Ambitious Project Aims to Improve Quality, Lower Costs for Dual Eligibles

February 05, 2013 11:00
Bob Rosenblatt / The Medicare NewsGroup

The government will begin an ambitious Medicare-Medicaid coordination program next year to try to bring better care at a lower cost to some of the 9 million people who are the sickest and poorest, and thus most costly, patients in the nation’s health care system.

Their ranks include a cross section of different groups, such as residents of nursing homes, the mentally ill, and the physically or developmentally disabled. They are called “dual eligibles” because they qualify for two massive government programs: Medicare, which covers people over age 65 and the disabled of all ages, and Medicaid, which covers poor people.

As many as 2 million of dual eligibles will be enrolled in local managed care networks, or in programs with a fixed total payment for providing their care during the year. The hope is that they will get better care, and that the taxpayers will save money because there will be better oversight of the way these patients  receive care from doctors, hospitals, visiting nurses, social workers and therapists. The goal is to have one contracting organization overseeing the myriad sources of care for a group of dual eligibles.

The program will be run by the government’s new Federal Coordinated Health Care Office.

Related FAQ: Who Are Dual Eligibles?
Related FAQ: What Does the Affordable Care Act Do With Regards to Dual Eligibles?
Related FAQ: Are There Examples in the States of Novel Approaches to Managing Dual Eligibles?

The population of dual eligibles  incurs higher medical costs than any other group of patients.  They bounce in and out of hospitals, have multiple ailments, take myriad medications, and get their care through a fragmented system of public and private hospitals, local nursing agencies and county emergency mental health centers.

Of these 9 million dual eligibles, more than one-third will spend some time in a nursing home. They represent 15 percent of the Medicare population, but consume 30 percent of Medicare spending. They are also15 percent of the Medicaid population, but consume 40 percent of Medicaid dollars.

Providing care for dual eligibles is one of the most intricate tasks of the nation’s complex health care system.

The current system, in which each thing a doctor does carries a separate charge, is called fee-for-service. Dealing with this fragmented approach is very hard for dual eligibles because it is “really fend-for-yourself,” said Matt Salo, executive director of the National Association of State Medicaid Directors.

Starting in 2014, the federal government will begin a major experiment in organizing coordinated care for dual eligibles in as many as 15 states. Beneficiaries will be offered the choice to enroll in managed care plans, which have networks of doctors, hospitals and other health care providers.

This experiment will offer more expansive care than found in a traditional managed care network. In California, for example, where Kaiser Permanente has a large network of its own providers, its plan will oversee the care of mentally ill people who might otherwise be treated at a county hospital.

Kaiser is “committed to this population,” said Susan D. Fleischman, M.D., vice president for Medicaid at Kaiser, when discussing the dual eligibles who may decide to join Kaiser’s plan.  But it’s a new population and “we’re nervous,” she told a panel discussion on dual eligibles on February 1, at the annual conference of the National Academy of Social Insurance, a nonpartisan think tank working on Medicare and Social Security issues.

Despite Kaiser’s extensive experience with both the Medicare and Medicaid populations, “We have limited experience in delivering the full scope of services to the dual eligibles,” she said, adding, “If we are nervous, then other plans ought to be really nervous.”   

Kaiser presumably has a head start on its competitors in taking on this new population because it has the highest ratings for quality bestowed on managed care plans by the federal government. Only 11 Medicare Advantage Plans (Part C) have the government’s top 5-star rating, and six of them are Kaiser plans.

Nonetheless, “Our learning curve is going to be steep,” Fleischman said.

One of the new steps for Kaiser, and other plans, will be learning to coordinate care with county mental health facilities, which have always operated separately from traditional health plans.

Under the experiment, the goal will be for a dual eligible to have all of his or her care overseen and coordinated by plans like Kaiser’s. This can include if a 90-year-old in a nursing home falls and breaks a hip; a mentally ill person stops taking medication, has a psychotic episode and is taken to a county mental health emergency center; a developmentally disabled person needs a ride to a job training session; or someone is discharged from a hospital and needs a visiting nurse to provide therapy at home. The goal is that all the details for any kind of needed care will be managed by a single health plan. Not all of the services fall under the category of what might be described as traditional health care, but the goal is to give the individual as much access to self-sufficiency as possible.

Along with big health care challenges are big financial ones. The plans that will participate at the government’s invitation are supposed to show within a year’s time that they are delivering to their patients better care for less money as compared to people who don’t join such a plan.

The difficulty will be in providing quality care for a very diverse group of people. A plan might be “terrific” in providing care for the mentally ill but not for the developmentally or physically disabled, according to Brian Biles, M.D., professor in the department of health policy at the School of Public Health at George Washington University. 

Because many of the individuals have multiple physical or mental ailments, there is concern that the transition to a new method for getting care may be difficult.

CMS has stated that demonstration plan benefits packages should include “all primary, acute, behavioral health and long-term services and supports presently covered by Medicare and Medicaid.”

However, “Patient advocates around the country, and some lawmakers in Congress, warn that managed care plans – some run by for-profit, publicly traded companies – are ill-equipped to deal with the complex health needs of those who are elderly, mentally ill or disabled,” according to a story by Kaiser Health News.

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