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Individuals who are eligible for both Medicare and Medicaid are among the most challenging patients for whom case managers coordinate care.
Dually eligible beneficiaries represent only about 14% of the total Medicaid population, but they consume about 36% of the resources, says Martin Samples, senior vice president of marketing and product management for HealthX, a technology company that provides cloud-based solutions for healthcare payers.
"Providing care for the 9.6 million dual eligibles in this country costs over $300 billion a year. Even though there is a significant amount of money spent on healthcare, the care these individuals receive is often inadequate or poorly coordinated," he says.
Dual eligibles typically require care from multiple physicians, specialists, and home and community service providers who may not communicate or coordinate care with each other. Not only is it costly to provide fragmented care, when dual eligibles have poor outcomes it can impact a health plan’s HEDIS (Healthcare Effectiveness Data and Information Set) scores and Medicare Advantage Star ratings, Samples points out.
Beneficiaries who are eligible for both Medicare and Medicaid have complex and long-term medical and social services needs and often have behavioral health issues as well, says Pamme Taylor, vice president for advocacy and community-based programs for WellCare Health Plans, based in Tampa, FL.
"The individuals in the program have critical needs, and the best place to meet their needs is not always in the hospital setting. Home or a community-based setting may be the best environment for them, but often the system is not set up to support them in the home as effectively as possible. Being able to coordinate the social issues as well as the medical issues is really critical," she says. (For a look at how WellCare coordinates care for dual eligible members, see article on page 88.)
People who are eligible for both Medicare and Medicaid are challenged by low socioeconomic status as well as healthcare issues, points out Jeri Peters, RN, BSN, vice president and chief nursing officer for UCare. In addition to physical and mental health issues, many dual eligible members need help with housing, meals, transportation, and support in the community, she adds.
UCare, with headquarters in Minneapolis, provides coverage for dual eligibles through two different programs, based on the individual’s age. Members who are over age 65 are covered by the Minnesota Department of Human Services’ Minnesota Senior Health Options program. UCare manages both the Medicaid and Medicare benefits for this population. Through UCare Connect, UCare manages the Medicaid benefits for members ages 18 to 64 who have been certified as disabled and meet certain financial guidelines, Peters says. (For details on both programs, see page 90.)
The problem of coordinating care for dual eligible patients is complicated by the fact that Medicare is a federal government program and Medicaid is run by the states and the benefits are not always aligned, Taylor says.
Boston-based Network Health is participating in the Massachusetts Medicare-Medicaid demonstration project, which integrates Medicare and Medicaid benefits for people who are dually eligible for both programs. (For details, see related article on page 87.)
One of the keys to providing high-quality care to dual eligibles is establishing lines of communication among all of the providers and organizations providing services, Samples says. "The technology used by the entire team needs to be integrated to allow all providers to see what the others are doing. Collaboration is a huge part of it. When providers do not collaborate, the care is fragmented and the results are poor," he says.
Samples recommends better care coordination for dual eligibles through education about gaps in care, wellness, and preventive procedures such as mammograms and other kinds of screenings.
Not only does this improve their health, it can help insurers improve their quality scores, he adds. He suggests a holistic communication strategy engaging member, payer, and provider in strategies to close those gaps in care.
"In a rapidly changing healthcare environment, it is critical for health plans to stay ahead of the curve. When you achieve better care coordination and communication among care managers, primary care physicians and specialists, and community-based providers, you drive better outcomes for the dual eligible population, improve performance on quality measures, and save healthcare resources by improving operational efficiencies," he says.