Field of Work: Blending Medicare and Medicaid funding to improve services received by Minnesota seniors who are eligible for coverage under both programs.
Problem Synopsis: Seniors who are eligible for both Medicare and Medicaid often encounter fragmented clinical systems, duplicative and often conflicting administrative rules, cost shifting between providers and programs and a lack of accountability. Financial incentives for physicians, nursing homes and hospitals are poorly "aligned," sometimes encouraging a health care provider or facility to transfer a senior to another facility, which may not necessarily provide the senior with optimal health care to meet his or her needs.
Synopsis of the Work: Minnesota's Department of Human Services planned, developed and implemented Minnesota Senior Health Options, a managed care program that blends funds from the Medicare and Medicaid programs to improve the delivery and coordination of all Medicare and Medicaid services received by seniors who are eligible for coverage under both programs.
Key Results: The state inaugurated Minnesota Senior Health Options in 1997. Enrollment grew to 36,000 by 2008. The program has the following key features:
- The state contracts with nine managed health care plans to provide coverage for enrollees on a capitation basis, using combined funds from Medicare and Medicaid.
- The health care plans in turn contract with provider groups (e.g., hospital systems, long-term-care facilities, preferred provider organizations [PPOs] and other physician groups) to provide care for enrollees on a capitation basis.
- All enrollees are assigned a care coordinator to help them navigate the various autonomous provider groups and obtain necessary services.
- The program includes a range of quality assurance and training activities, including:
- Periodic audits of the health plans.
- Videoconference training for care coordinators.
- Ombudsman services for enrollees.
- Quality improvement projects conducted collaboratively by the health plans, aimed at improving care to beneficiaries.