Caring for the nation's most vulnerable: Dual eligibles

Dual eligibles -- individuals eligible for both Medicare and Medicaid coverage -- are among the nation’s sickest and poorest. "Duals” as they are commonly referred to often fall through the cracks of two programs not designed to work together. The result is a lack of coordination that often leads to poor quality, inefficiency, and avoidable costs.

With the Affordable Care Act set to add 16 million people to the Medicaid rolls by 2019, the number of "duals" is certain to increase. Cash-strapped states are increasingly turning to the expertise of managed care companies to tackle skyrocketing dual eligible costs.

To address some of these concerns HRI issued a brief, Medicaid expansion: New patients new challenges.

Implications for caring for Duals

In assuming risk for duals, managed care organizations should carefully consider the cost effectiveness of current operations and how they can innovate care delivery to manage costs.
Some duals may be receptive to using digital communication for diabetes maintenance, weight management, disease management, and chronic care programs. (See figure above)
Plans and providers should fill education and awareness gaps to improve areas such as medication adherence. The HRI survey found that 53% of duals have participated in a prescription assistance program in which they can take advantage of free samples, discount cards, and coupons.
States and insurers should track progress of demonstrations on reimbursement versus medical cost trends, unique contracting mechanisms between managed care and providers, care management program efficacy, and effective coordination of clinical and non-clinical services such as transportation, meal service, and in-home assistance.
With long-term care support services accounting for 70% of state Medicaid spending on duals, plans deciding to increase those offerings must determine the most cost effective operating structure such as setting up in-house coordination and referral services, partnering with state, county, and community organizations, or outsourcing to a specialty provider.

For more information about caring for "Duals" you may read more here.

Dual eligibles—individuals who qualify for both Medicare and Medicaid coverage—are among the nation’s sickest and poorest. Many have multiple chronic conditions and more than half have annual incomes of less than $10,000.¹ “Duals” often fall through the cracks of two programs that were not designed to work together. This lack of coordination often leads to poor quality, inefficiency, and avoidable costs.

Cash-strapped state Medicaid programs report that projected long-term costs for this population are not sustainable. Some researchers say shifting dual eligibles to managed care plans or care coordination programs could save up to $20 billion a year.² But it will be an adjustment for patients accustomed to fee-for-service medicine in the traditional Medicare program.

With the aging of the baby boomers, the number of today’s approximately 9 million duals will steadily increase, and so will the cost of caring for them. Spending on duals reached nearly $320 billion in 2011, accounting for 39% of total Medicaid and 31% of total Medicare spending.^3,4 Federal spending on duals is projected to reach $3.7 trillion during the next decade.⁵ To manage the cost, the Centers for Medicare and Medicaid Services (CMS) is seeking health plans willing to take on financial risk through capitated managed care plans. Several states also intend to test a managed fee-for-service financial alignment model.

In the CMS Program of All-Inclusive Care for the Elderly, managed care providers receive capped payments to cover medical and related services for duals. An interdisciplinary team coordinates care, enabling many duals to receive care at home. In place for over a decade, the program has reduced hospitalization rates and improved care coordination but has yet to demonstrate savings, since capitated payments have exceeded the amount Medicare would have spent on fee-for-service.⁶

In 2011, CMS announced a three-year demonstration project that covers two million duals. Of the 26 state proposals, 18 proposed a capitated model paying a combined, risk-adjusted, per-member, per-month amount.⁷ The first demonstrations begin in April 2013, in Massachusetts with a capitated approach, and in Washington with a managed fee-for-service model.^8,9

Implications

In assuming risk for duals, managed care organizations should carefully consider the cost effectiveness of current operations and how they can refashion care delivery to better manage costs. While managed care may be familiar to Medicaid beneficiaries, Medicare beneficiaries historically have had freedom of choice in providers. With so many in Medicare fee-for-service, the adjustment to managed care may be difficult.
Some duals may be receptive to using digital communication for diabetes maintenance, weight management, disease management, and chronic care programs. A PwC’s Health Research Institute (HRI) internet survey of a subset of duals found they are more likely than other consumers to use social media for healthcare purposes (63% compared with 40%). Also, 42% of duals have communicated with a caregiver via email and nearly one-quarter via text. Twenty % of duals have healthcare apps on a mobile device, compared with 12% of non-duals.¹⁰
Plans and providers should fill education and awareness gaps to improve areas such as medication adherence. The HRI survey found that 53% of duals have participated in a prescription assistance program in which they can take advantage of free samples, discount cards, and coupons.
States and insurers should track progress of demonstrations on reimbursement versus medical cost trends, unique contracting mechanisms between managed care and providers, care management program efficacy, and effective coordination of clinical and nonclinical services such as transportation, meal service, and in-home assistance.
With long-term care support services accounting for 70% of state Medicaid spending on duals, plans deciding to increase those offerings must determine the most cost effective structure such as in-house coordination and referral services, partnering with state, county, and community organizations, or outsourcing to a specialty provider.¹¹

Footnotes

¹ Judith Solomon, “Moving ‘Dual Eligibles’ Into Mandatory Managed Care and Capping Their Federal Funding Would Risk Significant Harm to Poor Seniors and People With Disabilities,” Center on Budget and Policy Priorities, October 10, 2012; http://www.cbpp.org/cms/index.cfm?fa=view&id=3848.
² Randall Brown and David R. Mann, “Best Bets for Reducing Medicare Costs for Dual Eligible Beneficiaries: Assessing the Evidence,” Kaiser Family Foundation Medicare Issue Brief, October 2012; http://www.kff.org/medicare/upload/8353.pdf.
³ Judy Feder, Lisa Clemans-Cope, Teresa Coughlin, John Holahan, Timothy Waidmann, “Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead,” Robert Wood Johnson Foundation and Urban Institute, October 2011; http://www.urban.org/UploadedPDF/412418-Refocusing-Responsibility-For-Dual-Eligibles.pdf.
⁴ Ibid. ⁵ Kenneth E. Thorpe, “Estimated Federal Savings Associated with Care Coordination Models for Medicare-Medicaid Dual Eligibles,” September 2011; http://www.ahipcoverage.com/wp-content/uploads/2011/09/Dual-Eligible-Study-September-2011.pdf.
⁶ Ibid. ⁷ The Kaiser Commission on Medicaid and the Uninsured, “State Demonstrations to Integrate Care and Align Financing for Dual Eligible Beneficiaries: A Review of the 26 Proposals Submitted to CMS,” http://www.kff.org/medicaid/8369.cfm, accessed October 2012.
⁸ The Kaiser Commission on Medicaid and the Uninsured, “Massachusetts’ Demonstration to Integrate Care and Align Financing for Dual Eligible Beneficiaries,” http://www.kff.org/medicaid/8291.cfm, accessed October 2012.
⁹ Anthony Brino, “CMS Approves Washington’s FFS dual eligible demonstration,” Healthcare Payer News, November 1, 2012; http://www.healthcarepayernews.com/content/cms-approves-washingtons-ffs-dual-eligible-demonstration.
¹⁰ PwC Health Research Institute Consumer Survey, 2012. In October 2012, HRI conducted an Internet survey of 100 dual eligibles. One-quarter of the sample reported income before taxes of less than $15,000. Age ranges included 28% between 18 and 24, 35% between 25 and 44, 17% between 45 and 64, and 20% 65 or older. Sixtyfour percent reported they own a smartphone.
¹¹ The Kaiser Commission on Medicaid and the Uninsured, “Medicaid’s Long-Term Care Users: Spending Patterns Across Institutional and Community-Based Settings,” October 2011; http://www.kff.org/medicaid/upload/7576-02.pdf.

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Caring for the nation's most vulnerable: Dual eligibles