By Coleen Kivlahan, MD, MSPH
Dual. Usually “dual” reflects a positive state or condition: dual citizenship, dual degrees, dual ownership. But for the dual eligible’s, or “duals” those 10 million Americans who receive their health care from both Medicare and Medicaid, the ‘dual’ pathway is a complicated and confusing way to access health insurance coverage.
Eligibility criteria for dual eligibility results in a population exhibiting special risks. Two-thirds of the duals are over age 65 and one-third are under age 65 and disabled or chronically ill. More than 60 percent are poor and in poor/fair health, have multiple chronic conditions and cost 60 percent more than non-dual Medicare beneficiaries. Many have both physical and mental conditions, with about 60 percent who have cognitive or mental impairments and are four times more likely to have schizophrenia than non-duals.
Mrs. Franco is a 66-year-old strong-willed, independent widow. Her diabetes and high blood pressure have resulted in serious heart disease and a left leg amputation. She developed major depression and anxiety and uses alcohol to manage the symptoms. She has lived alone in her home since her husband died five years ago. She was recently admitted to a long term care facility after her admission to an acute care hospital for her leg amputation. She has one goal in her life: to live at her own house independently again with her two dogs.
Medicare paid for her amputation; Medicaid is paying for her long-term care (LTC) stay. But no one coordinates her care, helps her manage her complex medications, or develops strategies for her to go back home safely. She has seen more than 10 doctors in the last few months. The conflicting payment and coverage rules are confusing to her and her volunteer caregivers. She often becomes overwhelmed with all the decisions she needs to make, and she believes the only option open to her may be to die in a nursing home.
What she and the other millions of dual eligible patients need is support to prevent hospital admissions, support to stay in their own homes, and integrated behavioral health interventions. A recent Avalere Health study shows that SCAN Health (California) plan’s integrated care model, which provides coordinated care for dual eligibles, results in fewer hospital stays or readmissions than a group of similar beneficiaries receiving care under traditional fee-for-service. According to the study, health care quality can be improved and considerable dollars saved by delivering coordinated, integrated care to “dual-eligible” individuals. Not only was the risk-adjusted 30-day all-cause readmission rate better, but SCAN outperformed traditional Medicare fee-for-service in nine of the 12 individual prevention quality indicator (PQI) measures. SCAN performed 14 percent better than Medicare fee-for-service on the PQI overall composite.
Teaching hospitals are an ideal setting to offer coordinated care to this vulnerable population. Under CMMI’s demonstration project to integrate care for dual eligible individuals, states and health systems are now developing new ways to meet their complex and costly medical needs. Many academic health centers have taken advantage of this effort to provide leadership to improve the processes and outcomes of care for the most vulnerable patients.
Imagine a scenario in which the acute care hospital recognized Mrs. Franco’s alcohol risk, treated her depression, developed community resources for social home visits, coordinated with a short-stay rehab facility to teach her to manage the changes in ambulation resulting from her amputation, oversaw home visits focused on assuring a safe home environment, medication regimen simplification, and promoted a health care home for her?
The data is clear: most of the elderly and disabled can be cared for in the place of their choice and much of the time; that is in their own home. Their quality of care is better, their readmissions are less, and their pets are happier.
Coleen Kivlahan, MD, MSPH, is the Senior Director of the policy and regulatory group in Health Care Affairs at the AAMC. She has been a practicing physician for over 25 years and is a volunteer with Physicians for Human Rights (PHR) in the Asylum Network as a trainer and evaluator. She can be reached at firstname.lastname@example.org .