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Professional News
 DOI: 10.1176/appi.pn.2013.7b14
AMA Calls for Special Attention to Care for Dual-Eligible Patients
Psychiatric News
Volume 48 Number 14 page 1-1

Abstract

Individuals dually eligible for Medicare and Medicaid include many with psychiatric illness, and they account for a significant share of Medicare-Medicaid spending.

Abstract Teaser

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.” ■

The AMA report on reform of financing and delivery of care for dual eligibles is posted at http://www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-a.pdf.

Key Points 

AMA policy approved at last month’s annual meeting of the House of Delegates includes the following recommendations for reform of the financing and delivery of care for “dual eligible” patients:

  • Various approaches to integrated delivery of care should be promoted under demonstrations such as primary care physician-led patient-centered medical homes, with adequate payment to physicians, provision of care management, and mental health resources.

  • Customized benefits and services from health plans are necessary according to each beneficiary’s specific medical needs.

  • Care coordination demonstrations should not interfere with the established patient-physician relationships in this vulnerable population.

  • Delivery and payment reform for dually eligible beneficiaries should involve actively practicing physicians and take into consideration the diverse patient population and local area resources.

  • States should provide education and counseling to beneficiaries on options for receiving Medicare and Medicaid benefits.

  • Conflicting payment rules between the Medicare and Medicaid programs should be eliminated.

  • Medicare and Medicaid benefit plans and the delivery of benefits should be coordinated.

  • Care plans for beneficiaries should be streamlined among all clinical providers and social service agencies.

  • The Centers for Medicare and Medicaid Services should require all states to develop processes to facilitate “opting out” of managed care programs by dually eligible individuals no less than 120 days before the implementation date of a state’s dually eligible managed care program.

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