# data[].attributes.body
We need data to drive the process including, data on
where the money goes

quality of services

# data[].attributes.body
Duals and their choices do not exist in a vacuum… they can and do consistently opt out

# data[].attributes.body
The ACA requirements to demonstrate savings for MMP demonstrations and CBO scoring guidelines can sometimes stymie progress

# data[].attributes.body
Inertia/satisfaction with the way things are

lack of understanding among providers

Misunderstanding among recipients

Payment rates

Difficulty in assessing savings and the inability to attribute them to specific actions, policies or providers

Difficulty in convincing health providers to engage with MLTSS

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Siloed downstream entities - integration is bifurcated at local level 

# data[].attributes.subject
Siloed downstream entities - integration is bifurcated at local level 

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We’ve decided that integration is best for dual eligible people, but they don’t necessarily agree. We have a real messaging problem.

# data[].attributes.subject
We’ve decided that integration is best for dual eligible people, but they don’t necessarily agree. We have a real messaging problem.

# data[].attributes.body
They are still the locus of energy and money. They have zero incentive to work on integration.

# data[].attributes.body
Inequities in state HCBs design and instituí bias could be eliminated with standardized Medicare LTSS packages but financial impact too big for trust fund

# data[].attributes.headline
Lack of compliance options for states to enforce state requirements in integrated models 

# data[].attributes.subject
Lack of compliance options for states to enforce state requirements in integrated models 

# data[].attributes.body
Heterogeneous nature of the population and fragmentation in state and local government for delivery of important services

# data[].attributes.body
Will CMS have the ability to regulate anymore? What regs will die? Likely this will lead to more disintegration

# data[].attributes.body
If financial incentives aren’t enough, maybe it’s because we have the wrong incentives. Why can’t we hold feet to the fire on keeping people in the community, high satisfaction, and other outcomes?

# data[].attributes.headline
Primacy of payer. Absent a blended dollar it is near impossible to align incentives at a person level. 

# data[].attributes.subject
Primacy of payer. Absent a blended dollar it is near impossible to align incentives at a person level. 

# data[].attributes.body
Financial integration doesn’t solve beneficiary experience of care

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Concept of integration is often not explained or operationalized  in a way that communicates value to the end user

# data[].attributes.subject
Concept of integration is often not explained or operationalized  in a way that communicates value to the end user

# data[].attributes.headline
Some states won’t have stakeholder support for full integration / seen as threat to longstanding programs valued by Bh and/or disability communities 

# data[].attributes.subject
Some states won’t have stakeholder support for full integration / seen as threat to longstanding programs valued by Bh and/or disability communities 

# data[].attributes.body
Despite great work by CMMI to outline how to access it, lack of uptake and use of Medicare data by states

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Provider shortages in rural areas/certain specialities aren’t solved by integrated models

# data[].attributes.subject
Provider shortages in rural areas/certain specialities aren’t solved by integrated models

# data[].attributes.body
Lack of incentives for states to prioritize a focus here. To do this well takes more resource and understanding than most states have

# data[].attributes.body
Two fundamentally different programs with different reporting structures, payment, bid processes, etc. Regulatory environment does not efficiently allow for integration

# data[].attributes.body
Competing priorities for resources post pandemic in Medicaid space

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Lack of plan penalties at federal level; should require them to share savings/rebates with states or to reinvest them back into the communities they made the money off of

# data[].attributes.subject
Lack of plan penalties at federal level; should require them to share savings/rebates with states or to reinvest them back into the communities they made the money off of

# data[].attributes.headline
Conflicts of interests and external influence on policy priorities 

# data[].attributes.subject
Conflicts of interests and external influence on policy priorities 

# data[].attributes.body
Crowd out of these issues by matters that are stratifying higher on state radar screens (BH, maternal health, HRSN work)

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Lack of expertise and effective models of Geriatrics and display team Kaehr and limited influence by clinicians on the model of care implemented by plans for achieving integration. The role of positions is often relegated to utilization management and not clinical leadership.

# data[].attributes.subject
Lack of expertise and effective models of Geriatrics and display team Kaehr and limited influence by clinicians on the model of care implemented by plans for achieving integration. The role of positions is often relegated to utilization management and not clinical leadership.

# data[].attributes.body
Even in fully aligned models, many health plans aren’t actually integrated

# data[].attributes.body
To the extent that proposals increase federal and state funding, securing legislative support (or federal offsets should PAYGO rules apply) may be challenging

# data[].attributes.body
With all the focus on states it is easy to forget (although the state folks reminded us) that there is a tremendous amount of $$$$$ to be made in poorly integrated or non-integrated plans and achieving integration is dependent upon states standing in front of the gravy train with a big sign that says “no gravy for you.”

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Market dominance of large national plans

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Market dominance of large national plans

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There are powerful players in the system who don’t want change(eg nursing homes, brokers). And they block progress

# data[].attributes.body
dynamic Medicare environment, for beneficiaries, providers, health systems, plans

# data[].attributes.body
Challenges with managed care plans infrastructure to fully integrate

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Medicare freedom of choice (not bc choice isn’t important but it’s resulted in so many plans and complexity)

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Medicare freedom of choice (not bc choice isn’t important but it’s resulted in so many plans and complexity)

# data[].attributes.body
We need to keep in mind that people make decisions that are immediately gratifying, and the benefits of integration aren’t necessarily immediate.

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Savvy marketplace undercuts integrated plans with nonintegrated but attractive options to consumers 

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Savvy marketplace undercuts integrated plans with nonintegrated but attractive options to consumers 

# data[].attributes.body
Most of it take multiple years, yet most health leaders - especially in states - turn over faster than that.

# data[].attributes.body
Technology (Internet access)

Transportation

Literacy / Education

Politics

Extensive wait lists

Bandwidth of staff

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Lack of up front capital and complexity of negotiating shared savings models with the highly risk averse folks who represent Medicare

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Lack of state staff resources to implement and pursue significant change without assured/improved outcomes.

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In part because people are not knowledgeable enough to know that it’s needed.

# data[].attributes.body
Lack of dedicated resources for states

# data[].attributes.headline
Competing priorities and funding needs at state level. 

# data[].attributes.subject
Competing priorities and funding needs at state level. 

# data[].attributes.body
variability in state resources and expertise in managed care (Medicare and MLTSS) and managing contracts with plans (eg, SMACS)

# data[].attributes.body
Federal statutory constraints

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Political entrenchment in states keeping program carve outs in place that degrades value of integrated or aligned care

# data[].attributes.body
State bandwidth expertise and data infrastructure

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Brokers have misaligned incentives with consumers

# data[].attributes.body
Loooooong investment of time and energy before states are likely to see results.