The dual eligibles population – citizens receiving both Medicare and Medicaid services – is comprised of nearly 10 million people, including low-income seniors and people with disabilities under the age of 65.
Because of their often complex care needs and low incomes, the dual eligibles population accounts for a largely disproportionate share of costs for both Medicare and Medicaid.
Health care providers help play an important role in ensuring the proper care delivery for dual eligibles. With new rules in place from the Affordable Care Act (ACA) and a national focus on improving health outcomes for all populations, it is essential for providers to optimize their processes and best practices in order to meet the care needs of the dual eligible population. To accomplish this, they should take a closer look at two key areas: communication and data management.
Ensuring Effective Communication
In California, the state launched the Coordinated Care Initiative (CCI) with the goal of enrolling their 1.1 million dually eligible beneficiaries into a single managed care health plan that combined both Medi-Cal, the state's Medicaid program, and Medicare. Early on, California recognized that effective communication with the dual eligibles was an important key to success for the program, so they instituted communications strategies to locate and inform the beneficiaries of this program. The first step/strategy was to mail information, which the State published in multiple languages and was written in plain language so that it was relatively easy to understand. They followed this by developing an ombudsman program that utilized trusted community-based organizations to help reach out to these populations to educate them about the program. In addition to these efforts, they held town halls and tele-town halls throughout the state so they could meet the beneficiaries in the communities where they lived. As the program continues to rollout across the state, they continually revisit their methodologies and strategies to ensure that they are effectively communicating the benefits and options of the program to the dual eligible.
Providers can take some best practices from California when communicating with dual eligibles. Because health care and health insurance information can be difficult for most people to comprehend, not to mention someone with a language barrier or low literacy, the terminology and options presented to dual eligibles can be nearly impossible to understand, let alone act on. By conducting surveys of dual eligibles to learn how they best receive information, providers can develop materials and communications that are easily understood, are culturally relevant, and are written in their primary language.
Besides direct communication with dual eligibles, effective internal communication is also important, as this population accesses a variety of services. For example, if a Meals on Wheels recipient enters a hospital facility, their meal delivery service should be notified to temporarily stop service, then notified to begin again once the patient is discharged. This helps prevent the program from using their funds on services for members that may not need them, but also enables them to re-engage with the patient when they do. Open communication between support organizations and providers helps both the long-term health of their patients and the efficiency of their operations.
Coordinated Data Management
Dual eligible beneficiaries face a variety of social determinants that can make it difficult to maintain communication with them outside of a provider environment. Data management can be key to ensuring that dual eligibles receive good communication from admission to discharge, and that proper follow-up and care is administered after their hospital stay. To do this, Enhanced Care Coordinators (ECC) need a communication system to share patient information between the hospital, the provider and the government. These care coordinators will engage with the patient once they leave the hospital, arranging things like transportation to rehabilitation services or checking on the management of a preexisting condition. By using the communication system to manage their records, hospital visits, Primary Care Physician (PCP) check-ups and other information, ECCs are able to coordinate the patient's care across all channels and improve their long-term health. This can be the difference between a successful outcome – such as a patient completing a course of treatment – or not.
Data management also plays a key role in reducing readmissions. When a patient is admitted to the hospital, one of the first questions asked is whether they have a primary care physician. In the event they do not, all must work together to ensure a local, in-network provider is identified so they do not continue going to the hospital for conditions that should be treated by a PCP. Sharing this patient information can help reduce hospital readmissions and save the patient, state and federal government unnecessary expenses.
California's CCI program also utilized data management to improve the outcomes of their beneficiaries. In their program, Medicare and Medicaid claims data is shared with health plans prior to the coverage effective date so that providers have their health history and can develop care planning strategies to manage each dual eligible's unique health condition. The state also has the health plans and providers report their encounter data quarterly to the state and to CMS so that the data can be used to improve and develop new strategies for managing this population. Additionally, providers incorporate the data into their case management systems, electronic medical records, workflow tools and analytics engines to further develop their own care strategies.
Dual eligibles are an extremely vulnerable population, and careful oversight is required to meet their needs effectively and efficiently. By working to improve communication and data management processes from providers, we can all help improve the health outcomes for this important population.
Barbara Selter brings more than 30 years of experience in the design, development and implementation of health programs for a variety of state and federal agencies. She leads solutions for Long Term Services and Supports, using technology and business process management tools to gain efficiencies in the administration of Medicaid waiver programs, Medicare-Medicaid Dual Eligibles Demonstrations, and Home and Community-Based Services. She performs research on the use of telecare and telemedicine to enable senior populations in underserved rural areas to "age-in-place" safely and achieve better health outcomes. Ms. Selter holds a master's degree in technology management from American University.
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