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Using Dual Eligible Plans to Improve Care for our Most Costly Patients

Dennis Heaphy, a Boston resident and 30-year quadriplegic, received new health care coverage in 2014. As part of initiatives ushered in with the Accountable Care Act, Heaphy, a low-income disabled individual, was able to stay home and in his community. This was a drastic change from the expensive and disruptive alternative he was all too familiar with—frequent visits to the hospital and long-term stays at skilled nursing facilities.

Now, improvements are being tested in a pilot program—“dual eligible” plans—aimed at providing better coordinated care for patients like Heaphy, who is among a group of the most costly and complex patients.  

What are dual eligible plans?

What are Dual Eligible Plans?

Today, more than 100 million Americans are covered by either Medicare or Medicaid. Among this population, there are nearly 11 million low-income elderly or disabled people, like Heaphy, who qualify for both programs at the same time. Dual eligible plans were created to help these patients get the care they need while also containing costs.

Dual eligible plans are tasked with solving a difficult problem. They must provide care for not only the most vulnerable low-income populations, but the most senior portion of that population as well. 

Who Qualifies for Dual Eligible Plans?

Individuals qualify for dual eligibility if they currently receive Medicare (Parts A and B) and full Medicaid benefits. Plus, Medicaid pays for all or part of their Medicare co-payments, co-insurance, and deductibles.

Why are Dual Eligible Plans Needed?

The potential for more costly health visits is substantially higher due to age related issues including reduced mobility. A recent study found dual-eligible individuals experienced more emergency room visits, hospitalizations and re-admissions, and chronic diseases, and also were more likely to take seven or more medications. Thus, unsurprisingly, care for those in dual eligible plans is expensive.

According to the Kaiser Family Foundation, dual eligible beneficiaries make up only 13% of the population, yet account for 40% of total Medicaid spending and 27% of total Medicare spending.  

Historically, care for dual eligibles has been challenging. Because coverage between Medicare and Medicaid has been disjointed and care uncoordinated, patients were sent to the hospital and emergency rooms too often when it could have been prevented. And this has resulted in billions in unnecessary medical bills. As health care costs rise and the population ages, spending will only continue to climb. This is one of the primary issues Healthify addresses by providing the necessary care coordination to the most vulnerable populations.

Policymakers at the federal and state levels have been focused on developing initiatives to improve care coordination and reduce spending. In a program created by the ACA, 14 dual demonstrations in 13 states are conducting pilot programs like the one Heaphy is enrolled in. Most of these demonstrations are testing capitated models, where the state, CMS, and a health plan enter into a three-way contract, and the plan receives a capitated blended payment to provide comprehensive, coordinated care.

Providing Care at Home instead of the Emergency Room

Providing Care at Home instead of the Emergency Room

In this managed care solution, the difference is truly keeping patients healthy at home and in their community. For Heaphy, this meant his insurance provided flexible benefits to cover the purchase of a new bed, mattress, breathing machine, bandages, and covered in-home visits, massages, and acupuncture to help improve breathing.

But many patients need more than just access to medical supplies or traditional health care services. Those in dual eligible plans represent a diverse patient population. In addition to being elderly or disabled and poor, they also could be homeless, lack proper nutrition, or suffer from addiction. These complexities are why each patient requires unique, coordinated care. 

To provide this care efficiently, health plans are relying on a variety of community services. By connecting patients to community services such as food delivery, housing initiatives, and addiction services, health plans can address the social determinants of health, keep patients out of the hospital, and provide an integrated solution to coordinated care.  

Early Reports on Dual Eligible Plans Show Promise 

For the current demonstrations, early reports have shown that beneficiaries feel their quality of care is improving and inpatient admissions are declining. With some pilot programs scheduled to end next year, CMS and many advocates are hoping the states will continue their efforts.

While new initiatives are tested, we must continue to adopt modern approaches, including community-based care, specialized health management software, and other community based resources. With more integrated health services and social support, the rising cost of health care can be dissipated, and care for our most vulnerable members of society improved.

At Healthify, we are focused on supporting coordinating services within dual eligible plans using health management software. This better addresses social determinants of health and a range of socio economic factors affecting low-income people.

At Healthify we are focused on supporting coordinating services within dual eligible plans to better address social determinants. If you’re interested in learning how, please contact us below! 

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Topics: Medicaid Coordinate Care ACA Medicare Dual Eligibles Elderly