No Time to Go Wobbly on “One Care”

I am reprinting an article I wrote for the new issue of Commonwealth Magazine concerning One Care, Massachusetts’ bold and risky experiment to coordinate care for the so-called “dual eligibles” who are under age 65 and disabled.  It has been a tough ride in the program’s first two years.  In this piece, I give the background and context for One Care and propose that we stay the course as the smart and right thing to do:

one-care-banner-headerBACK IN 2008, when I was working in the US Senate on national health reform, a delegation of 20 business leaders from the New England Council visited Capitol Hill to offer advice. The group’s leader was Charlie Baker, then Harvard Pilgrim Health Care’s CEO. I recall his one recommendation: “You have to do something about dual eligibles because they are one of the most important and expensive pieces of the puzzle.”

As Massachusetts now struggles to sustain One Care, its nationally significant dual-eligibles demonstration project that launched in October 2013, Gov. Baker’s hope is happening. Given the project’s rocky and difficult first 18 months, he could be forgiven for wondering if he could rewrite that wish.

Today, Massachusetts is a leader among 13 states in a three-year Affordable Care Act demonstration to provide coordinated care for “duals” — those eligible both for Medicare because they are elderly or disabled and for Medicaid because they are poor. If there’s an improvement opportunity in US health care, this is it. There are some 10 million American duals, about 200,000 in Massachusetts. Compared with non-dual Medicare enrollees, duals are twice as likely to have three or more chronic conditions and three times as likely to have a mental illness. Care and services for them are chronically uncoordinated, mismanaged, inappropriate, inadequate, and expensive, estimated at $34,000 annually per individual in 2009, and $100,000-plus for the most expensive 10 percent.

All has not been well with One Care. With 17,500 enrollees on August 1, the project’s three participating health plans reported $54 million in losses during its first 18 months. The losses, split between the three plans and the federal and state governments, have resulted in the scrapping of projected savings to Medicare and Medicaid, a withdrawal from the project by Fallon Health Plan that left most of its 5,400 enrollees with no plan as of September 30, and other challenges that landed the program on the front page of the Boston Globe. In late September, state officials announced a new agreement involving MassHealth, the US Centers for Medicare and Medicaid Services, and the two remaining health plans to infuse an additional $47.6 million into One Care ($29.8 million for Medicaid and $17.8 million for Medicare) for 2015 and 2016. Some worry that One Care, launched by former governor Deval Patrick’s administration, may follow the Massachusetts Health Connector’s troubled website rollout as another example of good intentions gone awry.

These concerns are understandable — and misguided. My interviews with federal, state, and health plan officials, advocates, and others make clear that idiosyncratic features of One Care put the program more at risk than its peers in other states. One Care is tackling our health system’s starkest shortcomings, and officials with whom I spoke on background see financial stabilization and future success on cost and quality ahead.  As British Prime Minister Margaret Thatcher told President George H.W. Bush during the 1990 Kuwait crisis: “This is no time to go wobbly.”

Key to understanding the One Care dilemma is that dual eligibles include two distinct populations. One group is duals over age 65, seniors who worked most of their lives and now qualify because of low income. The other is duals under age 65 characterized by serious and often lifelong physical disabilities, significant mental illness, substance abuse, and homelessness. The first group stopped working at 65, and the latter, disproportionately, has limited work histories. Both account for huge costs to Medicare and Medicaid for medical and long-term services and support needs — $300 billion in total.

Prior to One Care, Massachusetts was already a national leader in using private health plans to organize better, less costly care for duals by combining Medicare and Medicaid funding into a single financing stream.  In 2004, the state launched its Senior Care Options program to provide coordinated care for 95,000 over-65 duals. Today, about 38,000 patients, or 40 percent of eligible seniors, are enrolled in one of five participating Senior Care plans. The plans receive an annual, risk-adjusted payment from state and federal governments to cover all care for each enrollee, replacing uncoordinated and dysfunctional fee-for-service payments for each visit or procedure. A 2013 evaluation found that Senior Care enrollees had a 17 percent lower risk of death after six months compared with non-enrollees and 16 percent fewer nursing home stays. Senior Care is judged a success with enrollees and plans, so much so that in its January budget cutting, the Baker Administration was able to reduce excess Senior Care payments to participating plans.

Given Massachusetts’s Senior Care success, it made sense to launch a parallel program called One Care for under-65 duals, a group with far more expensive and complex needs. This population includes some who suffer, for example, from bipolar illness and HIV complications, and also have experienced long periods of homelessness. Others have profound physical disabilities, such as quadriplegia and require a feeding tube.

Massachusetts is the only state with a program targeted exclusively for this group. All of the other 12 states taking part in the ACA’s “Coordinated Care” demonstration enroll over-65 patients, a much more stable patient population.

The One Care plan with the most enrollees — and losses — is Commonwealth Care Alliance, a Boston-based nonprofit established in 2003 to coordinate and provide care for duals — and nobody else. For One Care, the organization established two “crisis stabilization units” in Boston’s Brighton and Dorchester neighborhoods for mental health patients that provide team-based, short-term care at half the cost of psychiatric hospitals. To deal with primary care gaps, new facilities were opened in Boston, Lawrence, and Springfield.

Lois Simon, Commonwealth Care Alliance’s president, says One Care holds unprecedented challenges. “The overarching system pieces were not together for the under-65 group,” she says. “We found great providers but no unifying system pre-One Care to which we could connect for disability competent care management and long-term services and supports. We found a lack of meaningful primary care relationships for many enrollees, and insufficient alternatives to inpatient psychiatric hospitalization and community-based crisis stabilization units.”

Because of federal requirements that demonstration programs must show cost savings and quality improvements, One Care architects projected savings between 0.5 to 2 percent after six months — a provision that left many experts shaking their heads. Blue Cross and Blue Shield of Massachusetts and the Massachusetts Behavioral Health Partnership, for example, refused to participate because they viewed the projections as unrealistic.

Three plans joined: Tufts Health Plan, Fallon Health Plan in Central Massachusetts — which in June announced its withdrawal — and Commonwealth Care Alliance. Of the three, Commonwealth Care Alliance receives national attention because of its unorthodox mission as a health plan only for duals. Dr. Bob Master, the company’s founder, has been honing this model since the 1980s, when he served as medical director of the Massachusetts Medicaid program. While dual demonstrations in other states include large for-profit insurers such as United, Anthem, and Aetna, the nonprofit Commonwealth Care Alliance stands out for its consumer/patient engagement, its team-based care model, and its mission. While big Massachusetts plans stayed out or entered with tight enrollment limits, Commonwealth Care Alliance went all in — a gamble that could still sink its ship. Its One Care tagline: “Healthy is harder for some. That’s why we’re here.”

“Tufts Health Unify,” which entered One Care cautiously, experienced growing pains, but sees stabilization and growth opportunity ahead. Dr. Kit Gorton, who oversees the Tufts effort, says his plan’s experience demonstrates the need for a longer time curve to incorporate new One Care members than typical managed-care enrollees. “I don’t think people appreciated how different the under-65 population is,” he says. “They take at least a year to get engaged and plugged into a care plan, to meet unmet needs, and to reach the expense curve’s far side.”

Among One Care members, satisfaction is high. A May survey shows more than 80 percent “extremely” or “somewhat” satisfied, with 83 percent intending to stay.  Note-worthy has been expansive, disciplined advocacy associated with the effort. A new coalition, Disability Advocates Advancing Our Health Care Rights, has fostered unprecedented consumer engagement. One established advocacy group, Community Catalyst, says that One Care and the national demonstration represent “the first time in our nation’s history that the care of our most marginalized populations, such as those who experience serious mental illness, substance abuse challenges, homelessness, and HIV/AIDS, has been made a national policy priority.” Bill Henning, the co-chair of the new disability advocates coalition, says, “A hidden success of One Care is that over 25 percent of enrollees have been moved into higher-need categories. Under the prior fee-for-service system, significant needs were unrecognized or unaddressed, with substantially poorer health outcomes.” In approving the new funding for One Care, state officials emphasized that “strong support from the disability community was a critical consideration in the deliberations” with the federal government.

Federal officials at the US Centers for Medicare and Medicaid Services recently permitted all demonstration states to extend their participation from three to five years, an option Massachusetts will take. They have held meetings with state and plan officials to sustain the project. The Commonwealth Care Alliance-One Care experience is “really eye opening,” says Melanie Bella, the first and now former director of the federal Medicare and Medicaid Coordination Office. “They are the only ones in the heart of trying to figure out how to care for those with serious mental illness,” Bella told me. She called the Commonwealth Care Alliance “the poster child for investing in community-based mental health services and moving people from costly inpatient facilities — the epitome of what we want to happen.”

Massachusetts officials say they are not anticipating a One Care retreat. Health and Human Services Secretary Marylou Sudders says that although One Care has been “a painful innovation lab,” it is “a promising model starting to show signs of success. The financials are challenging, everyone knows that, and they are starting to improve.” As for Gov. Baker, Sudders says, “Charlie is with the program.”

As Massachusetts looks to broader transformation of its Medicaid program, One Care’s focus on the state’s most medically complex and most neglected population should form a critical part of that vision. It has been harder than predicted. But positive returns are appearing and going backwards makes no sense. No time to get wobbly, let’s stay the course.

About John McDonough

I offer insights and opinions on how to improve health care systems for everyone
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