How can the care and care management of impoverished seniors with special medical needs be improved? That is the focus of a new op-ed published on April 13 in the Perspective section of The New England Journal of Medicine online. The article, entitled “Improving Care Integration for Dually Eligible Beneficiaries,” was written by David C. Grabowski, Ph.D., a professor of healthcare policy in the Department of Health Policy at Harvard Medical School, Boston.
Grabowski begins by referencing the fact that the 12.2 million people dually enrolled in Medicare and Medicaid are “more likely than other Medicare beneficiaries to have multiple chronic conditions, functional limitations necessitating long-term care, or a serious mental illness or substance use disorder. Although dual eligibles make up only 19 percent of Medicare beneficiaries and 14 percent of Medicaid beneficiaries, they account for roughly one third of spending in each program,” he notes.
And yet, Grabowski notes, “Despite the large share of Medicare and Medicaid spending directed to their care, these beneficiaries have long faced issues related to fragmented care and poor health outcomes associated with inadequate coordination of benefits and services across the two programs. Medicare covers health care services and products (including hospital procedures, physician visits, prescription drugs, and postacute care) for dual eligibles, whereas Medicaid covers long-term care and Medicare premiums and cost-sharing obligations. Better coordination could improve care outcomes and limit duplication of services and incentives for cost shifting,” he notes. “For example, under a coordinated approach, nursing homes would have incentives to invest in stronger care models for long-stay residents whose care is financed by Medicaid to prevent Medicare-financed hospitalizations.”
Grabowski writes that “There are currently three approaches in place to encourage care integration for dual beneficiaries: state Medicare–Medicaid plans (MMPs), the federal Program of All-Inclusive Care for the Elderly (PACE), and federal dual-eligible special-needs plans (D-SNPs). MMPs, which were established in 13 states as part of Centers for Medicare and Medicaid Services (CMS) demonstrations, offer Medicare- and Medicaid-covered services under a single plan based on contracts with CMS and the state Medicaid agency. The plan receives a prospective, blended payment in exchange for providing comprehensive, coordinated care, with the delivery model varying among states. PACE organizations receive monthly capitated payments from Medicare and Medicaid for each enrollee.”
Yet the D-SNPs, Grabowski emphasizes, “are highly variable in terms of their degree of integration across Medicare and Medicaid. Fully integrated dual-eligible plans (FIDE-SNPs) provide access to Medicare and Medicaid benefits; each plan has both a Medicare Advantage contract with CMS and a capitated Medicaid managed-care contract with the state to fully cover long-term care services. Highly integrated dual-eligible plans (HIDE-SNPs) are similarly required to offer Medicare and Medicaid benefits under a single entity but aren’t required to have a Medicaid managed-care contract with the state, which typically results in weaker Medicare–Medicaid integration. Standard D-SNPs aren’t required to cover Medicaid services, which means they have little incentive or ability to coordinate care across programs.”
What’s the solution to this set of problems? There are a number of possible approaches, Grabowski suggests, ranging from “increase[ing] the use of passive enrollment,” to “improv[ing] program alignment,” to “convert[ing] standard D-SNPs into FIDE-SNPs.” And a fourth approach would be to “improve the data and measures used to evaluate care of dual eligibles. Studies of these integrated programs have generally found that, as compared with nonintegrated care, they are associated with better or similar outcomes, but they have higher total costs,” he notes.
Significantly, Grabowski notes, “Analyses using process-based measures of quality that aren’t tied to clinical outcomes have come to mixed conclusions regarding which plans are associated with the highest quality of care. Future research could incorporate measures related to enrollee satisfaction and claims-based outcomes. Data regarding Medicare Advantage encounters are improving, which could permit a more meaningful evaluation of measures such as hospitalizations for dual eligibles receiving care under various models.”
Whatever approach is adopted, Grabowski believes that “[I]t will be important to move toward a unified approach to integrated care. Access to a strongly integrated care model for dually eligible beneficiaries is largely a function of whether their particular state has a capitated Medicaid long-term care program.” So far, only a small number of programs have been created to give dual-eligibles with special needs access to integrated care models. There are a number of options in terms of payment incentives, he says, including combining current Medicare and Medicaid funding in a new program, or retaining existing programs, but requiring states to adopt fully integrated overage models. Ultimately, he believes, Congress could move towards some level of success in care-managing this population through guiding all states to being capitating Medicaid-covered long-term care services so that a single plan could manage all health and long-term care services.
