NYAPRS Note: Understanding the historic shifts in managed care for dual eligible across the country helps us understand the goals, potential, and potential drawbacks of a demonstration like the FIDA in NYS. Dual eligible persons with complex needs are better served when integrated service delivery and care management reduce institutionalization. But the federal government won’t move to mandatory MC for persons with dual eligibility, and thus states are implementing various fragmented steps to bring different dual members into integrated products. This may reduce costs, but can unduly burden providers that aren’t used to working with certain administrative constraints and EHRs.
Managed Care Enrollment Of Duals Almost Doubles Between 2011 & 2014
Open Minds; Laura Morgan, 5/8/2014
Developed by OPEN MINDS, 163 York Street, Gettysburg PA 17325, www.openminds.com. All rights reserved.
You may not alter, transform, or build upon this work. You may not use this work for commercial purposes without written permission from OPEN MINDS.
Reporting on dual eligibles tends to focus on the lurching start by the Centers for Medicare and Medicaid Services (CMS) Medicaid-Medicare dual demonstration projects (see The Dual Eligible Demo Projects: Momentum – Yes; Speed – Not So Muchall members). Often missed in these discussions is the parallel—but much faster—shift of dual eligibles into traditional and long term Medicaid managed care.
In both cases, the shift is driven by the complexity and cost of dual eligible beneficiaries who are typically served across multiple health and human service systems: medical, long-term care, behavioral health, and social services. Consider these few data points for dual eligibles for 2009 (see MedPAC Data Book: Beneficiaries Dually Eligible For Medicare & Medicaidpremium members):
- 14% of Medicaid enrollment and 34% of all Medicaid spending
- 19% of Medicare enrollment and 34% of all Medicare spending
- 45% used Medicaid long term services and supports (LTSS)
- 62% had at least one ADL (activity of daily living) limitation
- 56% diabetic
- 36% with cognitive impairment
- 21% with schizophrenia and other psychotic disorders
- 15% with bipolar disorder
To see how big this “sea change” in service delivery model is, roll the clock back to 2011. Dual eligibles numbered 9.2 million in 2011. Excluding plans offering only transportation or dental benefits, 2.1 million dual eligible beneficiaries (23%) received at least some of their Medicaid benefits from a managed care entity (see 2011 Medicaid Managed Care Enrollment Reportpremium members). The number and service delivery models varied widely by state:
- 37 states plus the District of Columbia (76%) enrolled dual eligible beneficiaries in some form of Medicaid managed care
- In states offering managed care for dual eligibles, the percentage of the state’s dual eligible population enrolled in managed care plans ranged from less than one percent in eight states to 100% in Hawaii
- Benefits managed ranged from minimal—as in the case of primary care case management (PCCM) programs with a small fee for care coordination paired with FFS service reimbursement—to fully capitated integration of Medicaid and Medicare benefits (by a small, but significant, number of PACE programs)
Jump forward to 2014. Between 2011 and 2014, at least 34 states either implemented or planned new managed care initiatives to better coordinate care for dual eligible beneficiaries (see 34 States Integrating Medicare & Medicaid Services For Dual Eligiblespremium members).
- 40 states plus the District of Columbia now include dual eligible beneficiaries in Medicaid managed care
- Seven of these states added dual eligibles as a mandatory population for Medicaid managed care or Medicaid managed long term services and supports (MLTSS): California, Delaware, Florida, Illinois, New Mexico, New York, and Texas
Taken together, these initiatives move as many as 675,000 additional dual eligible beneficiaries into Medicaid managed care in 2014—raising the estimated share of dual eligibles in Medicaid managed care programs from 23% to 30%. If you add enrollment in the nine CMS demonstration projects launching by 2014, and enrollment in existing alternative integrated care arrangements—the Arizona Long Term Care System (ALTCS) and Minnesota Senior Health Options (MSHO) being the two primary examples—the share of dual eligibles in managed care increases from 23% to over 40%.
So what are the opportunities for provider organizations? This is group of individuals with complex conditions and complex support needs. In the past, when those support needs have not been met, use of emergency rooms and hospitals have been the default system of care. With 40% of this population in some form of managed care plan, those plans will be looking for provider organizations with programs that are tailored to subgroups of these individuals, with proven effectiveness in reducing the use of hospital-based care (see Transition From Facility To Home- & Community-Based Care Increases Dual Eligibles’ Risk Of Hospitalization By 40%premium members). But those programs also need to be administratively capable of working with the managed care plans – with EHRs, care management competencies, and the ability to participate pay-for-performance contracting (see Surviving The Turbulenceall members, and Lead The Field – Or Others Will…all members).