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Quality Performance

Dual eligibles – One of healthcare’s perfect storms

September 25, 2017
How analytics can help health plans earn shared savings for high-risk, special populations like dual eligibles (those eligible for both Medicare and Medicaid).
Patricia Ingerick

Improving cost and quality of care for dual-eligible populations

It’s one of many perfect storms in healthcare – many of the poorest and most vulnerable people have coverage from two disjointed systems never intended to work together. However, within turmoil there is opportunity for those with vision, technology and the right know-how to navigate the storm and maneuver to smoother waters.

Complex Healthcare Needs

Across the nation, more than 9.2 million people qualify for Medicare and Medicaid coverage. While these “dual eligibles” represent only 20 percent of Medicare enrollees and 15 percent of Medicaid enrollees, they disproportionately represent 31 percent (Medicare) and 39 percent (Medicaid) of program costs. In 2011, dual eligibles accounted for more than $319 billion in healthcare spending.

Delivering high-quality, value-based care to dual-eligible people is a big challenge. They are among our nation’s most vulnerable populations – all are very low-income, but some are elderly and others are younger individuals living with serious disabilities. More than half of dual eligibles (58 percent) suffer from cognitive or mental impairments and 55 percent live with three or more chronic conditions.

Across the spectrum of the social determinants of health, dual eligibles fare much worse than the typical Medicare beneficiary. At rates much higher than the overall Medicare population, they tend to be female, above 65 years of age, and of a racial minority. From an economic standpoint, 55 percent have annual incomes of less than $10,000 compared to 6 percent of all other Medicare beneficiaries.

The result? A population of people with complex and diverse health needs with a broad range of circumstances, health literacy and capabilities to engage.

Complex Healthcare Structure

Unfortunately, many dually-eligible people receive care from traditional fee-for-service providers who seldom provide coordinated care and assistance in navigating the complex set of Medicare and Medicaid systems.

Dual eligibles, more than any other population, need the coordinated care and guidance offered to most people through their employer-sponsored health insurance or programs such as Medicare Advantage and managed Medicaid.

Recognizing the need for, and effectiveness of, coordinated care across government programs, the Centers for Medicare and Medicaid Services (CMS) is pushing hard to further adoption of value-based care for all beneficiaries, including dual eligibles.

The Opportunity

In 2011, exactly zero percent of CMS payments were based on quality. Today, that figure exceeds 30 percent, and by 2018 half of all Medicare payments will be made under risk arrangements. To reach this goal, CMS created a multitude of value-based vehicles including demonstration pilots, alternative payment models and shared savings programs.

To participate and succeed within value-based frameworks, innovative health plans combine sophisticated technologies, such as the Theon® analytics, insights and care management platform, with accredited clinical support and care team education to help reduce costs while steadily improving the quality of care for patients. Specifically, the Theon® platform and supporting services, have helped to:

  • Reduce hospital readmissions by more than 40 percent
  • Save more than $8,375 per enrolled remote monitored patient
  • Improve quality of care as demonstrated through improved Medicare Stars and HEDIS® ratings
  • Improve provider and payer relationships through transparent data sharing, clinical support and care team education in population health strategies and techniques
  • Improve member engagement, satisfaction and outcomes through accredited clinical services and educational programs 

Forward-thinking health plans understand the high reward potential associated with high-risk populations such as dual eligibles. By adapting the same strategies used with other populations, health plans can earn substantial shared savings while dramatically improving the lives and quality of care delivered to dual eligibles.

With a focus on improving outcomes for their dual-eligible population, health plans can leverage:

  • Coordinated, multidisciplinary care teams to make using healthcare easier for dual eligibles:
    • Social workers experienced in coordinating care across every type of community and healthcare resource
    • Case and disease managers specializing in helping members to overcome their barriers to care
    • Transitional care support to help dual eligible members as they are discharged home and move between care delivery sites
  • Remote patient monitoring programs to enable better care and engagement for dual eligibles within their homes, especially those with severe, multiple and overlapping chronic conditions such as heart failure, diabetes and hypertension.
  • Predictive analytics to identify likely adverse health events before they happen so physicians and care teams can keep dual eligibles as healthy as they can be while reducing the strain on expensive emergency and hospital services.
  • Predictive analytics to identify members most likely to engage in beneficial programs and then to determine the most effective path for outreach. Analytics balances member preferences against available outreach methods, budgetary restrictions and program effectiveness to facilitate cost-effective, coordinated and successful outreach.
  • Gap analysis with clinical workflow integration to easily track services delivered and needed across multiple healthcare and community services. Automation coupled with intuitive design helps increase crucial quality scores such as HEDIS® and Medicare Stars while reducing provider reporting fatigue.  

Delivering cost-effective, high-quality care to dual eligibles has always been challenging. Thankfully, today’s technologies and clinical capabilities enable health plans and providers to come together to better serve this vulnerable population while helping to control costs and earn shared savings.