First there six private insurance companies eager to become partners with the State in implementing the nation's first Dual Demonstration program for individuals eligible for both Medicare and Medicaid programs.  Now, only three remain.

The intent of the program was to achieve improved health outcomes for program participants while also keeping costs stable, with more efficient use of limited health care dollars eventually resulting in health care expenditure reductions.

Working in partnership with the federal government's Center on Medicare and Medicaid Services (CMS), the State and CMS were to provide sufficient rates to allow managed care organizations known as Integrated Care Organizations (ICOs) to deliver both quality and cost effective health and community care.

However, right from the start the program has encountered numerous delays and dissension among providers, insurers and advocates with regard to the program's design and the sufficiency of CMS determined rates needed to implement the program's ambitious goals.

In mid Spring, Neighborhood Health Care (NHP) concluded that the CMS determined rates were far insufficient to do the job; they were joined last month by BMC-HealthNet, affiliated with Boston Medical Center who came to the same conclusion; and today the third ICO has reached the same point with Blue Cross/Blue Shield announcing their withdrawal as well.

With 50% of the original ICOs abandoning the program, it remains to be determined how this will impact the overall stability of the Demonstration Project. It is possible that the State may consider a scaled back Demonstration Project with just two or three participating ICOs while others believe the third withdrawal may result in sufficient pressure on CMS and the Commonwealth to restructure rates in a manner that may result in a more stable program.