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Dual Eligible
Beneficiaries
Sarika Aggarwal MD, MHCM
SVP Population Health and Chief Medical Officer
xG Health Solutions
Powered By Geisinger
[email protected]
October, 2015
Dual Eligible Beneficiaries
• 9.1 million Medicare and Medicaid eligible (seniors and younger
individuals with disabilities)
• Account for 50 % of Medicaid and 30 % of Medicare spending
Source: Kaiser Family Foundation 2012
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Dual Eligible Compared to Other
Medicare Beneficiaries
Comparison of Dual Eligible and Other Medicare
Beneficiaries, 2006
Dual Eligible Beneficiaries
Income $10,00 or less
57%
23%
Less than High School
Education
55%
21%
Fair/Poor Health
Long-Term Care Resident
61%
9%
Cognitive/Mental Impairment
Nonelderly Disabled
Other Medicare Beneficiaries
51%
23%
10%
39%
15%
2%
Source: Kaiser Foundation analysis of the Medicare Current Beneficiary Survey, 2006
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Prevalence of Chronic Conditions in Dual Eligible
Age 85+
14%
No Mental
Impairments
Age 75-84
21%
Age 65-74
26%
51%
Community
87%
39%
49%
Facility
13%
Age
Type of
Residence
35%
3 Chronic
Conditions
20%
Mental
Impairment
Under Age 65
4 or more
Chronic
Conditions
2 Chronic
Conditions
20%
0 or 1
Chronic
Conditions
25%
Mental
Impairments
Number of
Chronic
Conditions
Source: Kaiser Family Foundation 2012
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Utilization by Dual Eligible Beneficiaries
Hospital, ER, home health and skilled nursing facility
rates are higher for dual eligibles than for other
beneficiaries
1+ Inpatient Stay
26%
18%
1+ ER Visit
17%
12%
1+ Home Health Visit
11%
Dual Eligibles
8%
All other Medicare
beneficiaries
1+ SNF Stay
9%
4%
Source: Kaiser Foundation analysis of the Medicare current beneficiary survey 2008
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Utilization and Spending in Dual Eligible with
Chronic Conditions
Total Medicaid and Medicare Spending
Per Dual Eligible by Chronic Condition
Selected Medicaid and Medicare
Services Used by Duals w/ Chronic
Conditions
Inpatient Hospital
Medicare Spending
Medicaid Spending
Nursing Home
$38,500
Community based LTC
50%
37%
$31,000
38%
$15,300
42%
$23,500
28%
17%19%
20%
20%
$13,500
$19,400
$8,600
$12,100
$23,200
$17,500
$10,800
> 1 Physical
Condition
>1 Mental
Condition
Source: KCMU study 2003
Physical and
Mental
Condition
All Duals
$11,400
> 1 Physical >1 Mental
Condition Condition
Physical
and Mental
Condition
Source: KCMU study 2003
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Dual Eligible Care Coordination Issues
Medicare
Medicare covers services that
are restorative or improve a
beneficiary’s functional status
Medicare denies payment for
services that are considered
“maintenance”
No care coordination
benefit in Medicare
Medicare Part D
Administered by private plan
Many duals are auto
assigned to the plan, do not
make an active choice
Plan has no relationship to
other providers
Medicaid
Medicaid pays for services
that prevent further
deterioration
Ambiguity about whether a
service helps maintain the
status quo or is restorative
No care coordination
benefit in Medicaid
Fragmented care due to enrollment in multiple plans
Little incentive to nursing homes to provide preventive care
Currently, there is limited coordination of care between Medicare
and Medicaid…providing significant opportunities in cost control
and care improvement
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HealthCare Reform—
Medicare-Medicaid Coordination Office
• Section 2602 of the Affordable Care Act
• Purpose:
– Develop innovative care coordination and integration models
– Ensure dually eligible individuals have full access to the services
– Improve the coordination between the federal government and
states
– Eliminate financial misalignments that lead to poor quality and
cost shifting
• Approach: Capitated Model and MFFS Model
• Massachusetts and 11 other states are involved in this demonstration
which ends in 2016
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Massachusetts One Care Dual Demonstration,
• Massachusetts was the first state to launch a 3-year demonstration for duals ‘One
Care’ in 2013
• Serves full benefit duals, aged 21 – 64 years who eligible for both Medicare and
Medicaid in 9 counties
• Capitated model; 3-way contract between One Care Plans, CMS, and EOHHS
• Enrollment: self-selection followed by passive enrollment, with opt out capabilities
• Delivers care through three One Care health plans who will be responsible for the
delivery and management of all covered services
• One care plan will develop teams who will provide clinical care management and care
coordination
•
The enrollees receive Medicare part A,B and D services along with state Medicaid
services including expanded services including behavioral health diversionary services
not previously available.
SOURCE: One Care: MassHealth plus Medicare 2014.;www.mass.gov
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One Care Population
• 70% with significant MH/SUD
• At least 75% smoke tobacco
• 40-60% of those with Schizophrenia are overweight
• 15% have diabetes
• Chronic/catastrophic Physical Conditions: 41.4%
• Developmental Disabilities: 16.4%
• Serious Mental Illness: 34.9%
• Substance Use Disorders: 28.1%
• Three or more inpatient admissions a year: 5.7%
• Use of long term services and supports: 30.7%
SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014;www.mass.gov.
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One Care Financial Alignment
• One Care plans receive a per member, per month global capitation
payment intended to cover all costs of caring for One Care
beneficiaries
• This global payment, which blends Medicare and Medicaid funding
streams, consists of three monthly capitation payments:
a. CMS for Medicare Parts A and B services, risk adjusted using the CMS Hierarchical
Condition Category (CMS-HCC)
b. CMS for Medicare Part D prescription drug services, risk adjusted using the RxHCC
model used for Part D plans
c. Medicaid, which is based on the beneficiary’s assigned rating category.
• CMS and the state withhold a portion of the capitation which plans
may earn back these funds if they meet certain quality standards
SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014;www.mass.gov
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2014 One Care Medicaid Rating Definitions
• F1 (facility-based care): used for individuals residing in a long-term
care facility for more than 90 days
• C3 subdivided into 2 categories:
C3B includes individuals with a diagnosis of quadriplegia, amyotrophic lateral
sclerosis (ALS), muscular dystrophy, and/or respirator dependence
C3A includes all individuals who meet overall C3 criteria but not C3B criteria;
• C2 subdivided into 2 categories:
C2B includes individuals with co-occurring diagnoses of substance
use disorders and serious mental illness
C2A includes all individuals who meet overall C2 criteria but not C2B
criteria.
• C1: used for individuals who do not meet criteria for F1, C3A, C3B,
C2A, and C2B.
SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014., www.mass.gov
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Overall Care Management Goals
for the Dual Eligible
• Move from member centric to member directed
• Coordinate Medicare and Medicaid benefits
• Integrate medical and behavioral health care management
• Use long term services and supports to keep members
independent in the community
• Maintain highly collaborative provider relationships
• Increase access to care
• Manage transitions of care
• Reduce utilization of ED and hospitals
• Maintain quality of life and autonomy of the individuals
• Involve ‘Medical Neighborhood’ which views the patient as a
member of his/her family, job, social system and community
network, in the treatment plan
SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014.
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Care Coordinator
• Deals Directly with Patient
• Functions as a quarterback
• Strong PCP involvement
• Develops individualized care plans
CARE
COORDINATOR
• Integrates multidisciplinary team
Source: Strategy& analysis
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Multidisciplinary Care Team
• Approaches patient care as a team
• Seamless handoffs among care
providers and care transitions
• Medical and behavioral providers
• Medical and behavioral nurse case
manager
• Pharmacists
• Centralized enrollee record
• Addresses the ‘Whole Person’:
Physical/Behavioral/Social
MULTIDISCIPLINARY
HEALTHCARE
TEAM
Source: Strategy& analysis
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Care Collaborators
• LTSS coordinator
• Community based independent from
health plans
o
o
o
o
o
o
o
Adult daycare/Foster care
Community groups/Faith groups
State agencies
Translator/interpreters
Transport
Home aides
Respite care
CARE
COLLABORATOR
Source: Strategy& analysis
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Informatics
• Health Risk Assessments
• Stratification and predictive modeling
• Workflow and notification
• Centralized enrollee record
INFORMATICS
• Accessible patient information
systems
• Performance measures
Source: Strategy& analysis
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Incentive structures
• Health plan is single accountable
entity and responsible for all medical
expenses
• 0 Co-pay for beneficiaries
• Medicare Part A,B,D and Medicaid
benefits
INCENTIVE
STRUCTURES
• Expanded benefits
Source: Strategy& analysis
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Supplemental Benefits in One Care Demonstration
SOURCE: One Care: MassHealth plus Medicare – January Enrollment Report, MassHealth. January 2014. Available
at http://www.mass.gov/eohhs/docs/masshealth/onecare/enrollment-reports/enrollment-report-january2014.pdf
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Key Performance Measures Of
Quality in Dual One Care Program
•
•
•
•
•
•
•
•
•
•
Access and availability
Care coordination and transitions of care
Behavioral health management
Integration of medical and behavioral health
Advocacy
Cultural competency and literacy
Disease and complex case management
Medication management
Utilization management
Quality of life assessment
SOURCE: One Care: MassHealth plus Medicare 2014
www.mass.gov
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Access, Coordination And Transitions Of Care
(Withhold Measures)
•
•
•
•
•
•
•
•
•
•
Getting appointments and care Quickly
Health Risk Assessments completed w/in 90 Days of Enrollment
Care plans completed within 90 days of enrollment
Care plans with documented discussion of care goals
Centralized enrollee record with tracking of demographics on race,
ethnicity, language, homelessness and disability
Members with LTSS Needs who have a LTSS coordinator
Care transitions problems identifies and prevented (SNP)
Transmission of transition record after inpatient to home or any other site
of care within 24 hours (withhold)
Medication reconciliation after discharge from inpatient (HEDIS)
Care coordinator training to support self-management
SOURCE: One Care: MassHealth plus Medicare 2014
www.mass.gov
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Behavioral Health Management
• Screening for unhealthy alcohol use and counselling
• Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment (HEDIS and Withhold)
• Tobacco Use Assessment and Tobacco Cessation
Intervention
• Depression screening and follow up plan (withhold)
• Pain screening and management (HEDIS)
• Follow up after MH hospitalization (withhold)
SOURCE: One Care: MassHealth plus Medicare 2014
www.mass.gov
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Integration Of Medical And Behavioral Services
• Exchange of information with behavioral health,
and primary care physicians
• Ensuring appropriate use of
psychopharmacological medications
• Management of treatment access and follow-up
for enrollees with coexisting medical and
behavioral disorders
• Behavioral health case managers working
closely with the medical case manager for
coordination of care
SOURCE: One Care: MassHealth plus Medicare
www.mass.gov
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Advocacy
• Establishment of consumer advisory board
• Compliance with the Americans with Disabilities Act
(ADA) and appointment of ADA compliance officer
• Provider training related to ADA compliance
• Demonstration of a work plan to ensure physical access
to buildings, services, and equipment
• Ombudsman program established to oversee functions
based on regional, language-based, and disability-based
capabilities
Source: ‘One care’ Masshealth plus Medicare
www.mass.gov
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Cultural Competency
• Specific recruitment and training strategies representative
of the demographics of the area
• Language assistance services, including bilingual staff and
interpreter services
• Easily understood patient-related materials, in the
languages of the common groups in the area
• Partnerships to facilitate community and patient
involvement in initiatives
• Cultural competency training
• Screening enrollees for their preferred language and the
time they waited to get interpreter services
Source: ‘One care’ Masshealth plus Medicare
www.mass.gov
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Health Management(HEDIS)
•
Complex case management
•
Prenatal and postpartum care(HEDIS)
•
Screening of colorectal, cervical and breast cancer (HEDIS)
•
Controlling Blood Pressure (withhold) ; Ischemic vascular disease (IVD): blood pressure
•
Adult weight( BMI) screening and follow up plan
•
Comprehensive diabetes care
•
Cardiovascular care: lipid screening
•
Use of Appropriate Medications for People with Asthma
•
Avoidance of antibiotics
•
Rheumatoid arthritis management
•
High risk residents with pressure ulcers
•
Care for adults functional status
Source: ‘One care’ Medicare plus Masshealth 2014
www.mass.gov
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Medication Management (Part D)
• High risk medications
• Medication Adherence for oral diabetes
medications, lipids(statins), hypertension(ACE/ARB)
• Depression medication adherence
• Care for adults medication review(HEDIS)
• Annual monitoring for persistent
medications(HEDIS)
Source: One care’ Medicare plus Masshealth 2014
www.mass.gov
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Utilization Management
• Plan All-Cause Readmissions(HEDIS, Withhold)
• Follow-up After Hospitalization for Mental Illness
• Emergency room utilization for medical health and
behavioral health
• Mental health admissions
• COPD admission rate
• CHF admissions rate
Source: ‘One care Masshealth plus Medicare 2014
www.mass.gov
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Program Strengths
• Design and implementation of One Care was conducted in an open,
participatory, and transparent manner encouraging feedback from all
participants
• Involvement and encouragement of robust stakeholder and
beneficiary participation throughout the planning stages and
implementation
• Sufficient enrollment numbers were ensured through the passive
enrollment process, which was helpful in reducing financial concerns
of participating plans.
SOURCE: One Care: MassHealth plus Medicare . 2014;www.mass.gov.
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Early Challenges
• Poor health plan participation, due to concerns about infrastructure costs
• Passive enrollment-related issues including tracking down reliable
contact information for new enrollees
• Health plan assessments showed several beneficiaries needed to be
placed in a higher rating category due to unmet needs
• Question whether the rates would be sufficient to cover the benefit
package, especially in individuals with high behavioral health needs
• Difficult building provider networks with sufficient primary care,
behavioral health, and LTSS capacity to meet the needs of the
population
SOURCE: One Care: MassHealth plus Medicare . 2014. , www.mass.gov
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Outcomes and evaluations
• CMS has contracted with an independent evaluator to
assess the on cost, quality, utilization, and beneficiary
experiences with care.
• This evaluation will use a mixed-methods approach to
capture both qualitative and quantitative information on
the impact of demonstration activities.
• Savings from the demonstration are expected to result
primarily from reductions in ED and inpatient use on both
the behavioral health and medical side.
• Expectation is care coordination and greater reliance on
intermediate levels of care is to achieve such reductions
SOURCE: One Care: MassHealth plus Medicare 2014. Available at
http://www.mass.gov/eohhs/docs/masshealth/onecare/enrollment-reports/enrollment-report-january2014.pdf
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THANK YOU !
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Dual Eligible Beneficiary Demographics
A larger share of dual eligibles than other beneficiaries is
low-income, female, under age-65 disabled and minorities
Share of beneficiaries who are:
Below 150% of the Federal Poverty Level
86%
22%
Female
61%
53%
Under Age 65 and Disabled
39%
11%
African American
20%
7%
Hispanic
Dual Eligibles
All other Medicare
beniciciaries
7%
6%
Source: Kaiser Foundation analysis of the Medicare current beneficiary survey 2008
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