The population enrolled in Medicare and Medicaid, commonly referred to as dual-eligible individuals in policy circles, has been one of the hardest hit by COVID-19. Even outside of the context of a pandemic, this population experiences worse outcomes in the forms of more hospitalizations and emergency department visits than their Medicare-only peers.
This is in part because they have a complex set of health care needs, but also because state Medicaid programs and the federal Medicare program cost-shift to one another. This means that a lot of dollars are spent, not on improving care, but inefficiently delivering it. The Medicare program, for example, spends almost double on care for dual-eligible individuals as compared to those who are only enrolled in Medicare.
Mark Miller, EVP of Health Care at Arnold Ventures explained Thursday in a testimony to Medicaid and CHIP Payment Access Commission (MACPAC) the urgency and the necessity to improve care and outcomes for dual-eligible beneficiaries, sketching out a direction for how to better integrate care between these two massive government health programs, building off a report released this summer by Bipartisan Policy Center, an Arnold Ventures grantee.
“Medicare and Medicaid integration is essential – the dually eligible should have a fully integrated health plan available to them,” Miller explained. “This plan should include the broad range of basic services that any dual-eligible individual might need including physical, behavioral health, and long-term services and supports.”
To improve care and contain costs for dual-eligible beneficiaries, we believe policymakers must:
- Increase integration between Medicare and Medicaid;
- Increase enrollment in integrated coverage options;
- Improve the mix of dual-eligible services to better serve the population.
Improving integration is not a new concept -- there have been many different models and demonstrations over the years – yet uptake has been disappointingly low, with fewer than one in 10 dual-eligible individuals enrolled in a truly integrated plan.
Figuring out where and why integrated care enrollment is falling short is essential to better coordinating care, Miller told MACPAC on Thursday. Because of gaps in the data, the answers aren’t clear cut, but early evidence suggests there are a number of barriers likely impacting enrollment, Miller told the commission.
Lack of “True” Integration
Although some plans claim to have an integrated model, far too many fall short of true integration between the two programs. Some have “carved out” – or excluded – certain services, such as behavioral health, and often, there fails to be one entity responsible for delivery and quality of care, to oversee the financial management of a patient’s care, or to manage grievances or questions about eligibility.
Lack of Access
Even though dual-eligible beneficiaries qualify for two massive government programs – Medicaid, which is run by the state, and Medicare, which is run by the federal government -- integrated models are only available in certain states that have agreed to make them available. Despite paying for a significant share of the costs associated with serving this population, the federal government has little control, and state Medicaid staff, already stretched thin, may have trouble implementing new models.
“The dual eligible population is not homogenous and thus states must take a diverse set of needs and perspectives into consideration when trying to develop integrated models,” Miller said. “As a result, states often opt not to make these models available or they do so in a limited scope, either in terms of the dual-eligible population they serve, the services covered under the models, or the geography in which the model is available.”
For dual-eligible individuals trying to decide coverage options, the choices can be overwhelming and it’s not always clear where they can turn for unbiased advice.
“Dual eligible individuals look to people they trust, like their providers, when making enrollment decisions,” Miller said. “However, these stakeholders can be financially motivated to encourage their patients to opt-out of risk-based models so they can continue getting paid on a fee-for-service basis.”
In most cases, if individuals fail to choose, they are automatically enrolled in coverage options that provide little to no coordination between Medicare and Medicaid. With varying models competing against each other – including so-called look-alike plans that undermine coordination efforts – the market can become fragmented for both consumers and organizations that want to coordinate these populations’ care.
A Path Forward
As policymakers look for ways to improve care and coverage options, evidence suggests certain models work better than others, Miller said.
These include models that make at-risk entities and plans responsible for financial outcomes of dual-eligible beneficiaries and care outcomes for the population, including fewer hospitalizations, fewer trips to emergency rooms, reductions in institutional long-term care settings, lower mortality rates, and more time living independently in their own communities.
He added that plans should be given greater flexibility to use dollars to best serve needs and drive better outcomes. This enhanced flexibility could include nontraditional care, such as food assistance and transportation.
In addition, types of options available to dual-eligible beneficiaries should be narrowed to those that are fully integrated to lessen the confusion, and integrated care plans should have an automatic enrollment with an ability to opt-out to better support beneficiaries in their decision-making process, Miller said.
Lastly, in order to best encourage integrated models, states will likely need incentives – or even disincentives – to encourage integration, Miller said. For states unwilling or unable to implement integrated options, a federal fallback should be considered.
Still, Miller acknowledged that due to long-standing limitations in Medicare and Medicaid data, more comprehensive research is needed to best understand the limitations of the existing integrated models and to build more effective solutions. That’s research that Arnold Ventures is seeking to fund.
“We know that the states, Centers for Medicare and Medicaid Services, plans, providers and beneficiaries want and need this evidence to improve care,” Miller said. “Arnold Ventures is actively supporting the accumulation of evidence on integrated care models and we are supporting technical assistance to the states to redesign their programs. We hope that work will be a resource.”