In December of last year, the Centers for Medicare and Medicaid Services (CMS) released guidance to state Medicaid programs on how to better serve consumers who are dually eligible for Medicare and Medicaid. The guidance recommended that states leverage managed care models to better ingrate care for dual eligible populations, including existing dual eligible special needs plans (D-SNPs) and Programs of All-Inclusive Care for the Elderly (PACE). The guidance also referenced new opportunities for states to improve data exchange and streamline the enrollment process (see CMS Guidance To State Medicaid Directors Recommends Leveraging Managed Care To Improve Services For Dual Eligibles and State Medicaid Director Letter #18-012 RE: Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and Medicare).
But the general direction of these recommendations seems to run counter to the market numbers. One example is PACE, a program that has been part of Medicare in some form since the 1990’s. Though PACE programs have been able to show some positive results, in 2019, there were about 49,000 consumers enrolled in PACE programs in 31 states—that’s just 0.04% of the 12 million consumers who are dual eligibles (see PACE by the Numbers). PACE programs in many states only have a few hundred enrollees.
Another example: enrollment in the much-touted dual eligible demonstration projects are not growing. Started in 2012, 13 states tested integrated financing models for their dual eligible populations through a waiver program. Though several states extended their original demonstration programs and shown some positive outcomes, only three states have been extended their projects through 2020—Massachusetts, Minnesota, and Washington (see Financial Alignment Initiative). The other states have opted to end their programs, and there is little comprehensive data about the return on investment for these models (see Dual Eligible Demonstrations: Where Are We 4 Years Later?).
Why does this matter? The dual eligible population is one of the most expensive populations to serve. The dual eligible population represent 20% of all Medicare enrollees and accounted for 34% of all Medicare spending. In Medicaid, the dual eligible population represented 15% of all Medicaid enrollees and 32% of all Medicaid spending (see Medicare 101 And 201: Key Issues For States).
It appears that the path forward for provider organizations serving the dual eligible population will continue to involve navigating separate health plans for the same consumer, with separate health plans for Medicare and for Medicaid long-term services and supports. For provider organization administrative and clinical team members, this was simpler when both Medicare and Medicaid were fee-for-service plans. But we now have an increasing number of consumers in Medicare managed care (see Managed Care Population In Medicaid & Medicare Continues Upward Trend – OPEN MINDS Releases Finding Of Managed Care Enrollment Trends Report), and of the 21 states with Medicaid managed long-term services and supports (MLTSS), 19 have included dual eligibles in their population (see State Medicaid Programs With MLTSS: The 2019 OPEN MINDS Update).
If your organization serves dual eligible consumers—whether you are with a provider organization, a care coordination entity, a health plan, or a government agency—there will likely be more administrative complexity for more consumers. There are three administrative competencies that will become more critical as we see fewer dual eligible consumers in a single integrated health plan and more of the services for these consumers in separate managed care plans. First, there is the ability to “braid” services at the consumer level—making services paid by different health plans a seamless consumer experience. Second, there is the ability to participate in multiple approval processes for the same consumer—from prior authorizations, to care coordination, to coordination of benefits and more. Finally, organizations with health information exchange capabilities with the multiple organizations financing or delivery services for dual eligible consumers have a distinct advantage—clinically, financially, and in consumer experience.
We’ll continue to track the trends in serving dual eligible consumers—consumers with a high proportion of chronic conditions and complex support needs. For more information on national trends in the dual eligible population, check out our market intelligence report, Medicare-Medicaid Dual Eligible 2018 Market Update: Enrollment & Coverage. And for information on the dual eligible financing system in your state, see our Dual Eligible System Landscape Profiles. Each state profile is organized to give instant access to essential state system characteristics and to allow for rapid cross-state comparison. All 51 profiles are available as part of an OPEN MINDS Circle Elite membership