Five Takeaways from the New Evaluations of the Financial Alignment Initiative

In late November, the Medicare-Medicaid Coordination Office (MMCO) released long-awaited evaluation reports for five states participating in the Financial Alignment Initiative (FAI) – first evaluation reports for California, Illinois and Ohio, and second annual reports for Minnesota and Washington. California, Illinois and Ohio utilized a capitated demonstration model, whereas Washington had a fee-for-service model and Minnesota’s demonstration focused on administrative alignment.

The evaluations come at an important time: the first demonstrations were launched just over five years ago. We marked this anniversary with a symposium reflecting on what we’ve learned to date and the implications for future policy and program directions.  

The newly-released evaluations hint at the successes and challenges of these new care delivery and financing models for Medicare-Medicaid enrollees. We’re still digging into these reports, but here are five preliminary observations:

More improvement needed on care coordination

Improving care coordination is a fundamental goal of the demonstrations, yet the full potential of care coordination has yet to be reached. In California, for example, only 35 percent of surveyed enrollees reported receiving care coordination while 33 percent were unaware the service even exists. Ohio faced high levels of turnover among care coordinators (21 percent in 2014 and nearly 17 percent in 2015.) And one Illinois enrollee noted, “I've had three care coordinators and now I'm on my fourth…it's a lot of turnover going on with them…so I don't like it.”

Positive findings for CAHPS, with rich data on beneficiary experience

Overall, findings from the evaluations suggest that enrollees were generally satisfied with their experience with their plan, as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS), though in some cases these scores did not differ from people who were not enrolled in the demonstrations. We’re eager to take a closer look at some of the findings for specific populations. In particular, we see potentially high levels of unmet need for people who need durable medical equipment, with wide variability across plans (for example, in Illinois, the percentage of respondents reporting it was “usually” or “always” easy to get personal care assistance at home or durable medical equipment through their care plan ranged from 59 to 81 percent and from 53 to 74 percent, respectively.) While sample sizes are small, we think this is an important area for further assessment. We also appreciate the rich focus group data presented and think it is worth a close read.

Some promising indicators of decreased utilization

Illinois, Ohio and Washington all showed reductions in inpatient admissions and in skilled nursing facility (SNF) admissions. However, these promising trends appear to differ for people who used Long-Term Services and Supports, and we’ll be looking to understand the drivers of these differences.

Medicare savings only tell half the picture

Three states (Illinois, Ohio and Washington) showed statistically significant Medicare savings for at least one demonstration period, while California showed no statistically significant savings or losses. However, none of the reports include Medicaid data, making it difficult to interpret these findings.  

Enrollment is a challenge across the board

As of December 2016, over 228,000 enrollees were part of the demonstrations in California, Illinois and Ohio, a much smaller number than what CMS, states and health plans were expecting. The evaluations cite challenges including mass opt-outs from nursing facilities, lack of enrollee outreach and education, and lack of provider outreach and education. The findings were not unexpected given prior research demonstrating that passive enrollment has not met expectations for increasing program uptake. A more comprehensive approach to enrollment that takes into account consumer education (see for example this tool by The SCAN Foundation), consumer and provider engagement, best practices for on-boarding consumers into plans, broker roles, and plan readiness will be important to the uptake of integrated products.

While our deeper analysis of the evaluations is forthcoming, our initial take is this: while some progress has been made, there is still a lot left to do to ensure the demonstrations make a positive impact on enrollees’ lives and to better understand what is and isn’t working. 

Stay tuned for more analysis from us, in the new year.  Are you reading the evaluations? What are your key takeaways? Tweet us @CCEHI.