The “One Care” Program at Commonwealth Care Alliance

Klein S, Hostetter M, McCarthy D
Publication Year: 2016
Patient Need Addressed: Care Coordination/Management
Population Focus: Dual eligible
Demographic Group: Adult
Intervention Type: Service redesign
Type of Literature: Grey
link: https://www.commonwealthfund.org/publications/case-study/2016/dec/one-care-program-commonwealth-care-alliance
Abstract

Commonwealth Care Alliance (CCA), the Boston-based Medicare Advantage plan and care delivery network to which Diane and Melissa were assigned, is a participant in the One Care demonstration. CCA has had more than a decade of experience providing integrated care to “dual eligibles” age 65 and older as part of the Massachusetts’ Senior Care Options (SCO) program. (The older members are part of CCA’s Special Needs Plan, while dual eligibles under age 65 are enrolled in a Medicare–Medicaid Plan.)

Insights Results

Overview of Model

  • Goal of Commonwealth Care Alliance (CCA), a Boston-based Medicare Advantage plan, One Care: MassHealth plus Medicare model is to see whether providing comprehensive, well-coordinated care can improve outcomes and lower costs for patients who have complex needs
    Methods
  • The One Care Program, a partnership of Massachusetts’ Medicaid agency and the Centers for Medicare and Medicaid Services, is the first demonstration to focus exclusively on dual eligibles under age 65. Participating plans receive capitated Medicare and Medicaid payments, which are used to provide enrollees with medical, behavioral health, dental care, an long-term services and supports they require. Plans must also work with community-based organizations (CBOs) and external coordinators for long-term services and supports
  • Core of model are interprofessional care teams comprising of nurse practitioners, physician assistants, social workers, community health workers, and other professionals
  • Target population: Under the One Care demonstration, CCA provides coverage to 11,134 dual eligibles under 65 in Massachusetts
  • Key program features: 1) Interdisciplinary care delivered where patients need it to identify where relationships exist between members and providers and reinforce rather than supplant them; 2) Increasing access to behavioral health services by creating two crisis stabilization units (CSUs) that provide short-term acute psychiatric care, including detox services; and 3) Coordination of long-term services and supports by identifying a coordinator from a community organization to help patients identify needed services and resources
  • Financing: to provide care for roughly 10,000 One Care enrollees, CCA received $385.7 million from Medicaid and Medicare in 2014 and $256.9 million for 15 months ending December 2014

    Results

    • A study of 4,500 CCA One Care enrollees found that, after 12 months of enrollment, they had 7.5% fewer hospital admissions and 6.4% fewer emergency department visits than in the 12 months prior to enrollment
    • 82% of enrollees said they were satisfied with the program
    • Preliminary analysis found that CSUs, in particular, contributed to lower admissions
    • CCA lost $34.9 million on revenue of $256.9 million in the first 15 months of the program, a loss that was reduced to $18.4 million by a risk corridor program intended to mitigate insurers’ extreme gains or losses. The health plan came close to breaking even for 2015, with a projected loss of $146,000 on revenue of $385.7 million, and expects to achieve savings in 2017
      Key Takeaways
    • Insights and lessons learned: 1) With underserved populations, better care coordination may lead to higher spending in the short run. It took 18-20 months to return to historical cost levels as the plan optimized their care; 2) Patient assessments help ensure that plans have the resources they need but can be difficult to execute. Transient patients are often hard to track down over time; 3) Active enrollment facilitates patient engagement but may be slower to scale. Automatic enrollment of patients allows the state to recruit a sizeable number of patients, but many may be difficult to locate, assess, and treat; and 4) Partnering with advocacy groups helps to engage patients. Partnerships are credited with countering resistance to the program from some providers of long-term services and supports who feared a more integrated approach would reduce demand for services
    • Member assessments, combined with better documentation and more accurate coding, enabled CCA to reclassify about 25% of its One Care enrollees into higher-risk categories CMS and MassHealth increased reimbursement rates and made modifications to risk-sharing agreements that resulted in CMS and MassHealth assuming greater responsibility for losses
    • Massachusetts was looking to expand Care One program. As of June 2016, only 13% of eligible residents were enrolled
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