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Laleman: Building a healthier Michigan

Marc Laleman

Much of the conversation on health care in Michigan and elsewhere over the last year has centered on health insurance marketplaces, and the expansion of Medicaid and coverage for the underinsured.

Much less discussed is a Centers for Medicare & Medicaid Services (CMS) demonstration program that has the potential to improve the delivery and cost efficiency of health care services for some of the most vulnerable Michiganians. And the people living in Wayne and Macomb Counties will soon begin to reap the benefits.

The initiative, CMS’ Financial Alignment Demonstration, targets dual eligibles, or people whose combination of age, disability status and income makes them eligible for both Medicare and Medicaid.

In no small part because of their age and lack of income, dual eligibles experience a more complex and compromised health status than the general population, including chronic health problems requiring significant coordination to manage effectively.

There are approximately 9 million dual eligibles nationwide, including more than 62,000 in Wayne and Macomb Counties.

A major roadblock to effectively coordinating care is that the Medicare and Medicaid programs were launched nearly a half-century ago as separate programs with different funding sources.

To address this challenge, CMS recently allowed states to submit proposals for testing new approaches to better align the financing of both programs and integrating the health care and support services dual eligibles require to lead healthy, productive and independent lives. Michigan, along with several other states, is participating in this initiative.

Michigan’s program utilizes a capitation model, where private health insurers are paid a monthly rate from both CMS and the state for each individual enrolled in the health plan. These health plans, called Integrated Care Organizations in Michigan, coordinate all of the enrollees’ health care services covered by both Medicaid and Medicare under one umbrella.

Each individual chooses a primary care physician and has an integrated care team. This group features all of the member’s health care providers, including primary care and specialist physicians, behavioral health practitioners, pharmacists and personal support caretakers, to ensure the member receives the best care possible.

As a native Michiganian, I believe this is great news for our state. Coordinated and integrated care that is fully attuned to an individual’s needs is higher quality care. This leads to better health outcomes.

Medicare and Medicaid have separately utilized a managed care approach across the country for decades. The Medicare version of this is called Medicare Advantage, and more than 14 million American seniors have chosen this health care coverage option.

According to a recent study published in the American Journal of Managed Care, Medicare Advantage plans had a readmission rate 13 percent to 20 percent lower than that of the fee-for-service Medicare program, proving this approach helps seniors stay healthy. On the Medicaid side, more than 67 percent of Americans covered by Medicaid nationwide — and 65 percent of those in Michigan — are enrolled in managed care plans.

Now, thanks to CMS and Michigan’s Department of Community Health, the benefits of Medicare Advantage and Medicaid managed care will be combined under one model to care for our neediest and most chronically ill residents.

It’s an idea that is a long time coming, and one that will well serve all Michiganians.

Marc Laleman is vice president of Medicare-Medicaid Plans for AmeriHealth Caritas.