Managed Healthcare Executive - January 2009 - (Page 26)

{ HEALTH MANAGEMENT } Roughly 85% of dual eligibles receive care under a fee-for-service arrangement. At the same time, moving a specialneeds population such as dual eligibles into a capitated environment, where health management and outreach services could be more easily integrated, is problematic because it “erodes the insurance principal” of spreading risk, he says. Ultimately, Meiners says, a solution will depend on “creating some exibility and stepping out of the rigid boxes that the two programs represent so you can work more creatively and appropriately to meet the needs of individuals.” Richard Surles, chief development ofcer for APS Healthcare, which provides disease management and other services to state Medicaid programs, agrees a di erent bene t design is necessary. “The current system is failing dual eligibles,” he says “The bene t is badly bifurcated, and there is a lack of coordination, but I don’t think full risk capitation is the answer. To me the business model for a full-risk capitation sets up some incentives for overmanaging utilization and not really managing care.” Capitation advocates disagree. The Lewin Group study, conducted on behalf of the Association for Community A liated Plans (ACAP) and Medicaid Health Plans of America, concludes that integrating care for dual eligibles using a capitated model already in use in a number of states, including Minnesota, Massachusetts and Wisconsin, would translate to enormous savings. EXECUTIVE VIEW Dual eligible care should be coordinated, but rarely is. Remove the socioeconomic barriers so patients can address their health. Seek to avoid confusion and redundancy by integrating care for dual eligibles using a capitated model. If all dual eligibles were moved into an integrated setting, Medicare and Medicaid would realize a 2.7% savings immediately and that would grow to a 4.7% savings after 15 years. What’s more, the report states, integrated care would improve clinical outcomes. While advocates on both sides of the issue debate how best to attack the issue, the ranks of the dual eligible population and their needs, are destined to swell. Baby boomers are aging, chronic diseases are on the rise, and the economic crisis is increasing Medicaid roles. Given those trends, the study projects annual spending on duals will top $775 billion by the year 2024. POOR, SICK AND EXPENSIVE the Kaiser Commission on Medicaid. It found 31% of dual eligibles su er from heart disease, and 16% have had a stroke, compared with 23% and 10%, respectively, of other elderly (non-disabled) Medicare bene ciaries. Dual eligibles are also more likely to struggle with activities of daily living, such as bathing, dressing, eating and toileting. “When you’re dealing with a dual eligible population it’s like Maslow’s hierarchy of needs,” says Christobel Selecky, CEO of LifeMasters Supported Self Care Inc., a disease management rm with programs for chronically ill dual eligibles in Florida. “If a person doesn’t have enough food, she’s not going to worry about the medications she’s on,” HELP BEYOND HEALTHCARE WHO ARE DUAL ELIGIBLES? Two-thirds of dual eligibles are age 65 or older; one-third are nonelderly adults with disabilities. Seven out of 10 have annual incomes below $10,000. Approximately 72% of elderly dual eligibles are women. Almost one-quarter of elderly dual eligibles are in nursing facilities, in contrast to only 2% of other elderly Medicare bene ciaries. Source: Kaiser Commission on Medicaid and the Uninsured Dual eligibles are also among the nation’s sickest, further contributing to costs. For example, many disabled dual eligibles also struggle with mental illness and elderly dual eligibles are far more likely to have a chronic condition than other Medicare bene ciaries, according to a 2004 study by For dual eligibles, some of the socioeconomic barriers must be removed so patients are ready and able to address their health, Selecky says. And many of those barriers—such as lack of family support, transportation, telephone service, a permanent address, and food—fall outside the strict de nition of healthcare. Given the fact that dual eligibles currently represent 40% of Medicaid spending and 25% of Medicare costs, experts say nding the cash, exibility and political will to provide more holistic care is a challenge. In light of those trends, Selecky says systematic reform, needed though it may be, won’t be a panacea. “There is a lot of high-level work going on to address the problems of dual eligibles, but how do you translate what you learn to the local level?” she says. “What works in rural Oklahoma may not work in urban Florida. My soapbox is: There is no silver bullet.” MHE FOR MORE INSIGHT See more Health Management on managedhealthcareexecutive.com 26 JANUARY 2009 http://www.managedhealthcareexecutive.com

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Managed Healthcare Executive - January 2009 Contents Editorial Advisors For Your Benefit News Analysis Politics & Policy Letter of the Law Managed Care Outlook New Day 5 New Realities of Disease Management Pharmacy Best Practices Health Management Technology State Report: Hawaii MHE Resource Ad/Edit Index

Managed Healthcare Executive - January 2009

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