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States are Making Strides Caring for Patients with the Most Complex Health Needs

People who are eligible for both Medicaid and Medicare make up a small part of the population but account for disproportionate spending on health care. A new report outlines how states are taking the lead in creative and successful models to improve their health and lower costs.

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When most people think about the health challenges facing states, they usually think about drug prices or the opioid crisis. More often absent from the headline is the challenge of caring for the low-income elderly or disabled individuals, the population enrolled in both Medicare and Medicaid. These 12 million people nationwide  — only 15 percent of the Medicaid population — have some of the most complex needs, resulting in spending that accounts for 30 percent of Medicaid budgets.

Now, states are increasingly looking for innovative solutions to more effectively and efficiently care for these so-called “dual eligibles” with programs that integrate Medicare and Medicaid benefits. Combining responsibility for medical and long-term care services and simplifying the administrative processes has the potential to improve dual eligibles’ care experiences, reduce avoidable hospital and emergency room visits, and drive smarter long-term care spending.

Amid growing interest in integrated dual-eligible care, several states have implemented strategies to better coordinate care, according to a new report by the National Governors Association Center for Best Practices.

“These pioneer states have shown us that the potential of integration is real,” said Arielle Mir, Vice President of Complex Care at Arnold Ventures. “It’s time for other states to follow their lead.”

The publication, supported by a grant from Arnold Ventures, showcases some of the best practices by states and offers a roadmap for other states hoping to achieve the same objectives.

“Improving quality of care and reducing costs for dual eligibles is of paramount importance for states,” the report states. “Increased collaboration and learning across states can help support the scale and spread of best practices, as well as increase the understanding of common challenges and pitfalls as states explore new approaches.”

Dual eligible individuals have long presented a unique challenge for states due to their significant and costly health needs as well as the inherent complexity in their coverage. Because federally run Medicare and state-operated Medicaid are distinct programs with their own sets of benefits and payments and data, care can easily become disjointed, and payers and providers often have misaligned incentives, which leads to higher costs and worse outcomes.

Because states are the nation’s primary payers for long-term care services and supports, such as home care, assisted living, and caregiver supports, they are well positioned to pilot innovative, bold ideas for serving dual-eligible individuals.

By demonstrating positive outcomes — increased quality, better satisfaction, and lower costs — states applying best practices tailored to their specific needs and demographics can better care for a population that has long suffered from fragmented, disjointed, and expensive care.

Read the full report here.