Partial SC Medicare and Medicaid program combination

centers for medicare and medicaid services logoMuch of the conversation about health care has centered on health-insurance marketplaces and whether or not to expand Medicaid. Far less discussed is a Centers for Medicare and Medicaid Services initiative that some say has the potential to improve the delivery and cost-efficiency of health-care services to South Carolinians.

The centers’ Financial Alignment Demonstration targets dual eligibles, or people whose combination of age, income and health status makes them eligible for both Medicare and Medicaid. In no small part because of their age and lack of income, dual eligibles tend to be sicker than the general population, often with chronic health problems that need a great deal of coordination to manage. There are approximately nine million dual eligibles nationwide, including more than 134,000 in South Carolina.

The federal government recently allowed states to submit proposals to test new approaches to better integrate the health-care services and supports that dual eligibles need. South Carolina, along with several other states, is participating in this initiative.

South Carolina’s Healthy Connections Prime utilizes what is called a capitation model, where private insurers are paid a flat fee from both the federal government and the state for each member they serve. In turn, these Medicare-Medicaid plans coordinate patients’ services under one umbrella. Patients are assigned a primary-care physician and an integrated care manager, who work with all of their providers — specialist physicians, behavioral-health practitioners, pharmacists, long-term care, etc. — to ensure that the patients receive cost-effective care.

The thought behind this trial is that coordinated care is fully attuned to the patient’s needs and thus higher-quality care. By eliminating redundancies and reducing errors that lead to complications, they expect to reduce costs.

Medicare and Medicaid have individually utilized a managed-care approach for decades. More than 14 million seniors have chosen Medicare Advantage, and a recent study published in the American Journal of Managed Care found that Medicare Advantage patients had a readmission rate 13 percent to 20 percent lower than those in the fee-for-service Medicare program. Two-thirds of Medicaid patients both nationwide and in South Carolina are enrolled in managed-care plans.

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