CHA News Article

MACPAC Report Details Early Beneficiary Experience in Duals Demonstration
Highlights feedback from California, Massachusetts and Ohio enrollees

The Medicaid and CHIP Payment and Access Commission (MACPAC) has released a study on early experiences with the Duals Demonstration in California, Massachusetts and Ohio. MACPAC conducted seven focus groups with beneficiaries in the three states over a nine-month period to obtain feedback on the enrollment process, understanding care coordination and access to services. Conducted between June 2014 and February 2015 the focus groups were comprised of 55 dual-eligible enrolled beneficiaries, most of whom had been enrolled in the demonstration for at least six months prior to the focus group. The report focuses on the findings of the focus groups and illustrates the challenges and benefits beneficiaries have experienced as these programs are implemented throughout the country.

Key report findings include:

  • The demonstration’s intent appealed to participants. When focus group participants were provided with a clear definition of the program and understood its purpose, they reported that they both agreed with the intent of the demonstration and desired this approach to care.  Across the focus groups, participants reported that having separate Medicare and Medicaid coverage resulted in fragmentation of services and confusion in navigating both programs. Participants felt they were solely responsible for managing their complicated health care needs. Most participants reported wanting more integration between Medicare and Medicaid, more care coordination, someone to help them access care and solve problems, and access to additional services such as dental coverage, transportation and behavioral health services. Additionally, those already utilizing long-term care services are particularly interested in this model of care – most believe they will receive better care and more support to remain independent as long as possible.
  • Participants and their providers were still learning about the demonstration. Prior to receiving an explanation of the demonstration during the focus group, many participants did not have a clear understanding of the program. When asked, they could not explain the purpose of the program, name of the program or identify all of the program’s expanded services or benefits. Many focus group participants also said their providers (primary care providers, specialists, dentist, and pharmacists) were not well-informed about the program, did not recognize the name of the program and were unclear whether they participated in the demonstration program. Others mistakenly charged copays for services in which a copayment was not required.
  • Program materials were not clear. Participants noted that materials they received prior to and after enrollment were not clear or written in simple language they could easily understand.  Others felt the amount of paperwork required was overwhelming.
  • Enrollment went smoothly for many. Each focus group site contained a mix of individuals who either voluntarily enrolled or were passively enrolled into the program. For participants who voluntarily enrolled, the enrollment process (which included selecting a plan and submitting paperwork) went smoothly for most. The process was easiest when participants had help from someone, such as a social worker or case manager, to aid them through the enrollment process. Those who passively enrolled had mixed experiences. Many were content with the process and found it convenient; however, others were not aware their coverage had changed, which caused problems when accessing care or picking up a prescription. A few participants were enrolled in plans they did not want or were unhappy their prior coverage was dropped.
  • The transition into the program was a challenge for some. During the first weeks and months in the new program, some focus group participants suffered lapses and delays in care, could not fill prescriptions, were mistakenly charged copays, had negative experiences with transportation services and had personal care attendants who were not paid. Often the participants who were passively enrolled in the program and were not aware of the changes to their coverage faced the most problems. Others attempted to schedule appointments with their primary care provider or dentist shortly after they enrolled only to be told they did not accept their coverage, which ultimately delayed care.
  • Most enrollees were able to keep their providers. When participants enrolled in the demonstration program, most said they were able to keep their current providers.  Some took an active role in contacting their providers to confirm they participated in the demonstration, which was an important factor when deciding to participate in the demonstration program and  picking a health plan. However, a few said they had to find new providers —particularly specialists — after enrolling in the program.
  • Participants value the expanded or new services offered. All focus group participants said they valued the coverage of the expanded and new services offered under the demonstration. They especially appreciated access to new dental, vision, non-medical transportation and behavioral health services. Those participants who have used the expanded or new services were often very satisfied with the care they received.  However, a few participants noted access issues that resulted from the expanded coverage, particularly with dental coverage.
  • Costs remained the same or decreased. Focus group participants reported that their costs stayed the same or decreased after enrolling in the demonstration. This was a positive outcome as participants considered the program to be affordable overall. While some were mistakenly charged copays for prescriptions and services early on, most of those problems have been resolved. Most said their doctor visits, dental and vision care, hospitalizations, and long-term services and supports needs such as home modifications have all been covered by their new plans. However, a few participants said that costs at pharmacies and for some durable medical equipment have increased.
  • There were challenges with the care coordinator role. A number of participants reported not yet having a care coordinator and some have only had minimal contact with their care coordinator. Not having direct or consistent contact with a coordinator created challenges for many participants, as participants who had connected and established a relationship with a care coordinator seemed to have better experiences in the program.
  • Some enrollees were experiencing a “team-based” approach to care while others were not. Some focus group participants said they were starting to see a change in how their providers were communicating and believe they were sharing information more so than before. A few participants explained that when a conflict arose — such as a possible negative interaction between prescription medications — the providers can work with one another to determine a solution. However, other participants were not yet experiencing a team-based approach among their providers. They felt the burden of communication still primarily rested with the patient, not their providers. Some were not aware that a team-based approach to care delivery was part of the demonstration program, or that they should look for this type of coordination.
  • Participants believed the model holds promise. While some participants already seemed to be experiencing the benefits of more care coordination and additional services, others were still struggling to understand and benefit from the program. Nevertheless, they agreed that this new approach to care has the potential to improve their care and overall health. Almost all said they wanted more coordination among their providers, more help navigating the system and resolving problems and access to additional services, such as expanded dental and transportation services.

The full report is attached.