Better care coordination may improve access to primary care for people who are dually eligible for Medicare and Medicaid. Recent evaluations of the Financial Alignment Initiative (FAI)–an initiative incentivizing the financial alignment of Medicare and Medicaid–suggests care coordination could improve access to primary care services for some dually eligible beneficiaries. Care coordination alone, however, may not be sufficient for improving access to primary care for more medically complex patients.
Approximately 13 percent of Medicare beneficiaries were dually eligible in 2022. The dually-eligible population tends to have complex medical and socioeconomic needs [pdf] that lead to greater healthcare utilization (including more preventable hospitalizations) and spending than the Medicare-only population. A lack of adequate care coordination across providers and payers may worsen these challenges.
Financial alignment demonstrations at CMS
The Centers for Medicare & Medicaid Services (CMS) has introduced reforms to help address the fragmented payment and delivery systems for dually-eligible beneficiaries. The FAI was one such reform. Through the FAI, states could integrate care in combined Medicare-Medicaid plans (MMPs) or implement a Managed Fee-For-Service model (MFFS).
Both models allow states to keep a portion of the savings from initiatives that improve quality and reduce costs to both Medicare and Medicaid. Under either model, participating states create person-centered care delivery models that integrate medical, behavioral health, and long-term services and supports. A key feature of both models is care coordination and case management across these services.
CMS incentivized the financial alignment of Medicare and Medicaid through capitated payments to MMPs and through shared savings under MFFS. States that are trying out these models (referred to as “demonstrations”) may also align enrollment and operational policies across the Medicare and Medicaid programs. These kinds of alignment may impact health care use and quality of care in a number of ways, including:
- Case finding (identifying individuals in need of specific services), which is a key care coordination task and helps MMPs serve enrollees with the greatest need. Recent evaluation reports highlight these efforts by the MMPs.
- Assuring an adequate network of primary care, specialist, personal care, acute and post-acute providers for all enrollees, which may reduce barriers to care for beneficiaries.
Studying the impact of financial alignment on primary care
CMS contracted with our research group at the Research Triangle Institute to evaluate the impact of the FAI on access, quality of care, and Medicare and Medicaid costs. We expected [pdf] that, as a proxy for access to primary care, evaluation & management (EM) visits would increase as a result of enhanced care-coordination, relative to a comparison group. To test this hypothesis, we used a difference-in-differences (DinD) analysis with a propensity score weighted comparison group.
Improved access to primary care for some dually eligible beneficiaries
Exhibit 1 shows the FAI contributed to improved access to primary care among dually-eligible populations in 6 out of the 9 demonstration states. In Illinois, Michigan, Massachusetts, Ohio, Rhode Island, and South Carolina the monthly number of EM visits increased over the course of the demonstration relative to the comparison group. The DinD monthly estimates ranged from 0.0415 and 0.3019 visits, or 0.50 to 3.62 more visits per person per year across the six states relative to the comparison group.
The FAI demonstration in Washington, however, resulted in either a decrease or no change in EM visits relative to the comparison group. A unique feature of the Washington demonstration was that beneficiaries must have multiple co-morbidities to be eligible for enrollment. This suggests the implementation of care coordination activities may have enabled greater access to primary care for FAI demonstrations that enrolled beneficiaries who were healthier than FAI demonstrations that targeted or enrolled less healthy beneficiaries.
Exhibit 1: Cumulative impact estimates of the FAI demonstration on EM visits, by state
Beneficiaries with greater medical complexity did not experience more EM visits
Exhibit 2 shows these DinD estimates plotted by state against average Hierarchical Condition Category (HCC) scores among each state’s FAI eligible population. HCC risk scores are a measure of beneficiary health; higher risk scores indicate more serious or chronic health conditions than lower scores. We expected that the FAI demonstrations would increase primary care visits more for sicker individuals because they have more room for improvement than those who are healthier. However, we found a large negative correlation (-0.74) between HCC and the size of the demonstration effect on EM visits among the 9 states. This was opposite of the hypothesized direction. FAI demonstrations with an eligible population that had lower HCC scores experienced either greater increases in EM visits or no change, relative to the comparison group. Demonstrations with the highest average HCC scores produced unfavorable effects on EM visits.
Exhibit 2: Scatterplot of demonstration impacts on the monthly number of physician EM visits by HCC risk score
Next steps on care coordination and dually eligible beneficiaries in MMPs
As CMS moves toward integrating Medicare and Medicaid payments and services, better care coordination may help improve access to primary care for beneficiaries. The demonstrations generally succeeded at increasing the frequency of EM visits. MMP care coordination activities appeared to help link beneficiaries with more frequent physician visits. Primary care providers help patients manage their health, support disease prevention efforts, and are often first to be contacted when medical problems arise. Linking dually eligible beneficiaries to a PCP or increasing primary care visits can be an important step toward improving medical care.
For some dually-eligible populations, care coordination alone may not be sufficient to improve access to primary care. In demonstration states with higher-risk eligible populations such as WA, CO, and TX, EM visits either decreased or did not change. One possible explanation for these findings may be that frequent contact with their care coordinator (e.g., monthly in-home meetings) may have addressed a range of patients’ needs, substituting for primary care. One FAI demonstration enrollee in WA stated, for example, that care coordinators help “…mainly how to handle my life and how to handle my stress and my depression when I don’t see my psychiatrist. She gives me ideas on how to relieve that or different things that I can do about it.”
CMS is engaged in ongoing reform efforts to improve the Medicare and Medicaid payment and delivery systems for the dually-eligible population. Lessons learned from these demonstrations of the financial alignment of Medicare and Medicaid suggest that care coordination is a necessary but not a sufficient component of integrated care to improve access to primary care. FAI demonstrations enrolling healthier dually-eligible populations may increase access to EM services, but there is little evidence of this effect for less healthy eligible populations.
Matthew Toth
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