providers and delivery systems.
We hope that this committee will look hard at better
aligning Medicare and Medicaid services at the patient and
community level, allow for shared savings in per-member, per-
month management fees that provide patient management without
capitation or risk models. We are a fee-for-service system. The
delivery system must be patient centered. The important thing
to remember is that patients need changes over time so a system
must follow their needs across settings and providers. Our
community-based medical home and network infrastructure focuses
on population management strategies, and we aim to achieve the
triple aims that we hear a lot in the literature, which is not
only about improving quality, access and reliability but
reducing the cost of that care. We have learned some key
lessons in North Carolina with the dual population, and you
have heard it by several of the other testimonies today that
they have multiple comorbidities. They use the system more than
a lot of other populations. They take a lot of medicines. And
so they truly do benefit from a wraparound support at the
community level. Our total annual budget for Community Care is
about 1 percent of the total Medicaid costs in North Carolina.
Our commitment to quality doesn't just mean better care, it
also leads to significant program savings. We asked the
analytics company, Trio Solutions, to help us estimate savings,
and they have done that and you have got more information of
that in some of the handouts. Our trend data is fairly
significant in terms of costs and savings.
Mr. Chairman, I would like to thank you and the members of
your subcommittee for the opportunity to be here today and
discuss these issues, and we hope we can be a resource to you
as you move ahead.
[The prepared statement of Ms. Hewson follows:]
[GRAPHIC] [TIFF OMITTED] 72402.065
[GRAPHIC] [TIFF OMITTED] 72402.066
[GRAPHIC] [TIFF OMITTED] 72402.067
[GRAPHIC] [TIFF OMITTED] 72402.068
[GRAPHIC] [TIFF OMITTED] 72402.069
[GRAPHIC] [TIFF OMITTED] 72402.070
[GRAPHIC] [TIFF OMITTED] 72402.071
[GRAPHIC] [TIFF OMITTED] 72402.072
[GRAPHIC] [TIFF OMITTED] 72402.073
[GRAPHIC] [TIFF OMITTED] 72402.074
[GRAPHIC] [TIFF OMITTED] 72402.075
[GRAPHIC] [TIFF OMITTED] 72402.076
[GRAPHIC] [TIFF OMITTED] 72402.077
[GRAPHIC] [TIFF OMITTED] 72402.078
[GRAPHIC] [TIFF OMITTED] 72402.079
[GRAPHIC] [TIFF OMITTED] 72402.080
[GRAPHIC] [TIFF OMITTED] 72402.081
[GRAPHIC] [TIFF OMITTED] 72402.082
[GRAPHIC] [TIFF OMITTED] 72402.083
[GRAPHIC] [TIFF OMITTED] 72402.084
[GRAPHIC] [TIFF OMITTED] 72402.085
[GRAPHIC] [TIFF OMITTED] 72402.086
[GRAPHIC] [TIFF OMITTED] 72402.087
[GRAPHIC] [TIFF OMITTED] 72402.088
[GRAPHIC] [TIFF OMITTED] 72402.089
[GRAPHIC] [TIFF OMITTED] 72402.090
[GRAPHIC] [TIFF OMITTED] 72402.091
[GRAPHIC] [TIFF OMITTED] 72402.092
[GRAPHIC] [TIFF OMITTED] 72402.093
[GRAPHIC] [TIFF OMITTED] 72402.094
Mr. Pitts. The chair thanks the gentlelady and recognizes
Mr. Bloom for 5 minutes.
STATEMENT OF SHAWN BLOOM
Mr. Bloom. Thank you very much, Chairman Pitts, Ranking
Member Pallone and distinguished members of the subcommittee. I
am Shawn Bloom, CEO of the National PACE Association. On behalf
of NPA and its members, I am honored to testify today, and I
appreciate the time that you have allotted us.
I would like to kind of focus on three things, very briefly
describe PACE to you and then offer some suggestions regarding
ideas with respect to overcoming barriers that we have
identified in expanding PACE, and three, identify some
voluntary demonstration programs that we have generated in
which we could expand the availability of PACE to additional
eligible categories of dually eligible.
First and foremost, PACE is a fully integrated model of
care that exclusively serves the frailest, oldest and sickest
subset of the duals, that is, the nursing home-eligible
seniors. We do so in a manner that is really focused in the
community in the sense that we are community based. Our goal in
PACE is to allow individuals to remain living in their homes in
the community. We do that through reducing nursing home use,
reducing hospitalization, and we do that in a comprehensive
fashion through integrated use of Medicare and Medicaid bundled
payment, and the heartbeat within PACE is the interdisciplinary
team, or the concierge team, if you want to call it that, in
the sense that they are a fully employed staff that on a daily
basis are involved in the care, delivery and management of the
care of the individuals that we serve. And the third key
feature of PACE is, we are accountable. We are accountable in
the sense that we are accountable to government for the payment
provided to PACE, 90 percent of which comes from Medicare and
Medicaid, and we are accountable to the families and the frail
that we serve. And I think those three things taken together
have very effectively aligned incentives for PACE. We are fully
accountable for the cost and quality of care that we directly
provide. So to the extent that we do a good job, those that we
serve are able to stay out of the hospital, in their homes and
achieve good health care.
I think recognizing the effectiveness of PACE, a recent
June 15th MedPAC report states: ``Fully integrated managed care
plans and PACE providers offer the best opportunity to improve
care coordination for dual-eligible beneficiaries across
Medicare and Medicaid services.'' Authorized by the Balanced
Budget Act of 1997, we have been around for 20 years. We are a
tested model of care, and we are very interested in finding
ways to kind of growth.
I think as has been mentioned earlier, and I think Melanie
mentioned it, there have been significant obstacles to PACE
growth, and we would like to kind of talk just a minute about
those now. One, some of the regulatory requirements certainly
focus on the required process of care rather than the outcomes
of care, and those particular regulatory requirements have so
far hindered growth, innovation and efficiency and how we
deliver care. Two, fairly significant capital startup costs and
long lead times for programs that accept full financial risk
for a population that on average is about 300 people, that is a
significant undertaking, and our eligibility for PACE is very
narrow. We serve, as I mentioned earlier, a very small subset
of the duals 55 years of age or older, and you have to be
nursing home eligible. We believe there are opportunities to
expand the availability of PACE.
So to overcome these barriers, we recommend the following
modifications to the PACE statute and regulation, and this is
based on a decade of operational experience under the current
regulation. One, allow us to more appropriately use contract
community-based physicians rather than full employed
physicians; two, take full advantage of the State license
capability of nurse practitioners and physician assistants to
practice up to their level of standards within the State
practice acts; and then without compromising PACE participants'
receipt of comprehensive care and assessment, allow more
flexibility to personalize and individualize the use of
interdisciplinary teams based on the individuals' needs, not
using a one-size-fits-all approach. And lastly, allow States,
and this is something of great interest to PACE providers right
now, really begin to look at States and encourage them to see
PACE as a means by which to pull people out of nursing homes.
Some of our PACE programs throughout the States without great
State support have had the ability to do that.
With respect to voluntary demonstrations, we have five
ideas with the goal of kind of expanding PACE and finding
additional regulatory modifications. One, we would like to
expand the availability of PACE to individuals under the age of
55 that are nursing home eligible. These are typically the
physically disabled individuals that we believe would benefit
from PACE. Two, allow at-risk or what we call high-need, high-
risk, high-cost beneficiaries to have access to PACE, many of
which are not currently nursing home eligible but we believe
would benefit from PACE services. Three, reduce PACE
organizations' reliance on the PACE center, which is really the
focal point for the organization of services but not
necessarily the need to kind of do it all there. Fourth, the
ability to kind of implement alternative approaches to
providing Part D drugs. Right now, we have to implement Part D
in the context of a very small program whose benefit was
designed for large health plans. And lastly, a demonstration
with the objective of increasing Medicare-only beneficiaries'
enrollment in PACE. Currently, about 90 percent of all
beneficiaries in PACE are duals but we believe it is a model of
care that should be applicable to others.
If I had more time, I could give you a great story about
the actual benefits of PACE to a consumer but unfortunately I
have run out of time, but we appreciate the opportunity to
testify before the care, and as mentioned before, PACE is a
tangible, proven model of care and we look forward to working
with the committee to find ways to expand its reach. Thank you
very much.
[The prepared statement of Mr. Bloom follows:]
[GRAPHIC] [TIFF OMITTED] 72402.095
[GRAPHIC] [TIFF OMITTED] 72402.096
[GRAPHIC] [TIFF OMITTED] 72402.097
[GRAPHIC] [TIFF OMITTED] 72402.098
[GRAPHIC] [TIFF OMITTED] 72402.099
[GRAPHIC] [TIFF OMITTED] 72402.100
[GRAPHIC] [TIFF OMITTED] 72402.101
[GRAPHIC] [TIFF OMITTED] 72402.102
[GRAPHIC] [TIFF OMITTED] 72402.103
[GRAPHIC] [TIFF OMITTED] 72402.104
[GRAPHIC] [TIFF OMITTED] 72402.105
[GRAPHIC] [TIFF OMITTED] 72402.106
[GRAPHIC] [TIFF OMITTED] 72402.107
[GRAPHIC] [TIFF OMITTED] 72402.108
[GRAPHIC] [TIFF OMITTED] 72402.109
[GRAPHIC] [TIFF OMITTED] 72402.110
[GRAPHIC] [TIFF OMITTED] 72402.111
[GRAPHIC] [TIFF OMITTED] 72402.112
[GRAPHIC] [TIFF OMITTED] 72402.113
[GRAPHIC] [TIFF OMITTED] 72402.114
[GRAPHIC] [TIFF OMITTED] 72402.115
[GRAPHIC] [TIFF OMITTED] 72402.116
[GRAPHIC] [TIFF OMITTED] 72402.117
[GRAPHIC] [TIFF OMITTED] 72402.118
[GRAPHIC] [TIFF OMITTED] 72402.119
[GRAPHIC] [TIFF OMITTED] 72402.120
[GRAPHIC] [TIFF OMITTED] 72402.121
[GRAPHIC] [TIFF OMITTED] 72402.122
[GRAPHIC] [TIFF OMITTED] 72402.123
[GRAPHIC] [TIFF OMITTED] 72402.124
[GRAPHIC] [TIFF OMITTED] 72402.125
[GRAPHIC] [TIFF OMITTED] 72402.126
[GRAPHIC] [TIFF OMITTED] 72402.127
[GRAPHIC] [TIFF OMITTED] 72402.128
[GRAPHIC] [TIFF OMITTED] 72402.129
[GRAPHIC] [TIFF OMITTED] 72402.130
[GRAPHIC] [TIFF OMITTED] 72402.131
[GRAPHIC] [TIFF OMITTED] 72402.132
[GRAPHIC] [TIFF OMITTED] 72402.133
[GRAPHIC] [TIFF OMITTED] 72402.134
[GRAPHIC] [TIFF OMITTED] 72402.135
[GRAPHIC] [TIFF OMITTED] 72402.136
Mr. Pitts. The chair thanks the gentleman and thanks the
panel for your opening statements, and we will now do a round
of questioning and the chair recognizes himself for 5 minutes
for that purpose.
Mr. Millwee, as you know, States are generally not informed
about hospitalizations or prescription drug information for
dual eligibles. How important is Medicare data to States in
coordinating care and reducing costs associated with dual
eligibles?
Mr. Millwee. Well, you are certainly correct. Without that
data, we can't know the health condition of the dual-eligible
member, and I think it is going to be critical as the Centers
for Medicare and Medicaid coordination forms to provide States
with that data so that we can implement the disease management
programs that can be more cost effective if we were to have
that data.
Mr. Pitts. How does Texas share in the savings generated
through the STAR+PLUS program with the Federal Government? How
important is it for States to be able to share in the savings
generated by integrated care programs for duals?
Mr. Millwee. Well, today we don't share in that savings.
The program was put in place to serve the population absent the
need to share in that savings, and it has been recent that CMS
was open again to discussions with the State about potential
gain-sharing arrangements. So as we get that Medicare data, we
believe that we can take to CMS a proposal that will
demonstrate that STAR+PLUS has created savings not only for the
State on the Medicaid side but also for the Federal Government
on the Medicare side, so we will be developing a proposal to
take to CMS.
Mr. Pitts. Thank you.
Mr. Bloom, you wanted to talk about the benefits of PACE to
consumers. Please explain in more detail your idea to modernize
the PACE program to include alternative settings of care. And
why is the facility requirement a burden on the program today?
Mr. Bloom. Yes, you know, I think historically the PACE
program, if you drive by PACE program you will see what appears
to be a very large day center within which there is space for a
medical clinic, rehab, social services, personal care and
possibly a kitchen. It has been a very convenient kind of focal
point of care organization and deliver but what we have
discovered over time is that the ability of PACE to grow is
somewhat geographically constrained by the center. To the
extent that we can begin contracting out, for example, for day
center services using existing infrastructure down the street
by an existing daycare provider would allow us to grow the
program without undertaking significant capital costs and
setting up a new center every time we want to expand our
geographic market. That is but one example, and I could
certainly offer you more.
Mr. Pitts. Thank you.
Ms. Hewson, you note in your testimony that the CCNC could
have saved the State of North Carolina approximately $1.5
billion between 2007 and 2009, and that 100 percent of all
Medicaid savings remain in the State. How are those savings
shared with your organization?
Ms. Hewson. At this point they are not shared. It goes back
into the Medicaid budget. But we have been able to maintain
provider fees at 95 percent of Medicare. So in a way, that is a
way to provide the infrastructure building and sustainability,
but the money goes back into keeping the Medicaid program and
dealing with the State budget issues.
Mr. Pitts. Do you have more information on what portion of
those savings are associated with the 80,000 dual eligibles you
serve?
Ms. Hewson. I don't have it on hand but we could certainly
get that information for you. We are missing some of the
Medicare data to be able to tell a complete story on the duals
at this point.
Mr. Pitts. How are the duals enrolled in your program? Is
that mandatory enrollment?
Ms. Hewson. It is voluntary. They typically choose--they
are going to a provider that is participating with us, and
oftentimes it is the provider that encourages them to enroll
because they can then provide the wraparound support service of
the care coordinators.
Mr. Pitts. Are the other 220,000 duals in North Carolina
mostly served through fee-for-service or are there other
coordinated care programs in the State to serve those duals?
Ms. Hewson. We have, I think, two PACE programs and several
in application and then there is the Medicare Advantage
program, a few of those, but primarily the rest are in fee-for-
service.
Mr. Pitts. Thank you.
Mr. Egge, in your testimony you note several beneficiary
examples where the complexity and fragmentation of the system
prevent frail duals from gaining access to available services.
You note that fully integrated system could alleviate
administrative barriers. Do you believe such a system is a one-
size-fits-all or do you believe there could be a variation of
models that could be used to help improve beneficiary access to
care?
Mr. Egge. First of all, there is great variety in the
experience of people with Alzheimer's and other dementias. Our
suspicion is that there could be very some important common
elements that we can use and design any kind of system, but at
this point, innovation and looking at different kinds of
approaches and how they work is very appropriate as we learn
what is going to work best.
Mr. Pitts. The chair thanks the gentleman and recognizes
the ranking member, Mr. Pallone, for 5 minutes for questions.
Mr. Pallone. Thank you, Mr. Chairman. I wanted to ask
initial questions of Ms. Hewson and also Mr. Bloom. In
Medicare, we have always maintained the principle that
enrollment in managed care plans is voluntary for all Medicare
beneficiaries. So let me start with Ms. Hewson.
As I understand it, your program of coordinated care,
although not a managed care plan, is voluntary for Medicare
beneficiaries. Is that correct, and how does that impact the
program, that it is voluntary?
Ms. Hewson. Well, it is correct. I think by being
voluntary, there is probably less enrollment than if it was an
opt-out program, but typically they are enrolling because they
want to have assured access to a primary care physician that
they go to, and that physician is encouraging them so that they
can use the resources of the network that supports the
physician in leading their care.
Mr. Pallone. And then similarly, Mr. Bloom, I know that the
PACE association has long believed that it is important to have
beneficiaries buy in through voluntary enrollment rather than
requiring dual eligibles into PACE. Do you want to comment on
that too?
Mr. Bloom. Yes. Dually eligible beneficiaries have the
opportunity to opt in and out of PACE, and that has been the
longstanding track record within the PACE program since its
inception. Having said that, we have very, very low levels of
disenrollment which I think certainly aligns the incentives for
us to keep our eye on the quality and the satisfaction to the
beneficiary.
Mr. Pallone. And I note that in MedPAC's chapter on dual
eligibles released last week, they said that many of the groups
they interviewed raised concerns about access to care for
beneficiaries, particularly individuals with disabilities who
have established relationships with doctors already, and I just
want you to know, I support efforts to get duals into better
care relationships but we need to be careful not to take away
Medicare protections for the lowest income Medicare
beneficiaries because they are trying to access help though
Medicaid as well.
Let me go back to Mr. Bloom. We recognize that PACE is a
specialized program focused on the very medically needy and the
fragile population so it not intended to nor would it be
appropriate to serve all 9 million dual eligibles but currently
PACE organizations have an enrollment of about 22,000 people
nationwide, and while we don't know exactly how many people
could theoretically be eligible, we know it is not 9 million
but it is obvious that there are a lot more people that you
could serve. You described the desire of PACE organizations to
expand enrollment, can you just tell me a little bit about what
Congress could do to help PACE grow and the cautions you have
about growing too fast. You know that PACE has long been
supported by bipartisan members of the committee but we want to
make expansions that would work and help improve care for
people and not create problems.
Mr. Bloom. Very good question, very good question. First
off, I think as Melanie testified earlier, it is very important
to note that the duals are a very diverse population. This
ranges from the young disabled to the elderly that are simply
low income to the elderly that are frail to older individuals
with intellectual disabilities. It is a very diverse
population. And I think based on our experience and experience
working with other integrated-type providers, there are
different approaches for different populations that we need to
look at. In the context of PACE, PACE is very well designed for
a very high-need, very frail, very functionally impaired
population. The examples I gave earlier with respect to
barriers to growth were really focused on the federal side.
I would argue that there are an equal number, if not a
greater number, of barriers that exist on the State side, one
of which, and I will just throw it out, in this era that we
live in today, you can get into a nursing home within a day
typically. It often takes you 4 to 6 weeks to get into a
community-based service program like PACE. That is because of
the eligibility determination process in most States as well as
some other administrative and other obstacles that exist. That
is a significant barrier for growth in addition to some other
kind of State-specific examples.
Mr. Pallone. What is your sense of how many additional
people could be helped, you know, could go into PACE if we made
the improvements, you know, if we managed to do things that you
are suggesting to make it more accessible?
Mr. Bloom. Good question as well. You know, it is probably
to note, we are not a health plan. At the heart of PACE is the
provider. We fully employ all--I mean, I think 90 percent of
all care is provided directly by PACE employees, physicians,
nurses and the like, so we are not going to be able scale each
individual program on par with the United Health Plan or other
large commercial health plans. Having said that, we do have
programs that are as large as 2,600 people. We have programs in
Appalachia as small as 40. So this is a program that can move
large and small, so I do think each individual program is
capable of serving several thousand people but I think you need
multiple programs on the ground.
Mr. Pallone. So theoretically, if you had a lot of them you
could handle a lot more people?
Mr. Bloom. Correct.
Mr. Pallone. But they are going to have to be relatively
small?
Mr. Bloom. The solution to PACE growth is not to scale upon
76 that are on the ground today but to replicate the
availability of the model throughout the country. The other
witness testified, the State of North Carolina has two on the
ground. They are filling the entire State with PACE. They will
have 10 in development within 2 years. The State of
Pennsylvania is another State where almost the entire State is
full. The State of New Jersey within 2 years will probably have
PACE available to every senior in the State. It takes a lot of
leadership on the State. It takes a long-term vision, and I
think it takes a strategic kind of approach to budgeting for
Medicaid long-term care costs, which looks beyond the next 6 to
9 months, and that is difficult in this current era,
admittedly. But I think it is possible and you are seeing
examples of that across the States today.
Mr. Pallone. All right. Thank you.
Mr. Burgess [presiding]. The gentleman's time is expired.
Let me just ask each of you, what we have heard from this
panel in various forms is the fact that an integrated-type
model is possible and it does work seemingly every time it is
tried. Is that something that I understand? Although the
programs may be different that we have heard about, they all
basically involved an integrated model of care with someone
being responsible for the patient. I will start with Mr.
Millwee from Texas.
Mr. Millwee. Well, I think you are right. There are
integrated care models out there, and what strikes me is none
of these are mutually exclusive. There is no best answer. We
have the STAR+PLUS program because it works for us. We also
have PACE. STAR+PLUS and PACE can coexist, or they work well
together. I am familiar with the North Carolina model and it
could work very well for Texas in a rural area where we have
STAR+PLUS in urban areas. So I think the answers are out there.
I think States have done a lot of work, a lot of innovative
work on this very important issue for us because of the
Medicaid expenditure and also Medicare is going to benefit from
that too. So the models are out there.
Mr. Burgess. Yes, Mr. Bloom.
Mr. Bloom. Yes, I think that is exactly the answer. I
couldn't agree more. The only thing I would add is that if you
look at commercial health plans which typically are the
approach to integrating care for the duals, they do receive
integrating financing. They attempt through their contract
network to integrate care but do they do a wonderful job I
think at improving the coordination of care for the most part
but they often will carve-out long-term care risk from their
payment and that is the population we serve so I think as Mr.
Millwee mentioned, these are programs that work very
complementary, albeit for very distinct populations and
segments of the duals. So if done right, I think Texas is a
good example, they have a very good vision for how they want
this to roll out. It provides great hope, great opportunity and
also provides the rights to service product for the right
population based on their unique needs at a particular point in
time. But I do think this is the direction to go.
Mr. Burgess. Mr. Egge, obviously the Independence at Home
is a little bit difference but still it is care coordination.
Is that not correct?
Mr. Egge. That is right. With Independence at Home and
other models, our aim is not to create a certain silo just for
those with Alzheimer's and dementia but to make sure that every
system like Independence at Home is fully dementia capable.
Many people with Alzheimer's, for example, have greatly
appreciated PACE programs and their enrollment there, so we
just want to make sure that whatever systems are there, we
fully recognize the importance of dealing with cognitive
impairment and the caregiver.
Mr. Burgess. I just have to say, your story about the
gentleman with Alzheimer's who also had diabetes who accessed
care the best that he could, that is a tough thing to listen to
as a physician, that someone could be exposed to that many gaps
in their care in seemingly a caring and competent environment
of a major hospital emergency room. That is just tough to hear.
Ms. Hewson?
Ms. Hewson. I agree with the other panelists, other than I
don't think just having integrated care assures that you are
doing the right thing. I think you have to have a delivery
system that does the right thing, and integrated care just is a
way to align the incentives and the reimbursement strategies,
and in North Carolina, we are not yet aligned in the
reimbursement strategy although we are one of the 15 States
that will be working with the coordinated office to develop a
plan along that line, but we also have a very strong bias
towards the medical home and keeping folks in the community,
you know, delivered primarily through primary care providers is
probably a model that has worked really well for us.
Mr. Burgess. But primarily you do have to have--someone has
to be responsible for that patient's care, and in my limited
view of the world, that is obviously a physician, a single
physician, but nevertheless, somebody has to be accountable for
that patient's care on an ongoing basis.
Well, what do you make of the fact that the MedPAC report
from this year, the current one, says less than 2 percent of
all duals are enrolled in some type of integrated care program?
Are they just not counting accurately because they are missing
all of you out there or is that truly that we are only
capturing a very, very small percentage of the dual eligibles?
Ms. Hewson. I think MedPAC is counting when Medicaid and
Medicare are putting funding together as an integrated approach
which the PACE model is an example where both Medicare and
Medicaid are funding the care of that individual. Our program,
which serves over one million, is still a fee-for-service
system so none of our individuals are counted in the MedPAC
report. So the delivery system is integrated; the financing is
not.
Mr. Burgess. And what are the barriers to, or is there a
problem with it being a fee-for-service system? Does that work
well for you?
Ms. Hewson. Well, I think you have to align the incentives.
There are still silos and there is cost shifting that occurs so
I think aligning the financial strategies and having, you know,
Medicare and Medicaid sharing in those responsibilities, taking
care of, in this instance, the duals is really important. So I
think that is why we wanted to be one of those 15 States to
develop that integrated model which aligns the integration with
financing in addition to delivery.
Mr. Burgess. Well, do you think more federal control is
necessary? I mean, could you do your job better with a bigger
and more powerful----
Ms. Hewson. Well, I think you have heard ours is very
local.
Mr. Burgess. Yes, I think so too.
OK. My time is expired. I will recognize Dr. Cassidy for 5
minutes.
Mr. Cassidy. The STAR+PLUS program, now, I am just trying
to understand it. Ms. Bella said that 70 percent of the costs
of dual eligibles in Medicaid is related to the long-term care
aspect of it and most of the Medicaid acute medical expense, is
the wraparound for that which Medicare does not cover. It seems
like your savings are quite substantial if the--and I am not
challenging, I am just trying to learn--that the provider or
the Medicare managed care organization with which you are
contracting, the only place they can lower cost is in the
Medicaid component of the acute care. Is that correct?
Mr. Millwee. That is not the only place that have to manage
cost and achieve effectively better utilization. I think it is
through a number of mechanisms on the acute and long-term care
support side. Remember, we are talking in STAR+PLUS about the
entire aged, blind and disabled population. It is not just a
model for dual eligibles. So about 40, 50 percent are dual
eligibles.
Mr. Cassidy. I see.
Mr. Millwee. So you have an acute care model of care that
is integrated with the long-term care and what the HMO will
likely do, particularly for the Medicaid that is aged, blind
and disabled, is leverage those less expensive community-based
services to keep them out of the more expensive acute care
services, which is what we both want to do. We want to keep
people out of nursing facilities and out of hospitals and
sometimes a personal attendant will do that for you relatively
inexpensively.
Mr. Cassidy. So just for a specific example, if you can use
your Medicare dollar to get a personal attendant for a patient
who is pre-nursing home, if you will, then that can save money
on the Medicaid side, which would be a much greater expense, by
using the Medicare dollar to pay for a service that would not
be available under Medicaid. Is that a good example?
Mr. Millwee. That is correct. In fact, you might use a
Medicaid cost to save Medicare money on the acute care side,
and that is what we need to work through with CMS to talk about
how we can leverage that to talk about some gain-sharing
opportunities.
Mr. Cassidy. Now, Mr. Bloom, although you said that you are
not a health plan, you really do appear to be a staff model
HMO. I mean, you are at risk, and you are using your own
people. If you will, you are the Kaiser Permanente of the frail
and fragile. Is that a fair statement?
Mr. Bloom. That is an absolutely fair statement,
absolutely, and I think we feel that burden every day in some
of the requirements that we have to shoulder with respect----
Mr. Cassidy. Let me ask you, I mean, because I only have a
couple minutes, I don't mean to be rude. So when you speak of
going beyond the duals into the Medicare only, again,
effectively, you are becoming a staff model HMO for Medicare
patients?
Mr. Bloom. Correct. I would argue, however, that what we
are suggesting is not all Medicare patients but those that we
believe are high need, high risk and need kind of a medical
home.
Mr. Cassidy. Now, next, I have been fascinated since Dr.
Nelson came from Baton Rouge to speak to her, and of course, we
know each other personally and I have read about your program,
but I have spoken to folks who criticize it and saying that
really the cost savings are not there. In your testimony, you
gave an anecdote which spoke of an individual but that when you
actually kind of run the numbers with a big spreadsheet, that
PACE has not been shown to save money. Is that a fair or unfair
criticism?
Mr. Bloom. I think it is an unfair criticism. There have
been definitive government studies, two of which actually that
looked at the Medicare cost in PACE and found that at worst we
were budget neutral. On the Medicaid side, there has never been
a definitive longitudinal study of PACE cost. Having said that,
we continue to see States added to the list of PACE states. I
think that what we have told States from day one is to the
extent you set your rates appropriately, all of which are
significantly below nursing home costs, then you in the
longitudinal measurement will save money.
Mr. Cassidy. Now, but again, maybe the criticism was that
by keeping people out of the nursing home but still getting
nursing home per diems, that again there are Medicaid savings
that are not realized. Now, again, I am channeling right now.
Mr. Bloom. I think what you are suggesting yes, our PACE
rate includes a component of costs that reflect the full risk
that we are assuming for long-term placement, and there are,
you know, roughly on any given day 7 to 8 percent of the people
we serve are permanently placed in a nursing home at cost to
us, not to the State. So again, the true benefits of the----
Mr. Cassidy. So it is a cohort savings, if you will?
Mr. Bloom. It is a cohort savings, so the State is
literally in many ways similar to----
Mr. Cassidy. I am about of time. Sorry. Can you send those
two articles that you have?
Mr. Bloom. Yes.
Mr. Cassidy. Now, Ms. Hewson, the savings that you have,
you actually have your pediatric population in your CCN and you
have your duals in the CCN. You savings you describe are
global. What percentage of those are attributable to the dual
eligibles? And that is my last question.
Ms. Hewson. Well, I would say a greater percentage are due
to the aged, blind and disabled, which include the dual
eligibles, so we have over 100,000 straight Medicaid aged,
blind, disabled so when we look at savings we are looking
primarily at the aged, blind and disabled that are straight
Medicaid because we don't have all the data on the Medicare so
we are missing some of the hospital data in Part D and Part B
data.
Mr. Cassidy. You have done a good job of analyzing your
data. Could you forward the more complete report on that?
Ms. Hewson. Yes.
Mr. Cassidy. Thank you. I yield back.
Mr. Burgess. The gentleman's time is expired. The chair
recognizes the gentlelady from the Virgin Islands, Dr.
Christensen, 5 minutes for the purposes of questions.
Mrs. Christensen. Thank you, Mr. Chairman.
I guess I have a pretty broad question that anyone can
answer. I probably would address is mainly to Mr. Millwee and
Mr. Bloom and Ms. Hewson. I know that minorities figure very
disproportionately in Alzheimer's cases as well, but some of
the sickest individuals in Medicare and Medicaid of course are
racial and ethnic minorities, so can each of you tell me what
percentage of your population are people of color of those that
you serve? Are the referrals proportional to the need? Is more
outreach needed and are you experiencing the same positive
outcomes and cost savings in the racial and ethnic minority
population compared to the others?
Mr. Millwee. I don't have those numbers with me today. I do
know that there is an equal benefit but I just don't have those
numbers with me today but we would be glad to get those for
you.
Mr. Bloom. Yes, I can't cite specific statistics but I am
fairly confident that the majority of people served by PACE are
minorities. I anecdotally note many programs where it is
literally nearly 100 percent minority based on the neighborhood
within which they exist and the like, but I would be happy to
get you the specific figures. But yes, it is a program that is
focused on that segment of the population.
Ms. Hewson. We serve all the minority Medicaid population
in the State. We have all the safety-net providers
participating in our program, and in the medical home models
when you actually look at some of the quality performance
metrics have been able to really show improvement in
disparities because if you are providing best care for
diabetes, you are doing it across the board for all your
patients and so that has been a very rewarding quality metric
that we have been tracking. I will be glad to send you more
information if you would like.
Mrs. Christensen. Thanks. I know that they are there. We
just weren't hearing about them, and I would expect that the
models that you are talking about would be improving the care
across the board.
Mr. Bloom, have you had occasion to look at or been asked
to look at the PACE model in any of the territories, and if you
know, do you foresee any barriers that would prevent you from
setting up one of the PACE programs in one of the offshore
areas?
Mr. Bloom. We did have some initial and very preliminary
discussions with Puerto Rico a number of years ago. They didn't
progress on anything constructive after that, however. Having
said that, we are always open, and I am not aware of any
barriers to expanding PACE into any of the territories and
actually would argue what little I know about the Medicaid
program for the territories that I think it would be very
mutually beneficial, so I would be happy to talk to you about
that.
Mrs. Christensen. Everybody has talked about, you know, the
need for your programs and the fact that your programs are
really community based. One of the amendments that I was
involved in in the Affordable Care Act had to do with grants
for community health workers, and I was just curious as to
whether you utilize them in your programs. Mr. Egge, do you
think that the community health worker would be a program that
would be of assistance in care giving, even as the alternate
caregiver in the Alzheimer's situation?
Mr. Egge. Yes, we certainly found that is the case, that
services that are provided in the community by social workers
and by others can be tremendously important, especially at the
early stages of Alzheimer's and other dementias while people
are still able to live quite successfully in the community if
they have that kind of support. We have found that is extremely
important to well being for both the individual, and if they
are living with somebody else, for their caregivers as well.
Mrs. Christensen. Everybody uses community health workers?
Ms. Hewson. In North Carolina----
Mrs. Christensen. Promotores?
Ms. Hewson. Promotores, and with the self-management of
chronic disease, we engage lay community health advisors that
actually live in the community that they are doing the chronic
self-management programs so they have been very, very
beneficial.
Mrs. Christensen. Thank you. I am always concerned that the
issue of quality of health care is often pitted against whether
health care costs--if you are bundling and trying to bring
these programs together, do you see any problems in moving
forward to ensure that the dual-eligible health care quality
and access in the health outcomes are not pitted against or
held hostage to the health care cost containment issues?
Mr. Millwee. Well, in STAR+PLUS, we believe that critical
to that is the external quality review organization where we
aren't dependent upon just the State's data, we aren't
dependent upon the HMO data but have an independent source to
verify and look at the data that can measure, sure, the program
is cost-effective but is it providing high-quality service or
access to services where they should be. So we believe that is
critical, and as we learn more about quality and its importance
on the program to change the program to respond to those
concerns.
Mrs. Christensen. Anyone else?
Mr. Bloom. I would simply say that in PACE, we are, as I
mentioned, we operate at full financial risk for all Medicare,
Medicaid and medically necessary services with no carve-out, no
copay, no deductible, no benefit limitations. We are immensely
motivated and incentivized to provide good health outcomes. As
the provider of care and the bearer of risk at the end of the
day we are accountable, and it is truly in our best interest to
get out in front of individuals' care needs and so that is what
perfectly aligns the incentives within PACE.
Mr. Burgess. The gentlelady's time is expired. The chair
now recognizes the gentleman from New Jersey, Mr. Lance, for 5
minutes for the purposes of questions, please.
Mr. Lance. Thank you, Mr. Chairman, and I yield my time to
you, Mr. Chairman.
Mr. Burgess. That is very kind of you.
Let me just ask you, Mr. Millwee, since we have a little
additional time, you have talked in your testimony about the
service coordinators, but some people look at that and say
well, you are adding personnel so you are going to be adding
cost. How does that work? How do you justify that?
Mr. Millwee. Well, some might speculate that would increase
cost but actually that service coordinator, remember, that
service coordinator is a clinical person who is working with
that client so that clinical service coordinator is actually a
dollar saver in many ways because they are identifying what
that patient needs and how to get that for them so that we can
have those early interventions so we don't have the
hospitalizations or the nursing facility admits or the
emergency department visits. So they literally pay for
themselves time and again by having that intervention to make
sure that the people who need those services, whether they are
Medicaid or Medicare, that they are getting those things.
Mr. Burgess. So you have demonstrable savings that you can
point to in your program in Texas?
Mr. Millwee. Absolutely.
Mr. Burgess. And do you think that works in Texas, do you
think it would transition or translate to work on a national
scale?
Mr. Millwee. Well, I think it could work in other States. I
think the model is transferable. I don't think that people who
are sick in Texas are any different that much really than
people in Washington or California but I think that they
could--the model is completely transferable to other States.
Mr. Burgess. Do you have, can you share data with the
committee, not necessarily right now, but is there data that
you can share with us as to the actual dollar figures that have
been saved?
Mr. Millwee. We certainly can. We can provide the committee
with that information.
Mr. Burgess. And how do you get around HIPAA?
Mr. Millwee. Well, we wouldn't provide you with client-
specific data. We would provide you with deidentified aggregate
information that would----
Mr. Burgess. But more generally, how do the service
coordinators themselves, how do they navigate the system under
the constraints of HIPAA?
Mr. Millwee. Well, they are working with the client as an
agent of the client, so they can----
Mr. Burgess. So they are fully integrated into it?
Mr. Millwee. They are fully integrated into it, so they are
not really burdened by HIPAA.
Mr. Burgess. Generally, how do they monitor the day-to-day
health of a patient? Is it telephonic, or how do they do that?
Mr. Millwee. It is not high tech, it is high touch. It is
people talking to people, picking up the phone and talking to
that person, finding out how they are doing. We do use
electronic health records. A lot of the HMOs are moving to
that. But it really comes down to relationships and somebody
caring about another person, picking up the phone and calling
them and seeing what they need.
Mr. Burgess. That is what is so crucial, somebody caring
about someone else. And Mr. Egge's story that still haunts me,
you know, somebody caring about someone else, that wouldn't be
happening.
Mr. Millwee. Right.
Mr. Burgess. I am going to yield back the balance of my
time and recognize the gentleman from Massachusetts for 5
minutes for the purpose of questions.
Mr. Markey. Thank you, Chairman Burgess, very much.
Mr. Egge, you did a good job in highlighting the important
place for Alzheimer's patients in this discussion. More than 22
percent of seniors with Alzheimer's disease qualify for both
Medicare and Medicaid coverage. Often these seniors rely on
Medicaid to pay for expensive nursing home services. Since
Alzheimer's patients can require constant attention, nursing
home care for patients and Alzheimer's can ultimately wind up
being three times as expensive as nursing home care for those
without it. As a result of those costly nursing home stays, in
2004 the average Medicaid payment for a Medicare beneficiary
over 65 with Alzheimer's was nine times larger than the average
Medicaid payment for other beneficiaries in the same group. As
such, seniors with Alzheimer's represent an extremely
vulnerable portion of the dually eligible population.
I also have a particular interest in Alzheimer's since my
mother passed away from it, which is why I created the
Alzheimer's Caucus with Congressman Smith from New Jersey 13
years ago. I have seen it firsthand and I know the incredible
commitment that our family had to make to keep my mother at
home during that entire period of time.
One ongoing problem is the disconnect between those in the
medical office seeing patients and those in the home caring for
them. In your testimony, Mr. Egge, you mentioned the bill that
Dr. Burgess and I have introduced, the Hope for Alzheimer's
Act, which would encourage doctors to diagnose Alzheimer's
patients earlier. After an Alzheimer's diagnosis is made, the
bill that allows caregivers to be included in a conversation
between doctors and patients to help plan for the disease and
treatments. That conversation would give caregivers and doctors
a reason to be working together because it will be the
caregiver who will help the patient remember their diabetes
medication and avoid ending up in a hospital.
In your testimony, you talked about John, who suffered from
diabetes but because of his Alzheimer's disease found it
difficult to follow his doctor's instructions. As a result, he
ended up in the emergency room, and the doctors there were
unaware of the Alzheimer's disease which created a struggle to
provide further care. Can you, Mr. Egge, explain how a formal
and documented diagnosis of Alzheimer's will help to improve
care amongst different providers and settings?
Mr. Egge. Yes, we found from our experience that the
documentation of Alzheimer's or other forms of dementia is
critical care and it is critical to coordinated care. So the
reason it matters is because you cannot provide appropriate
care if you don't know dementia exists, and we talked about how
that pertains of course to how you handle instructions for
compliance, for instance, whether that can be directed to the
individual or provided to a caregiver if available or perhaps
to a surrogate when not, so in that sense it is fundamental. It
is also fundamental when we think about documentation of the
condition, the medical record, follows that person with a well-
functioning system from setting to setting. We know that care
transitions are one of the most risky moments for those with
Alzheimer's and other dementias because of all the problems
that can happen, especially in a hospital setting and others as
they transition in and out. So it is critical to this committee
that there is that documentation, diagnosis and then
documentation.
Mr. Markey. So this is an amazing number, but just one
disease, Alzheimer's, last year cost the Federal Government
$130 billion out of Medicare and Medicaid. It is just an
astounding number. You know, it is about a quarter of the
entire defense budget, and that is just one disease,
Alzheimer's. How with the Hope Act support caregivers and help
provide them access to the resources they need to care for
their loved ones, to keep them at home and as a results keep
down the costs to the program?
Mr. Egge. That is a great question, and one element of the
Hope Act in particular is groundbreaking in that it provides
for the first time for the health care provider to have
consultations with the caregiver, whether or not the individual
with Alzheimer's or other dementia is present, which is
extremely important because sometimes it is most appropriate
for the conversation to happen in number of different ways, so
we applaud that and it is built on the recognition of how
important a caregiver is for these individuals.
Mr. Markey. Thank you, Mr. Egge. You know, it is $130
billion now. By the time all the baby boomers have it, 15
billion, the bill for Alzheimer's will equal the defense
budget. It will be about $500 billion or $600 billion a year.
So I think it is also calling upon us to increase the NIH
research budget so that we can find a cure because ultimately
we can't balance the budget if we have a problem like this that
is on the horizon.
Thank you, Mr. Chairman, so much.
Mr. Burgess. The gentleman's time is expired, and actually
that concludes today's hearing. I remind members they have 10
business days to submit questions for the record, and I ask
that the witnesses all agreed to respond promptly to these
questions.
The committee is now adjourned.
[Whereupon, at 4:27 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
[GRAPHIC] [TIFF OMITTED] 72402.137
[GRAPHIC] [TIFF OMITTED] 72402.138
[GRAPHIC] [TIFF OMITTED] 72402.139
[GRAPHIC] [TIFF OMITTED] 72402.140
[GRAPHIC] [TIFF OMITTED] 72402.141
[GRAPHIC] [TIFF OMITTED] 72402.142
[GRAPHIC] [TIFF OMITTED] 72402.143
[GRAPHIC] [TIFF OMITTED] 72402.144
[GRAPHIC] [TIFF OMITTED] 72402.145
[GRAPHIC] [TIFF OMITTED] 72402.146
[GRAPHIC] [TIFF OMITTED] 72402.147
[GRAPHIC] [TIFF OMITTED] 72402.148
[GRAPHIC] [TIFF OMITTED] 72402.149
[GRAPHIC] [TIFF OMITTED] 72402.150
[GRAPHIC] [TIFF OMITTED] 72402.151
[GRAPHIC] [TIFF OMITTED] 72402.152
[GRAPHIC] [TIFF OMITTED] 72402.153
[GRAPHIC] [TIFF OMITTED] 72402.154
[GRAPHIC] [TIFF OMITTED] 72402.155
[GRAPHIC] [TIFF OMITTED] 72402.156
[GRAPHIC] [TIFF OMITTED] 72402.157
[GRAPHIC] [TIFF OMITTED] 72402.158
[GRAPHIC] [TIFF OMITTED] 72402.159
[GRAPHIC] [TIFF OMITTED] 72402.160
[GRAPHIC] [TIFF OMITTED] 72402.161
[GRAPHIC] [TIFF OMITTED] 72402.162
[GRAPHIC] [TIFF OMITTED] 72402.163
[GRAPHIC] [TIFF OMITTED] 72402.164
[GRAPHIC] [TIFF OMITTED] 72402.165
[GRAPHIC] [TIFF OMITTED] 72402.166
[GRAPHIC] [TIFF OMITTED] 72402.167
[GRAPHIC] [TIFF OMITTED] 72402.168
[GRAPHIC] [TIFF OMITTED] 72402.169
[GRAPHIC] [TIFF OMITTED] 72402.170
[GRAPHIC] [TIFF OMITTED] 72402.171
[GRAPHIC] [TIFF OMITTED] 72402.172
[GRAPHIC] [TIFF OMITTED] 72402.173
[GRAPHIC] [TIFF OMITTED] 72402.174
[GRAPHIC] [TIFF OMITTED] 72402.175
[GRAPHIC] [TIFF OMITTED] 72402.176
[GRAPHIC] [TIFF OMITTED] 72402.177
[GRAPHIC] [TIFF OMITTED] 72402.178
[GRAPHIC] [TIFF OMITTED] 72402.179
[GRAPHIC] [TIFF OMITTED] 72402.180
[GRAPHIC] [TIFF OMITTED] 72402.181
[GRAPHIC] [TIFF OMITTED] 72402.182
[GRAPHIC] [TIFF OMITTED] 72402.183
[GRAPHIC] [TIFF OMITTED] 72402.184
[GRAPHIC] [TIFF OMITTED] 72402.185
[GRAPHIC] [TIFF OMITTED] 72402.186
[GRAPHIC] [TIFF OMITTED] 72402.187
[GRAPHIC] [TIFF OMITTED] 72402.188
[GRAPHIC] [TIFF OMITTED] 72402.189
[GRAPHIC] [TIFF OMITTED] 72402.190
[GRAPHIC] [TIFF OMITTED] 72402.191
[GRAPHIC] [TIFF OMITTED] 72402.192
[GRAPHIC] [TIFF OMITTED] 72402.193
[GRAPHIC] [TIFF OMITTED] 72402.194
[GRAPHIC] [TIFF OMITTED] 72402.195
[GRAPHIC] [TIFF OMITTED] 72402.196
[GRAPHIC] [TIFF OMITTED] 72402.197
[GRAPHIC] [TIFF OMITTED] 72402.198
[GRAPHIC] [TIFF OMITTED] 72402.199
[GRAPHIC] [TIFF OMITTED] 72402.200
[GRAPHIC] [TIFF OMITTED] 72402.201
[GRAPHIC] [TIFF OMITTED] 72402.202
[GRAPHIC] [TIFF OMITTED] 72402.203
[GRAPHIC] [TIFF OMITTED] 72402.204
[GRAPHIC] [TIFF OMITTED] 72402.205
[GRAPHIC] [TIFF OMITTED] 72402.206
[GRAPHIC] [TIFF OMITTED] 72402.207
[GRAPHIC] [TIFF OMITTED] 72402.208
[GRAPHIC] [TIFF OMITTED] 72402.209
[GRAPHIC] [TIFF OMITTED] 72402.210
[GRAPHIC] [TIFF OMITTED] 72402.211
[GRAPHIC] [TIFF OMITTED] 72402.212
[GRAPHIC] [TIFF OMITTED] 72402.213
[GRAPHIC] [TIFF OMITTED] 72402.214
[GRAPHIC] [TIFF OMITTED] 72402.215
[GRAPHIC] [TIFF OMITTED] 72402.216
[GRAPHIC] [TIFF OMITTED] 72402.217
[GRAPHIC] [TIFF OMITTED] 72402.218
[GRAPHIC] [TIFF OMITTED] 72402.219
[GRAPHIC] [TIFF OMITTED] 72402.220
[GRAPHIC] [TIFF OMITTED] 72402.221
[GRAPHIC] [TIFF OMITTED] 72402.222
[GRAPHIC] [TIFF OMITTED] 72402.223
[GRAPHIC] [TIFF OMITTED] 72402.224
[GRAPHIC] [TIFF OMITTED] 72402.225
[GRAPHIC] [TIFF OMITTED] 72402.226
[GRAPHIC] [TIFF OMITTED] 72402.227
[GRAPHIC] [TIFF OMITTED] 72402.228
[GRAPHIC] [TIFF OMITTED] 72402.229
[GRAPHIC] [TIFF OMITTED] 72402.230
[GRAPHIC] [TIFF OMITTED] 72402.231
[GRAPHIC] [TIFF OMITTED] 72402.232
[GRAPHIC] [TIFF OMITTED] 72402.233
[GRAPHIC] [TIFF OMITTED] 72402.234
[GRAPHIC] [TIFF OMITTED] 72402.235
[GRAPHIC] [TIFF OMITTED] 72402.236
[GRAPHIC] [TIFF OMITTED] 72402.237
[GRAPHIC] [TIFF OMITTED] 72402.238
[GRAPHIC] [TIFF OMITTED] 72402.239
[GRAPHIC] [TIFF OMITTED] 72402.240
[GRAPHIC] [TIFF OMITTED] 72402.241
[GRAPHIC] [TIFF OMITTED] 72402.242
[GRAPHIC] [TIFF OMITTED] 72402.243
[GRAPHIC] [TIFF OMITTED] 72402.244
[GRAPHIC] [TIFF OMITTED] 72402.245
[GRAPHIC] [TIFF OMITTED] 72402.246
[GRAPHIC] [TIFF OMITTED] 72402.247
[GRAPHIC] [TIFF OMITTED] 72402.248
[GRAPHIC] [TIFF OMITTED] 72402.249
[GRAPHIC] [TIFF OMITTED] 72402.250
[GRAPHIC] [TIFF OMITTED] 72402.251
[GRAPHIC] [TIFF OMITTED] 72402.252
[GRAPHIC] [TIFF OMITTED] 72402.253
[GRAPHIC] [TIFF OMITTED] 72402.254
[GRAPHIC] [TIFF OMITTED] 72402.255
[GRAPHIC] [TIFF OMITTED] 72402.256
[GRAPHIC] [TIFF OMITTED] 72402.257
[GRAPHIC] [TIFF OMITTED] 72402.258
[GRAPHIC] [TIFF OMITTED] 72402.259
[GRAPHIC] [TIFF OMITTED] 72402.260
[GRAPHIC] [TIFF OMITTED] 72402.261
[GRAPHIC] [TIFF OMITTED] 72402.262
[GRAPHIC] [TIFF OMITTED] 72402.263
[GRAPHIC] [TIFF OMITTED] 72402.264
[GRAPHIC] [TIFF OMITTED] 72402.265
[GRAPHIC] [TIFF OMITTED] 72402.266
[GRAPHIC] [TIFF OMITTED] 72402.267
[GRAPHIC] [TIFF OMITTED] 72402.268
[GRAPHIC] [TIFF OMITTED] 72402.269
[GRAPHIC] [TIFF OMITTED] 72402.270
[GRAPHIC] [TIFF OMITTED] 72402.271
[GRAPHIC] [TIFF OMITTED] 72402.272
[GRAPHIC] [TIFF OMITTED] 72402.273
[GRAPHIC] [TIFF OMITTED] 72402.274
[GRAPHIC] [TIFF OMITTED] 72402.275
[GRAPHIC] [TIFF OMITTED] 72402.276
[GRAPHIC] [TIFF OMITTED] 72402.277
[GRAPHIC] [TIFF OMITTED] 72402.278