The people who will benefit most from a new Medicaid initiative in Virginia also are the ones who need the most help and cost the most to treat.

On Aug.1, a program called Commonwealth Coordinated Care Plus (CCC Plus) was launched by the Virginia Department of Medical Assistance Services (DMAS). CCC Plus started in Hampton Roads and will be expanded across the rest of the commonwealth by the end of the year.

About 216,000 people in Virginia will be enrolled in the program when it is fully in place. Many are “dual-eligible” enrollees who get benefits from Medicaid and Medicare. Many are older adults or people with disabilities. They often receive a lot of services and medical care without anyone coordinating their treatment. Sometimes there is unnecessary care, which doesn’t help the patient or the state’s Medicaid budget.

CCC Plus has been in development for several years in Virginia, and other versions of the program are already in place in about 30 states. The program is making its debut in Virginia after years of steady criticism of the overall Medicaid system from conservatives who call it wasteful and ineffective. Recent failed efforts by Congress and the White House to end the Affordable Care Act included major funding cuts to Medicaid spending.

CCC Plus is designed to make services for this particular population more effective and less wasteful. The elderly and people with disabilities represent 23 percent of Virginia’s Medicaid population, yet they consume 68 percent of the state’s $8.41 billion Medicaid budget. These figures are from 2016.

“How do you bend the cost curve?” asks Cindi B. Jones, the director of DMAS. “It’s not an easy thing to do. We feel that by focusing on quality, the savings will come.”

Managed-care system
The program moves the elderly and disabled patients from a fee-for-service system to managed care, which gives insurers tighter control over medical spending. These patients are eligible for a lot of services, but they don’t always know the best way to access or use them.

“There’s nobody trying to coordinate their care” except for the patients themselves or a support person, usually a family member, Jones says. “I call those ‘fend for yourself’ programs.  Sometimes that process is almost worse than the disease.”

Before CCC Plus was launched, a test program in Virginia limited to about 30,000 people began in 2014. It showed good results, Jones says. Patients liked having care coordinators, and the program cut the costs associated with those patients, she says.

Virginia-based Optima Health has the contract with DMAS to handle services to eligible recipients in the Hampton Roads region and Virginia’s Eastern Shore. Randy Ricker, vice president of Optima Health Community Care, says the deal gives the state some certainty about what it will be spending. “They pay us a capitated rate each month, and that allows the state to set a budget,” he says.

Optima has leased space in the Military Circle Mall in Norfolk, which will house about 200 employees. Each employee will handle a number of cases.

Suzanne Coyner, director for program care services for Optima Health Community Care, says the new care coordinators have diverse backgrounds. They include registered nurses (RNs) and licensed practical nurses (LPNs) along with people with backgrounds in social work and mental health.

The amount of involvement the coordinators might have in the lives of recipients can go pretty far. Besides the management of their changing health-care needs, recipients sometimes need help with more basic issues, such as paying a utility bill or finding the right support group.

Amanda Becker, director of behavioral health and addiction services for Optima, recalls a recipient who needed help arranging for home pest control, which can be a health issue. “Coordination is key,” she says. “We’re able to identify gaps because we’re looking from the top down.”

Jones says DMAS officials have spent a lot of time talking to providers in preparing for this program. “The main reason somebody might give us blowback is they’re afraid they might not make as much money, which is not true if they’re a quality provider,” she says.

Similar work is underway now across the rest of Virginia. The central region of the commonwealth launches the program Sept. 1, and by Dec. 1 CCC Plus will be at least started everywhere. “My goal, a personal and professional goal, was to get to this point where these Medicaid clients have comprehensive care and coordination,” Jones says.

Optima is part of Sentara Health Plans. The other insurance companies contracted with DMAS to handle CCC Plus are Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Magellan Complete Care of Virginia, United Healthcare and Virginia Premier Health Plan.

In general, the Medicaid program has long been under pressure from Republicans. The resistance to Medicaid stiffened after a 2012 Supreme Court ruling allowing states to refuse to expand Medicaid under the ACA. Bill Howell, the retiring speaker of the House of Delegates, successfully led the blockade against expansion in Virginia. “Medicaid costs are out of control, patients are not receiving the quality care they deserve, and the program is plagued by waste, fraud and abuse,” he wrote in a 2014 newspaper column.

Jones says Medicaid expansion opponents wanted a political victory, no matter what the practical outcome was. “What they fell back on is: ‘The current Medicaid program is unsustainable so we have to reform that first.’ So that was their excuse. But once they gave us 19 things to do, and we accomplished those, then they moved the goalposts and said, ‘We need to see if it works.’”

Jones says her department has shown that Medicaid is efficient and effective and CCC Plus shows it is working to get more efficient. She reminds critics of what is at stake. “I always say the current Medicaid program [helps] babies, pregnant women, seniors and people with disabilities. Which one do you throw off the train?”

Jill A. Hanken also is tired of Medicaid criticism. She is director of the Virginia Poverty Law Center’s Center for Healthy Communities.

“Medicaid isn’t broken,” she says. Evaluations from the Joint Legislative Audit & Review Commission have supported that conclusion. One recent JLARC review, Hanken says, found $30 million in improper spending, about 0.4 percent of the Medicaid budget. “But $30 million in the context of a $9 billion program … it’s not something you want to support, but it’s not terrible.”

One in eight Virginia residents uses Medicaid benefits, according to DMAS. Two out of every three residents in nursing facilities use it, too. That ratio is a big deal, considering the aging baby boomer population and the increasingly high cost of private-sector, long-term-care insurance. “There always needs to be oversight and review,” Hanken says. “That doesn’t mean there’s anything wrong, but there’s always room to improve it. But you can’t lose sight of the value of the program.”