The story was originally published in AcademyHealth.
Navigating one health insurance program is challenging enough for most people, yet the 12.2 million Americans who are dually eligible for Medicare and Medicaid face the reality of navigating two distinct programs, and managing complex heath needs, every day. Fragmentation not only complicates their care experience and creates inefficiencies, it also contributes to higher government spending. Dual-eligible individuals account for more than 30% of spending across Medicare and Medicaid, despite only making up about 15% of the population in each program.
Despite the high government spending on this population, significant gaps exist in the understanding of dual-eligible individuals’ care, preferences, and needs and the solutions available to improve their care and outcomes. It has also slowed federal and state policymakers to understand the importance of integrated care for the dual-eligible population and the different tools available to improve care.
Integrating Medicare and Medicaid can improve patient experiences and outcomes, produce higher quality of care, and lower health care spending, but additional research is needed to better understand the impacts of integrated models, including:
- Is one type of integrated model more effective than another (i.e. impact to cost, quality, and health disparities)?
- Do integrated programs produce different outcomes for dual-eligible individuals with different conditions? Are some programs better suited to care for specific subgroups?
- How do health care utilization patterns differ in integrated vs. non-integrated coverage options?
Answering these types of questions has not always been so straightforward, but several new resources and expanded data sets have recently become available for researchers to expand and strengthen their work in these areas. Given increased national attention on home and community based services (HCBS), state attention on integrated programs, and the long lasting effects of the pandemic, the time is now for researchers to invest in furthering the evidence-base on the dual-eligible population.
- Medicare-Medicaid Data Inventory. The State Health Access Data Assistance Center (SHADAC) in April published a report of data sources that can be used to study the dual-eligible population, identifying strengths and gaps in the existing data sources and whether or not those sources could be used to answer key questions to help drive better policy solutions.
- Newly released Medicaid data and Data Quality Reports. The Centers for Medicare and Medicaid (CMS) recently released analytic files from the Transformed Medicaid Information System (T‑MSIS) that researchers can analyze care needs and patterns among people who are dual-eligible. To complement these files, the Urban Institute also released a set of data quality briefs to help investigators understand the strengths and limitations of the data for asking questions about the dual-eligible population, at a state specific and national level.
- New evaluation reports on integrated Medicare-Medicaid models. For nearly a decade, CMS has been supporting demonstration projects with several states to pilot integrated Medicare-Medicaid programs through the Financial Alignment Initiative. New evaluation reports were recently posted, though none include Medicaid data in the analysis. There is a real opportunity to augment these evaluations to better understand the care delivery in integrated models.
- Consumers’ Journeys Illuminate Opportunities for Care Improvement. As investigators hone in on research questions, one powerful source of information can come from consumers themselves. IMPAQ International used a Human-Centered Design (HCD) approach to identify the pain points, gaps, and opportunities that dual-eligible individuals experience when navigating and receiving care. Common pain points identified were long wait times for in-network providers, trouble accessing transportation for medical appointments, and lack of coordinated, whole-person care. These stories provide a good point of departure for research projects to better understand the barriers to effective care and potential solutions that can drive better care experiences and outcomes.
While a lack of timely, comprehensive data has inhibited high-quality research on the dual-eligible population to date, these newly expanded resources are poised to help investigators answer key questions about integration, eligibility and enrollment. State and federal policymakers — and people who are dual-eligible — have waited long enough.
Visit our toolkit for researchers for more information about the available data and funding opportunities for researchers from Arnold Ventures, a philanthropy focused on building the evidence-base on dual-eligible individuals.