	Background

		Characteristics of Dual- Eligible Beneficiaries

Dual-eligible beneficiaries are a particularly vulnerable group. 1.) Financial Alignment Demonstration: Design and Implementation, Care Coordination, and Sources of Potential Savings

			Design and Implementation of the Demonstration

CMS’s goal for the Financial Alignment Demonstration is to integrate  Medicare and Medicaid services and financing and improve care  coordination for beneficiaries, therefore resulting in improved care and  savings to Medicare and Medicaid. Then, the state, CMS, and an integrated care organization enter into a  three-way contract, and the integrated care organization receives a  prospective blended capitated payment, which includes both Medicare  and Medicaid payments, to provide coordinated care across both  programs. One state, Washington, is using Medicaid  health home agencies to coordinate Medicare and Medicaid services  among existing fee-for-service providers for dual-eligible beneficiaries. Due to the flexibility states have in designing these  elements in their demonstrations, implementation varied among the  organizations in these five states. Care Coordinator

Staff from organizations in our review reported different ways that they  assigned care coordinators to beneficiaries. Some organizations assigned  care coordinators on the basis of geographic proximity to the beneficiary  or the beneficiary’s primary care provider. Care  coordinators we spoke with reported interacting with beneficiaries by mail,  e-mail, telephone, and in person, but most care coordinators said they  interacted with beneficiaries by telephone or in person. Organizations Described Challenges in Coordinating Care, and the Extent to Which Care Coordination Occurs in the Demonstration Is Not Fully Known

Organization staff in the five states in our review described challenges  that affected their ability to coordinate care for beneficiaries. When organizations are unable to locate beneficiaries, it can be  challenging for the organizations to coordinate their care, which is one of  the key goals of the demonstration and one that CMS views as essential  to the successful integration of care between Medicare and Medicaid. CMS Has Established a Framework of Monitoring Activities to Oversee the Demonstration

To oversee the coordination of care provided in the demonstration, CMS  has established a framework of monitoring activities. One key component of CMS’s oversight is monitoring of core and state- specific measures that the organizations, for the capitated model, and  states, for the MFFS model, are contractually required to report. CMS Collects Information that Assesses the Extent to which Care Coordination Is Occurring in the Demonstration, but Not All of This Information is Comparable

CMS collects different sets of core measures for the capitated and MFFS  model states. Two out of 10 core measures in the capitated model  provide information on the extent to which care coordination is occurring,  while no core measures in the MFFS model examine this area. While the results of  the capitated and MFFS surveys are still forthcoming, these questions  may be able to provide CMS with important information about whether  beneficiaries are meeting with their care coordinators. Moreover, while CMS collects some state-specific  measures that examine this area, they are not comparable across the  states. Internal control standards for the federal government specify that  monitoring should be designed to help an agency accomplish its goals. Because not all of the information that CMS collects to examine the  extent to which care coordination is occurring is comparable across the  demonstration, the agency does not fully know whether it has achieved its  goal of improving care coordination for dual-eligible beneficiaries. However, we believe that  establishing additional measures that would allow CMS to obtain these  data from all states and organizations participating in the demonstration  could help it better understand the reasons why care coordination is or is  not occurring and thus help the agency to strengthen the demonstration. Recommendations for Executive Action

To strengthen oversight of the provision of care coordination services in  the Financial Alignment Demonstration, we recommend that the  Secretary of Health and Human Services direct the Administrator of CMS  to take the following two actions:
Expediently develop and require organizations in the capitated model,  and the states in the MFFS model, to report comparable core data  measures across the demonstration that measure the following:  the extent to which ICT meetings are occurring, and  for MFFS states, the extent to which health risk assessments are  completed. For example, HHS noted that it is  developing a set of care coordination measures to supplement data  obtained from the CAHPS surveys.
Why GAO Did This Study

The Medicare and Medicaid programs spent an estimated $300 billion on dual-eligible beneficiaries—those individuals who qualify for both programs—in 2010. These beneficiaries often have complex health needs, increasing the need for care coordination across the two programs. In 2013, CMS began the Financial Alignment Demonstration, with the goal of integrating Medicare and Medicaid services and financing and improving care coordination. Thirteen states are participating.
GAO was asked to examine care coordination under the demonstration. GAO examined (1) how integrated care organizations—which are health plans or other entities—are implementing care coordination and (2) what, if any, challenges organizations have encountered in implementing care coordination and the extent to which CMS oversees these care coordination activities. GAO interviewed officials from CMS and, during site visits to a nongeneralizable sample of the first five states to implement the demonstration, interviewed state officials, organizations, advocacy groups, and providers. GAO also reviewed CMS guidance outlining CMS's oversight role and the measures it uses to monitor the demonstration.

What GAO Found

Due to the flexibility that states have in designing their Financial Alignment Demonstrations, the integrated care organizations that GAO interviewed in California, Illinois, Massachusetts, Virginia, and Washington implemented care coordination for dual-eligible Medicare and Medicaid beneficiaries in a variety of ways. For example, these organizations assigned care coordinators to beneficiaries using different approaches, such as assigning them by geographic proximity to the beneficiary or to the beneficiary's primary care provider. Care coordinators also used a range of interactions with beneficiaries in order to coordinate care, including by mail, e-mail, telephone, or in person.
The organizations GAO interviewed described facing challenges that affected their ability to coordinate care, such as difficulties in locating beneficiaries. Specifically, organizations noted that certain characteristics of dual-eligible beneficiaries, such as high levels of transience, can make it challenging to coordinate their care—one of the key goals of the demonstration. GAO's interviews with beneficiary advocacy groups and providers raised questions about the extent to which care coordination is actually occurring.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), collects information that assesses the extent to which care coordination is occurring, but not all of this information is comparable across the states. To inform its oversight, CMS has established a framework of monitoring activities, and one key component of this oversight is the monitoring of core and state-specific measures for each of the two demonstration models that states can implement: (1) the capitated model, where organizations receive a capitated payment to provide integrated care, and (2) the managed fee-for-service (MFFS) model, where states are eligible for retroactive savings resulting from initiatives to integrate care with existing fee-for-service providers. CMS collects different sets of core measures from the capitated and MFFS model states. Two out of 10 core measures in the capitated model provide information on the extent to which care coordination is occurring, while no core measures in the MFFS model examine this area. The states in our review had state-specific measures that explored aspects of care coordination, but they were not comparable across the states or both demonstration models. In addition, CMS added comparable, demonstration-specific questions to the Consumer Assessment of Healthcare Providers and Systems, a survey that CMS requires all organizations for the capitated model, and states for the MFFS model, to complete annually. While the results of the surveys are still forthcoming, information from these questions may be able to provide CMS with important information about whether beneficiaries are meeting with their care coordinators across both models. Federal internal control standards state that monitoring should be designed to help an agency accomplish its goals. Because not all of the information that CMS collects to examine the extent to which care coordination is occurring is comparable, CMS does not fully know whether it has achieved its goal of providing coordinated care to dual-eligible beneficiaries. Establishing additional measures that would allow CMS to obtain these data could help it better understand the reasons why care coordination is or is not occurring and thus help the agency to strengthen the demonstration.

What GAO Recommends

GAO recommends that CMS develop new comparable measures and align existing measures to strengthen oversight of care coordination. HHS proposed actions that it plans to take in response to GAO's recommendations, as discussed in the report.