Health insurance benefits for patients who are dually eligible for both Medicare and Medicaid should be customized to the unique individual needs of a patient population that includes many individuals with psychiatric illness.
Moreover, the choice of “opting out” of managed care plans should be preserved for this population, and states should ensure that processes for opting out are made available to patients not less than 120 days prior to the implementation of a managed care program.
Those policies—and at least seven others affecting financing and delivery of care for a patient population of special importance to psychiatry—were approved by the AMA House of Delegates during last month’s annual policymaking meeting in Chicago. The policies, approved unanimously and with little debate, were contained in a report by the AMA’s Council on Medical Services titled ”Delivery of Care and Financing Reform for Medicare and Medicaid Dually Eligible Beneficiaries.”
Psychiatrist John McIntyre, M.D., a member of the council that wrote the report, told Psychiatric News that the population of individuals who qualify for both Medicare and Medicaid (dual eligibles) is small numerically—constituting about 15 percent of all those on Medicaid—but accounts for nearly 40 percent of all Medicare-Medicaid spending, or approximately $300 billion.
“A lot of these individuals are our patients,” he said. “The report recognizes that many have mental illness, and the council felt strongly that benefits need to be customized to the unique needs of the individual patient.”
(At the meeting last month, McIntyre was voted chair-elect of the council and will become chair at the end of next year’s annual meeting.)
A number of states are adopting demonstration projects aimed at providing more integrated, cost-effective care for high-cost Medicare-Medicaid–eligible patients, and the new AMA policy emphasizes that a wide variety of “approaches to integrated delivery of care should be promoted under demonstrations such as patient-centered medical homes, with adequate payment to physicians, provision of care management and mental health resources.” The council report further emphasizes that “delivery and payment reform for dually eligible beneficiaries should involve actively practicing physicians and take into consideration the diverse patient population and local area resource.”
McIntyre noted that many integrated care demonstration projects involve a “care coordinator” who helps patients navigate their way through an integrated care network. The council report includes policy recommendations stressing that “care coordination demonstrations should not interfere with the established patient-physician relationships in this vulnerable population.”
Another crucial reform highlighted in the council report is the need for alignment and coordination of services—including rules affecting physician care of patients—between the two programs. McIntyre noted that the disproportionate payment policies between Medicare and Medicaid create incentives for cost-shifting; for instance, nursing homes benefit from the hospitalization of patients (regardless of the necessity of hospitalization), because when patients return to the nursing home, Medicare will pay 100 percent of the care (whereas Medicaid rates are a fraction of the cost of care).
Finally, the report recognizes that many dually eligible individuals will require significant amounts of counseling and education regarding options for care under new integrated care demonstration projects.
“This is a patient group that is important to psychiatrists,” McIntyre said. “This is a key report to come out of the council and has a lot of good information for clinicians. The policies AMA supports in this report are designed to protect the doctor-patient relationship, advocate for adequate resources, including funding for mental health care, and ensure that patients receive adequate counseling and education concerning their insurance options.” ■