New initiative aims to integrate care of costly 'dual-eligibles'
New initiative aims to integrate care of costly 'dual-eligibles'
"Dual-eligibles"-individuals who are simultaneously enrolled in both Medicare and Medicaid, are generally in poor health and one of the most costly populations covered by public health programs. Now a new initiative, Transforming Care for Dual Eligibles, launched by the Center for Health Care Strategies (CHCS), will test innovative care models for this population.
Colorado, Maryland, Massachusetts, Michigan, Pennsylvania, Texas, and Vermont will implement strategies to improve care and control costs for dual-eligibles. The seven states will design patient-centered delivery models for this critical, yet often- overlooked, population.
More than 8 million adults who are dually eligible represent only 18% of the Medicaid population but account for 46% of Medicaid's total expenditures, due to their complex array of medical, behavioral, and long-term care needs.
However, more than 80% of dual-eligibles remain in fee-for-service systems seen as "treatment silos" with little to no care coordination. The initiative aims to integrate the financing, delivery, and administration of services across Medicaid and Medicare, in order to reduce unnecessary hospitalizations and decrease the use of institutional care over time.
Process is complicated
The participating states will develop and implement integrated approaches with Medicare Advantage Special Needs Plans (SNPs), a type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries, including dual-eligibles.
Alternative models for integration will involve working with the Centers for Medicare & Medicaid Services (CMS) to find ways to overcome the administrative and regulatory challenges that currently hinder integrated care approaches. Lessons from participating states will be disseminated to Medicaid stakeholders.
"While many states are interested in integrating care through special needs plans and other alternatives, it is a complicated process, due in large part to administrative and regulatory obstacles, financial misalignment of the two programs, and the complex needs of the dual-eligible population," says Melanie Bella, CHCS' senior vice president for policy and operations.
Expediting efforts to integrate the financing and delivery of care for dual-eligibles is expected to improve care and control cost growth for this high-need population. "We will work with states to address the obstacles they face in integrating care for duals," Ms. Bella says. "We will also work with states and CMS to develop financial mechanisms that allow Medicaid and Medicare to share in the savings generated by integrated care, as well as support alternative options for integration."
The ultimate goal of the project is to increase the number of dual- eligibles receiving care through fully integrated programs, while making it easier for other states to develop and implement similar models of care.
"One size will not fit all for states in terms of integrated care models. That is why we are exploring a variety of options through SNPs, as well as other alternatives," says Ms. Bella.
Although there are multiple vehicles for achieving integration, these models typically share core common elements. These include a strong patient-centered primary care base, a multidisciplinary care team, a comprehensive provider network, robust data-sharing and communications systems, consumer protections, and financial alignment.
"Ultimately, these models provide a fully integrated set of Medicare and Medicaid services in a way that is transparent to beneficiaries, and where there is an entity accountable for improvements in both cost and quality," says Ms. Bella.
Concerns are growing
According to Mark Trail, a principal of Lansing, MI-based Health Management Associates, most state Medicaid programs have been concerned about the growing number of people becoming eligible for both Medicaid and Medicare. Mr. Trail is based in Tyrone, GA.
"This is especially heightened as the 'baby boomer' age group is approaching Medicare eligibility," says Mr. Trail. "The most significant concern for state Medicaid programs in this regard comes from the increased demand on long-term care services."
As Medicare's benefit for long-term care is basically limited to short-term rehabilitative care, Medicaid programs have had to step in and offer both nursing home care and long-term home and community-based care. For FY 2007, more than 34% of all Medicaid expenditures were for long-term care, and 65% of all Medicaid expenditures were for the elderly and the disabled. "As the population grows, so will the expenditures," says Mr. Trail.
According to Molly O'Malley, a senior policy analyst with the Henry J. Kaiser Family Foundation in Menlo Park, CA, the goal is to improve care coordination and better manage high-cost cases. However, she notes that "the return on investment from disease and chronic care management programs in this population is potentially great, but the evidence on programs implemented to date is currently inconclusive."
Currently, dual-eligible SNPs currently serve only about 11% of the total dual-eligible population. "Evidence from an evaluation of two programs shows improved or stable quality of care and access to services but higher program costs relative to comparison groups," says Ms. O'Malley. "Little evaluation of SNPs' performance in terms of costs and outcomes is currently available."
A total of 8.8 million rely on Medicaid for help paying Medicare premiums and cost-sharing, as well as important benefits that Medicare does not cover, such as long-term care. "Shifting some portion of these costs to the federal government could provide significant fiscal relief to states," says Ms. O'Malley.
Most states have managed expenditures for the dually eligible population by limiting benefit design, utilization, and unit price, notes Mr. Trail. Several states have certificate-of-need programs to limit the number of nursing home beds available in that state.
Most states that offer home and community-based waivers limit their expenditures by also limiting the number of slots authorized and available in a waiver. "Going forward, we can expect to see an increasing interest in SNPs," says Mr. Trail.
The Medicare Improvements for Patients and Providers Act requires a SNP to contract with the state. "One can expect states to consider whether that contractual relationship should be risk-based to gain some further cost predictability, as has been done with so many of the low-income groups in Medicaid," says Mr. Trail.
Contact Mr. Trail at (404) 313-8432 or [email protected] and Ms. O'Malley at (202) 347-5270, or [email protected].
"Dual-eligibles"-individuals who are simultaneously enrolled in both Medicare and Medicaid, are generally in poor health and one of the most costly populations covered by public health programs. Now a new initiative, Transforming Care for Dual Eligibles, launched by the Center for Health Care Strategies (CHCS), will test innovative care models for this population.Subscribe Now for Access
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