Flexibility needed in FFS and capitated environments in order to weave in care coordination, disease management
CAUGHT BETWEEN A ROCK AND A hard place. If the clich� wasn't coined to describe the plight of individuals who are for both Medicare and Medicaid, it should been. While dual eligibles may be entitled to benefits, their care is rarely coordia fact that endangers their health and costs billions.
Nearly 8 million people are dual eligibles: elderly disabled Medicare beneficiaries who also qualify Medicaid coverage because of their poverty. Carfor these patients cost U.S. taxpayers an esti$239 billion in 2008, according to a recent by the Lewin Group. They represent about 40% of all Medicaid spending and about 25% of Medicare spending, and account for roughly 10% of all health spending in the United States.
On paper, dual eligibles have what George Mason University Professor Mark Meinen calls 'the gold card' of coverage. They receive acute care coverage under Medicare, while Medicaid fills in the gaps and coven long-term care. But what's on paper often bears little resemblance to reality.
SEARCHING FOR SOLUTIONS
Experts generally agree that lack of coordination between the Medicare and Medicaid systems is a major stumbling block. Medicare and Medicaid often force dual eligibles to access services from different systems with different rules, case managers and telephone numbers, using different identification cards and procedures. That duplication not only drives cost, it impacts quality of care.
But bridging the two systems presents an enormous challenge. As director of the Robert Wood Johnson Foundation's Medicare/Medicaid Integration Project, George Mason University's Meiners has been studying the dual eligible population since 1995. He's studied states with fully integrated models, partially integrated systems and managed fee-for-service programs.
'There are a lot of models out there, but after 13 years, I haven't seen a lot of progress on the issue,' he says. Meiners believes that's partly due to the fact that useful strategies, such as care coordination and disease management, can be difficult to weave into a FFS environment.
Roughly 85% of dual eligibles receive care under a fee-for-service arrangement.
At the same time, moving a specialneeds population such as dual eligibles into a capitated environment, where health management and outreach services could be more easily integrated, is problematic because it 'erodes the insurance principal' of spreading risk, he says.
Ultimately, Meiners says, a solution will depend on 'creating some flexibility and stepping out of the rigid boxes that the two programs represent so you can work more creatively and appropriately to meet the needs of individuals.'
Richard Surles, chief development officer for APS Healthcare, which provides disease management and other services to state Medicaid programs, agrees a different benefit design is necessary.
'The current system is failing dual eligibles,' he says 'The benefit is badly bifurcated, and there is a lack of coordination, but I don't think full risk capitation is the answer. To me the business model for a full-risk capitation sets up some incentives for overmanaging utilization and not really managing care.'
Capitation advocates disagree. The Lewin Group study, conducted on behalf of the Association for Community Affiliated Plans (ACAP) and Medicaid Health Plans of America, concludes that integrating care for dual eligibles using a capitated model already in use in a number of states, including Minnesota, Massachusetts and Wisconsin, would translate to enormous savings.
If all dual eligibles were moved into an integrated setting, Medicare and Medicaid would realize a 2.7% savings immediately and that would grow to a 4.7% savings after 15 years. What's more, the report states, integrated care would improve clinical outcomes.
While advocates on both sides of the issue debate how best to attack the issue, the ranks of the dual eligible population and their needs, are destined to swell. Baby boomers are aging, chronic diseases are on the rise, and the economic crisis is increasing Medicaid roles. Given those trends, the study projects annual spending on duals will top $775 billion by the year 2024.
POOR, SICK AND EXPENSIVE
Dual eligibles are also among the nation's sickest, further contributing to costs. For example, many disabled dual eligibles also struggle with mental illness and elderly dual eligibles are far more likely to have a chronic condition than other Medicare beneficiaries, according to a 2004 study by the Kaiser Commission on Medicaid.
It found 31% of dual eligibles suffer from heart disease, and 16% have had a stroke, compared with 23% and 10%, respectively, of other elderly (non-disabled) Medicare beneficiaries. Dual eligibles are also more likely to struggle with activities of daily living, such as bathing, dressing, eating and toileting.
'When you're dealing with a dual eligible population it's like Maslow's hierarchy of needs,' says Christobel Selecky, CEO of LifeMasters Supported Self Care Inc., a disease management firm with programs for chronically ill dual eligibles in Florida. 'If a person doesn't have enough food, she's not going to worry about the medications she's on,'
HELP BEYOND HEALTHCARE
For dual eligibles, some of the socioeconomic barriers must be removed so patients are ready and able to address their health, Selecky says. And many of those barriers - such as lack of family support, transportation, telephone service, a permanent address, and food - fall outside the strict definition of healthcare.
Given the fact that dual eligibles currently represent 40% of Medicaid spending and 25% of Medicare costs, experts say finding the cash, flexibility and political will to provide more holistic care is a challenge.
In light of those trends, Selecky says systematic reform, needed though it may be, won't be a panacea.
'There is a lot of high-level work going on to address the problems of dual eligibles, but how do you translate what you learn to the local level?' she says. 'What works in rural Oklahoma may not work in urban Florida. My soapbox is: There is no silver bullet.' MHE
[Sidebar]
WHO ARE DUAL ELIGIBLES?
* Two-thirds of dual eligibles are age 65 or older; one-third are nonelderly adults with disabilities.
* Seven out of 10 have annual incomes below $10,000.
* Approximately 72% of elderly dual eligibles are women.
* Almost one-quarter of elderly dual eligibles are in nursing facilities, in contrast to only 2% of other elderly Medicare beneficiaries.
Source: Kaiser Commission on Medicaid and the Uninsured
MHE EXECUTIVE VIEW
* Dual eligible care should be coordinated, but rarely is.
* Remove the socioeconomic barriers so patients can address their health.
* Seek to avoid confusion and redundancy by integrating care for dual eligibles using a capitated model.
[Sidebar]
FOR MORE INSIGHT
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[Author Affiliation]
Shelly Reese is a freelance writer based in Cincinnati.
