Most dual eligible care still paid for under FFS model

A new study found that most low-income people dually eligible for both Medicare and Medicaid continue to receive benefits separately via fee-for-service arrangement and that gaps in data may hinder deliberations on how to effectively manage care for this population.

The research from Mathematica Policy Research with support from the Kaiser Family Foundation and Kaiser Commission on Medicaid and the Uninsured, published this month in Health Affairs, shows that few states have experience coordinating care for duals within an integrated health plan. Further, it cites lack of data both on a federal and state level from which to effectively make policy decisions on how to better care for this high-cost group.

"While seeking to improve care for dual eligibles is important, policymakers would be well advised to consider the level of existing experience and how to target integration efforts so they yield benefits for people, the programs and the public budget," said Marsha R. Gold, lead author of the report and a senior policy fellow at Mathematica, in a prepared statement. "Furthermore, as these proposals are debated, better data need to be made publicly available in a timely fashion so researchers and other analysts can better understand enrollment in current arrangements, how programs work together now and how that is changing."

In total, there are 9 million people in the U.S. who qualify for both Medicare and Medicaid benefits. While their healthcare needs are diverse and include a mix of social and healthcare services, their care is typically not well coordinated and is expensive.

The Affordable Care Act created a new office within the Centers for Medicare & Medicaid Services to help coordinate care and develop new payment models intended to provide more integrated care and savings to both programs.

Early efforts on achieving these goals have focused on enrolling duals in managed care programs, which is a tack taken by about half the states. To date, however, enrollment in these plans, while growing, remains low, and due to their fledgling status in many states, most do not have a critical mass of data from which to draw conclusions about the effectiveness of the programs.

"Our findings reveal the limited experience of most states with coordinating care for their dual-eligible populations and reinforce the need for caution in considering policies that would rapidly move responsibility for coordinating dual eligibles' coverage to states," the report noted. "Any such shift in policy must be sensitive to the states' different experience levels and capacities, as well as the scope of their dual-eligible population. It also should take into account the diversity across dual-eligible individuals."

And while how to effectively managed the care and the costs of care for this population is a hot topic in Washington and in state capitals across the country, the report targets areas for improving available data in order to better frame "what is likely to be a highly controversial debate over strategies for coordinating care for dual eligibles and the respective roles of the federal and state governments."

Four specific areas where better data is needed are:

• Basis for Determining Dual Eligibility. Policy makers would be better served by data that distinguishes full and partial dual eligibles in order to more effectively measure the scope of coverage duals are receivin in their respective programs.
• Dual Eligible Enrollment Data In Medicare Advantage. While extensive state and county Medicare data now exist, they only indicate dual eligibles' enrollment in Dual Eligible Special Needs Plans (D-SNPs). The data should also provide details about the significant number of individuals enrolled in other kinds of Medicare Advantage plans.
• More Timely National Data on Medicaid Plan Enrollment by State. Current Medicaid managed care enrollment for states reported each year for June lags more than a year behind data for Medicare. Due to the extensive data capture required at the state level combined with the high cost of caring for this population the report suggests the need for investments in data management systems in order to provide more timely data that can support policy debate.
• Consistent Categorization of Medicaid Plan Type. While the CMS Medicaid Enrollment Reports include data on dual eligibles' enrollment by plan for each state, they do not show know how many are enrolled in multiple plans.