The 9 million “dual eligible” people who qualify for both Medicare and Medicaid end up having to navigate two separate programs whose rules and incentives are often misaligned. The Leonard Davis Institute for Health Economics at the University of Pennsylvania recently hosted a panel of experts who discussed policy avenues that could promote integrated coverage and care for dually eligible beneficiaries.
Earlier this year, together with health matters, and with support from the SCAN Foundation and Arnold Ventures, Penn LDI convened a group of researchers, dual eligible individuals and caregivers, state representatives, and policymakers to develop a policy report and white paper with recommendations to improve care for dual-eligible beneficiaries.
“The availability of integrated options varies widely among states,” said Melanie Bella, executive counsel at Cressey & Company, a health care investment firm. “Some states have many options; “Some states have some options and others, for very legitimate reasons, have not been able to do anything.”
Bella noted that the white paper discusses some of those challenges, but also offers concrete recommendations on how to get to a point where each state has at least one option where there is a single entity that administers Medicare and Medicaid benefits and has some degree of responsibility. financial risk to Medicare and Medicaid spending.
Bella previously served as executive vice president of policy and dual strategy at Cityblock Health and is the former chair of the Medicaid and CHIP Access and Payment Commission (MACPAC), a position she held from 2019 to 2024. She was also founding director of the Office of Coordination of Medicare-Medicaid at the Centers for Medicare and Medicaid Services (CMS), where he designed and launched demonstrations of payment and delivery systems to improve quality and reduce costs.
He added that the white paper does a good job of being very specific about where Congress could act, where CMS could act, and where states could act.
For example, the policy brief says CMS should develop a menu of integrated program models, all of which should include financial integration. Each model should aim to integrate coverage and care experience, and provide comprehensive benefits in each state, with features such as:
• A single set of enrollment materials and notices for members;
• A unified care plan and a single care coordinator with access to information about all aspects of care and who can represent a beneficiary’s interests in reviews and appeals of coverage decisions;
• A core set of quality measures and specific assessment of the dual-eligible patient experience.
“Unfortunately, the experience for people is everywhere,” Bella added. “It is a very complicated system. We have seen growth in integrated products in every state, but still, most duals do not receive Medicare and Medicaid services through the same organization, and we also have a variety of non-integrated options available. So when you’re a person trying to make a decision about how to get healthcare, you’re bombarded with things, but most of them are very confusing. “They don’t help coordinate between the two programs and there are still a lot of cost changes that, at the end of the day, don’t usually end up in the individual’s favor.”
Matthew Behrens, Integrated Care Policy Supervisor for the Virginia Department of Health Care Services, said one of the policy report’s recommendations — seed money or planning grants for states — is incredibly important. “In Virginia, we started with a demonstration of financial alignment and moved to D-SNP [Dual Eligible Special Needs Plans]so we’ve had a bit of a commitment to this. But it’s incredibly difficult for a state if you’re starting from scratch, trying to balance this with other priorities.”
Coordinating CMS data and state data is incredibly difficult, he said. “It takes a long time to learn that. So any kind of resources that can be provided to the state to help them on that journey would be enormously beneficial.”
Behrens also said searching for plans can often be confusing. “Yesterday I went on Medicare Plan Finder and pretended I had double,” he said. “There were 57 plans available to me in my zip code alone. And if you go to the Plan Finder, it took me to the fourth page before I found a decent one. All those ahead were unintegrated plans. That is why we have spent a lot of time working to offer an integrated product and it is not the first thing that appears.”
Panel moderator Rachel Werner, M.D., Ph.D., executive director of the Leonard Davis Institute for Health Economics, noted that if dual-eligible patients are confused about their options, providers are often equally confused, and it’s They may not have incentives for people to enter the program. integrated plans and cannot offer the support that people are looking for.
Toyin Ajayi, MD, is co-founder and CEO of Cityblock Health, a value-based, technology-enabled healthcare provider for Medicaid, low-income, and dual-eligible Medicare beneficiaries in underserved communities. He said there are “fundamental issues that go back to medical education and the management of care delivery, and that is that doctors are often not taught about insurance, period. They are not getting an immersive education about what insurance is all about.” experience”. from the member’s perspective, and that’s a real problem. That results in them optimizing to make their daily work easier, so it creates a real onus on plans to show value and be discernible to providers, and to ease their administrative burden. because that is often one of the biggest challenges they face.”
Ajayi sees an opportunity to specifically target providers who serve these populations with nuanced, well-designed education so they understand the implications of insurance and the type of coverage for the people they serve. “And then it creates the right incentive for the plans to be differentiated and value-added, so that not only does the member and their family see the value of being in an integrated product, but so does the primary care physician who provides it.” attend.” for them and make referrals for home health care or DME at home. “They really have to be able to see that it adds value to them and the patient they care for.”
Policy experts recommend creating new accountable care organizations (ACOs) in fee-for-service Medicare that are at risk for both Medicare and Medicaid spending; Meanwhile, phase in requirements that risk-bearing entities serving dually eligible individuals have a formal relationship with the states in which they operate.
Werner noted that Medicare Advantage plans can help develop integrated options, but nearly half of dual-eligible beneficiaries are enrolled in fee-for-service Medicare. To improve and coordinate integrated care for those enrolled in traditional Medicare, one of the recommendations is that there should be pathways to enroll dual-eligible beneficiaries in accountable care organizations that are specifically for dual-eligible beneficiaries and that carry longer upside risks. the decline for both Medicare and Medicaid Spending.
The policy brief suggests that CMS should require all risk-bearing entities (such as ACOs) that serve substantial numbers of dually eligible individuals to have formal relationships with state Medicaid agencies, outlining their responsibilities for coordinating care. and share information.
Ajayi noted that many of those people are enrolled in or receive care from a provider that participates in some type of ACO arrangement. These are providers who, on the fee-for-service side of Medicare, have chosen to begin doing some of the work of coordinating and managing care for a population of people who are dually eligible, and not just Medicare beneficiaries. “This is a way of saying: let’s create as many doors as possible, as many pathways as possible, to ensure that a dual-eligible beneficiary can benefit from integration. So if they receive care from a provider that is involved in an ACO, how do we ensure that that provider can also provide the level of integration that that patient needs?
One component, Ajayi added, is giving the provider an avenue to participate in the Medicaid risk and actually be responsible for that portion of the benefit. “That means we’re actually thinking about how both programs work together. They’re not just focused on reducing acute hospitalizations and the types of interventions that one might focus on in a Medicare ACO. They are also thinking about how to take advantage of home and community services, long-term care and support. How do we understand and align the entire care process for that beneficiary so that there is a single point of connection for them?
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