State seeks to revamp poor, disabled care

Streamlining plan for ‘dual eligibles’

The state is planning to dramatically change the way health care is provided for about 109,000 adults who are low-income and disabled, with the goal of improving the quality and cutting the cost of treatment that is often fragmented.

Members of the group -which includes people with mental illness, drug and alcohol addictions, and development disabilities - are enrolled in both Medicaid and Medicare. Navigating the state and federally run programs, which have different rules and pay for different services, can confuse patients and create roadblocks to communication between providers.

Governor Deval Patrick’s administration will release a draft within two weeks of a plan to enroll most of those patients, aged 21 to 64 and commonly referred to as “dual eligibles,’’ in a network of providers that would receive one payment to provide all services to a patient, including medical and dental care and support services.

Patient advocates say it is a necessary remodeling of a system that was never designed to operate the way it does, but some are concerned about limits on choice of doctors and other providers under the new framework.

“We see it as a once-in-a-generation chance to change how health care is delivered for a significant population,’’ said Bill Henning, director of the Boston Center for Independent Living, who chairs a committee of disability advocates focused on this issue.

Medicare and Medicaid “are good, but they work against each other,’’ he said. “One will say the other should pay, then the other will say that one should pay, and people get left in limbo.’’

Dual-eligible patients are among the more expensive to care for in the state. About half have physical diagnoses and behavioral or developmental conditions. In fiscal year 2011, their Medicaid costs totaled an estimated $2.6 billion, 25 percent of the budget for MassHealth, the state’s program. Medicare paid about $1.3 billion for their care.

The challenges of managing this population is in part a reflection of a health care system in which the treatment of mental and physical illnesses is often done in separate facilities by doctors who do not communicate with one another.

The state plan is another step in the push to change how health care is paid for, moving from a system in which fees are paid for every test or treatment to one that pays a so-called global fee to a network of health care providers that is responsible for all of a patient’s care.

The program could have implications for the broader population if it encourages doctors and other providers to work together more, said Kate Nordahl, director of the Massachusetts Medicaid Policy Institute, a program of the Blue Cross Blue Shield of Massachusetts Foundation.

“We need behavioral health and primary care and specialty care working together,’’ she said. “We need providers working to develop a care plan that considers the whole needs of a person. We need to pull in the long-term support services for those who need them.’’

MassHealth Director Dr. Julian Harris said he hopes to begin patient enrollment in January 2013. Those qualifying would be automatically signed up, with an opt-out option.

The proposal, he said, could save up to 2 percent for the state and federal programs.

In April, the state was one of 15 that received federal aid to devise ways of improving care for the dual-eligible population. Its plan must be approved by the federal Centers for Medicare & Medicaid Services, after which the state will take applications from health plans, provider groups, or others that want to become integrated care organizations and manage patients’ care.

Those applying must commit to providing the same services now covered under Medicare and Medicaid, plus additional ones the state says are necessary to fill in the care gaps, Harris said.

“We believe those additional services will play a role in making sure people are getting care in the right settings,’’ Harris said.

Henning is looking for the governor’s plan to include provisions to protect relationships patients have with their current providers, allowing them to continue to see their preferred doctors - even those out of the network in which they are enrolled.

Al Norman, executive director of Mass Home Care, a network of nonprofits that provide home-based care, said he thinks the state should have given patients the choice to opt into the program, rather than automatically enrolling them.

Norman worries payments will be controlled by medical organizations, leaving little say for home care aides and others who provide support services outside health care institutions.

“We need to have a way for ensuring that long-term dollar doesn’t get transferred over to the medical side,’’ Norman said.