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Report: Integrated Care Models are Better for Dual-Eligibles

Millions of people eligible for both Medicare and Medicaid are often sicker and drive higher health care spending, but aligning care delivery and financing could better address complex care needs and reduce spending, a new MACPAC report finds.

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Integrating care for individuals who qualify for Medicare and Medicaid would help to better address the needs of an especially vulnerable population and also reduce spending, a new report argues. As a result, a key Congressional advisory committee on Medicaid policy, the Medicaid and CHIP Payment and Access Commission (MACPAC), is dedicating significant research and resources to finding a policy solution.

Medicaid and Medicare are two massive — and distinct — government programs that were never designed to work together, which has led to fragmented care, a lack of coordination that results in cost shifting, and misaligned incentives that don’t always put the needs of the beneficiary first.

Medicaid and Medicare are two massive — and distinct — government programs that were never designed to work together.

“The goal of integrating care is to improve care for dually eligible beneficiaries, eliminate incentives for cost shifting, and reduce spending that may arise from duplication of services or poor care coordination,” MACPAC stated.

Yet despite the research that integrated care models result in higher-quality care (lower rates of hospitalizations and readmissions) for dual-eligible individuals, nine out of 10 dual-eligible beneficiaries aren’t enrolled in them. This is, in part, because integrated coverage options are not available to every dual-eligible beneficiary in the country because either states do not permit their availability or private health plans have decided not to offer a product in a market.

That’s problematic. Fragmented care leads to poorer outcomes — dual-eligible individuals tend to have more significant health needs and report worse health overall — and as such, they require intensive and expensive care. Despite representing just a fraction of the total Medicare and Medicaid demographic, dual-eligible individuals account for one-third of total spending, according to the report. Several states have integrated care models, but more can — and should — be done to boost enrollment in integrated care models and increase their availability, MACPAC argued.

Noting that the coronavirus pandemic has disproportionately affected individuals with complex care needs, such as dual-eligible individuals who often live in nursing homes and long-term care facilities that have been hit hard by COVID-19, MACPAC said the report’s findings are even more urgent than before as state and federal policymakers grapple with how best to serve a “high-cost, high-need” population.

Going forward, MACPAC commits to support Congress to identify ways to: (1) increase the degree of integration between Medicare and Medicaid; (2) increase the availability of integrated options within states; and (3) increase enrollment in integrated coverage options.

MACPAC’s strategy directly aligns with Arnold Venture’s Complex Care strategy — one that is also dedicated improving care delivery for the most vulnerable populations in our health care system, especially people considered dual-eligible.

“We are very excited see MACPAC prioritizing this issue and most importantly, prioritizing the 12 million people who bear the harm of a fragmented system and stand to benefit from an integrated, person-centered approach,” said Arielle Mir, VP of Complex Care.