Coordinating Care for Dual-Eligible Medicaid-Medicare Beneficiaries

At the 14^th Annual World Health Care Congress, held April 30-May 3, 2017, in Washington, DC, an executive summit convened a panel to discuss ways to improve care for the dual-eligible population of patients eligible for both Medicaid and Medicare benefits.

Moderator Casey Ross of STAT kicked off the panel by asking Shawn M. Bloom, president and chief executive officer of the National PACE Association, to give a brief overview of the dual-eligible population. Bloom explained that these low-income, elderly beneficiaries are responsible for a disproportionate amount of health spending, as they are often in poor health due to their socioeconomic status and social risk factors like housing instability. There are also complexities with both Medicare and Medicaid that are “inherent to spanning 2 programs that don’t talk the same language,” meaning there are substantial opportunities to improve coordination and communication between the programs.

As Ross asked the panelists about their approaches to care coordination, James Schuster, MD, chief medical officer (CMO) of the Community Care Behavioral Health Organization and CMO of behavioral health and Medicaid services in University of Pittsburgh Medical Center’s insurance division, outlined how his Special Needs Plan attempts to better coordinate beneficiaries’ care. These efforts include information sharing between plans and providers, integrated Medicare and Medicaid claims analysis, and patient-centric care planning.

Panelist Lori Tishler, MD, vice president of Medical Affairs at the Commonwealth Care Alliance, noted that coordination disconnects persist beyond just Medicaid and Medicare for this population. Her program uses a high-touch approach that looks at each member’s whole needs, including social determinants of health, and forms partnerships with community-based programs that can help the Alliance’s community health workers fit healthcare into the lives of the patients.

These social complexities are a significant barrier to caring for the dually eligible population, the panelists agreed, which is why the programs tend to use motivational interviewing strategies to identify the patients’ goals instead of presenting medical information that can feel abstract. The panelists also emphasized the importance of respecting members’ choices even when they disagree, and the need to find a balance between autonomy and protection. Bloom explained that the ethics of Programs for All-inclusive Care for the Elderly (PACE) care delivery require that “all approaches are predicated on the goals of care” set by the patients.

Schuster noted that these efforts to keep patients engaged and adherent must be combined with strategies to engage providers. His organization uses a 2-pronged approach of ongoing technical assistance and a financial incentive, which, he said, help complement each other and remove the barriers that can get in the way of the high-quality care that clinicians aim to provide.

Returning to the topic of community partnerships, the panelists discussed the complex social needs faced by their members and patients, and the questions relating to their organizations’ role in solving these issues. Schuster voiced his opinion that the greatest problem with healthcare in the United States is that it is separated out from the other services that people need. Medical systems want to help this population, for both humane and economic reasons, which is why they must find “innovative and creative ways to partner with other organizations” that provide housing and food.

Tishler said that caring for dually eligible patients requires “breaking down barriers,” as she gave the example of a paramedic who went grocery shopping for a member who didn’t have food. Bloom agreed that creativity was needed to keep patients out of nursing homes and hospital facilities, and that simply medicalizing the needs of this population will not serve them well.

Still, there are some policy considerations that can obstruct efforts to integrate care for dually-eligible patients. For instance, Schuster brought up the unknowns that arise when starting a new program, like the ones experienced by payers when they incorrectly expected that the costs for patients enrolling in new exchange plans under the Affordable Care Act would be similar to those in traditional commercial plans.

Bloom proposed an integrated model of healthcare and housing developed through a partnership between HHS and the Department of Housing and Urban Development, and also called for more attention on the “unsustainable” issue of baby boomers that will need care soon. “I don’t think anybody’s listening, but I think it will be something society demands in the future,” he said.

Finally, the conversation turned to telemedicine, as an audience member asked if it could expand access to care for the dually-eligible population even if they might “lack the technological wherewithal.” The panelists agreed that there are many exciting opportunities for the use of telehealth in this field, depending on the resources and skill set of the patients and the healthcare team.

According to Tishler, an important question in developing models of care is where telemedicine and all technologies belong in the structure. There will be many different answers for each individual circumstance, but she advised that “technologies shouldn’t drive the process, but processes should support technology.”