Quality & Practice

Initiatives Focused on the Medicare-Medicaid Enrollees

Financial Alignment Initiative for Medicare-Medicaid Enrollees

This initiative is a joint process between Medicare and Medicaid, implemented to try to improve the care received by dual eligible beneficiaries and to align the financial incentives of the two programs. One aim is to lessen the patient’s need to navigate among multiple sets of rules, benefits, cards, and providers.  Another aim is to bring more care coordination into the model, since many of the patients have multiple chronic conditions. Benefits for the beneficiary include: working with an interdisciplinary care management team to develop person-centered, individualized care plans, specialized programs to assist with transition of care and to reduce avoidable hospital and nursing facility admissions, and 24-hour telephonic access to medical professionals.  Medicare and participating states are testing two possible models –
  • A Capitated Model which entails a three-way contract among the State, CMS, and a health plan to enter into a three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care. 
  • A Managed Fee-For-Service Model entails a contract between CMS and the state in which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.  

Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents

This initiative is for patients with both Medicare and Medicaid who are long term residents in nursing homes, to reduce hospital admissions and improve quality.  CMS contracts with seven Enhanced Care and Coordination Provider (ECCP) organizations.  These organizations are to assist nursing home to provide higher-intensity treatment services for residents who may otherwise be hospitalized upon an acute change in condition, improving the capacity of nursing facilities to treat common medical conditions, and providing oppotunities to improve the residents’ care experience at lower cost than a hospital admission. The model also includes payments to practitioners (i.e., physicians, nurse practitioners and physician assistants) at levels similar to the payments they would receive for treating beneficiaries in a hospital. Practitioners would also be eligible to receive new payments for engagement in multidisciplinary care planning activities