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Refocusing Responsibility For Dual Eligibles : Why Medicare Should Take The Lead*. May 1, 2012 Judy Feder Georgetown Public Policy Institute/Urban Institute federj@georgetown.edu * Feder et al., 2011. Experience with managed care for “dual eligibles ” is limited .

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refocusing responsibility for dual eligibles why medicare should take the lead

Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead*

May 1, 2012

Judy Feder

Georgetown Public Policy Institute/Urban Institute

federj@georgetown.edu

*Feder et al., 2011

experience with managed care for dual eligibles is limited
Experience with managed care for “dual eligibles” is limited
  • Most Medicaid managed care plans do not deal with dual eligibles. Medicaid has come to rely heavily on managed care for the bulk of its beneficiaries who are low-income children and families. But Medicaid managed care plans lack both experience and capacity to handle the care needs of the most expensive dual eligibles. (Verdier et al., 2011)
  • Most Medicare managed care plans do not deal with dual eligibles. About a million dual eligibles are enrolled in Special Needs Plans.But Medicare collects limited information on these plans and does not hold them accountable for quality, as measured by patient experience, hospital admission or readmission rates, emergency room use, medication errors, or institutionalization for long-term care. (MedPAC, June 2011)
managed care plans may not manage care
Managed care plans may not “manage” care
  • Economists find that, in general, savings from managed care plans—in both private insurance and Medicaid—reflect lower payments to providers rather than more appropriate or more efficiently-delivered care. (Duggan and Hayford, 2011)
  • Medicare’s reliance on managed care actually increased, rather than decreased, program costs, leading to significant savings from payment reforms enacted in 2010 .
  • Effective care management or care coordination requires delivery reformthat includes primary care with coordination of other services, in-person patient-coordinator contact, timely information on hospital admissions and emergency room visits, and close relationships between care coordinators and primary care physicians.
better managing medicare financed care is key to control of dual eligibles costs
Better managing Medicare-financedcare is key to control of dual eligibles’ costs
  • Delivery and payment reforms (like ACOs and medical homes) promote care coordination to prevent unnecessary hospital use—experienced by dual eligibles at far higher rates than by other Medicare beneficiaries. (Jiang et al., 2010)
  • Medicare, not Medicaid,pays for virtually all dual eligibles’ acute care.
  • Not counting Medicaid payments for Medicare Part B premiums, 77 percent of Medicaid’s total spending for dual eligibles goes to long-term services and supports—used by only 30 percent of dual eligibles.

(Feder et al., 2011)

federal government f inances 80 percent of s pending on dual e ligibles
Federal government finances 80 percent of spending on dual eligibles

Taken from : Feder et al. 2011. “Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead.”

Washington, DC: The Urban Institute

dual eligibles are primarily a federal responsibility
Dual Eligiblesare primarily a federal responsibility
  • States should partner with Medicare to better coordinate services for dual eligibles—especially for long-term services and supports—and can share in savings that result.
  • But allowing states to benefit from these savings without sufficient constraints risks enabling cost-shifting from state to federal budgets-- allowing states to substitute Medicare funds for expenditures Medicaid would otherwise make. (MedPAC, June 2011)
  • Dual eligibles, as Medicare beneficiaries, get consumer protections not always available to low-income Medicaid beneficiaries. A shift of responsibility for their Medicare services to Medicaid programs puts these protections at risk and creates financial incentives to limit care.

(Center for Medicare Advocacy)

medicare should lead in improving care for dual eligibles with
Medicare should lead in improving care for dual eligibles with:
  • Aggressive oversight and “pay for performance” in Medicare Special Needs Plans (SNPs).
  • Emphasis on dual eligibles, especially those using long-term supports and services, in ACA-authorized Medicare payment and delivery reforms. (Komisar and Feder, 2011)
  • SNF payment policies to prevent unnecessary hospitalizations for nursing home residents.