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Care Coordination Improves Outcomes for Dual Eligible Patients

CMS has announced that dually eligible Medicare and Medicaid patients face better outcomes because of integrated health plans that promote care coordination between the programs.

By Jacqueline LaPointe

- Patients who are eligible for both Medicare and Medicaid experience better healthcare outcomes when they have access to health plans that bolster care coordination between both programs, according to a recent blog post from the Centers for Medicare and Medicaid Services (CMS).

Integrated care plans promote care coordination for dual eligible patients

“Since the passage of the Affordable Care Act, the Centers for Medicare & Medicaid Services has focused on promoting integrated care and developing new payment and service delivery models for dually eligible beneficiaries,” wrote several CMS leaders in the post. “Now the evidence is stronger than ever: integrated care is improving outcomes.”

The announcement comes in light of a Department of Health and Human Services report about how the Minnesota Senior Health Options (MSHO) program boosted patient outcomes for dually eligible beneficiaries between 2010 and 2012 by integrating Medicare and Medicaid benefits.

According to the report, MSHO enrollees were 48 percent less likely to experience a hospital admission, and out of those that were hospitalized, about 26 percent had fewer stays than dual eligible beneficiaries outside of the health plan.

MSHO enrollees also were 6 percent less likely to visit an outpatient emergency department, while those who did go to an emergency room had 38 percent fewer visits.

Additionally, researchers found that dually eligible beneficiaries in the MSHO program had more access to home and community-based long term care services, with enrollees being 13 percent more likely to receive these services compared to non-participants.

“Integrated care is improving the lives of some of the most vulnerable Americans,” stated the blog post. “These new findings from Minnesota affirm the promise of integrated care and reinforce the urgency with which we need to continue to develop, test, and scale successful models for better serving dually eligible individuals.”

The MSHO program was developed in 1997 to provide better service for dually eligible beneficiaries who were 65 years or older. The health plans were designed to coordinate all Medicare and Medicaid benefits that the enrollees receive, such as Medicare coverage for acute medical care and Medicaid coverage of long-term care support.

In 2013, CMS planned to support the existing MSHO program by positioning it in line with Medicare and Medicaid program administration, investing in federal-state data sharing, and promoting beneficiary resources.

CMS has also recently worked with 12 other states to develop similar integrated care models through the Financial Alignment Initiative, which aims to coordinate care for Medicare-Medicaid enrollees by closing the financial misalignments between the programs.

More beneficiaries are also benefitting from better care coordination efforts, reported CMS. By 2015, about 650,000 dually eligible beneficiaries were part of an integrated care model, representing a 301 percent increase since 2011.

Improving patient outcomes for Medicare-Medicaid beneficiaries has been a major challenge for CMS because the population tends to experience worse outcomes, such as more hospital readmissions and inadequate chronic disease management.

Last year, a study from Inovalon found that dual eligible individuals experienced more emergency room visits, hospitalizations and readmissions, and chronic diseases, while they were also more likely to take seven or more medications. Dual eligible beneficiaries also reported a disability as the reason for entitlement (46.3 percent) more than other individuals (16.9 percent).

However, researchers discovered that almost 80 percent of care disparities involving Medicare-Medicaid beneficiaries stemmed from socioeconomic and demographic factors rather than quality of health plans.

For example, the driving factor for predicting hospital readmissions was living in a low-income neighborhood, which 41 percent of dual eligible patients did.

“We’ve suspected all along that the poorer health outcomes of dual eligible members are not caused by the quality of plans, but are due to other factors,” stated Dr. Paige Reichert, Cigna HealthSpring’s Medial Senior Director of Quality.

“However, because the study controlled for similar member characteristics, we see that it’s sociodemographic factors that are affecting health outcomes,” continued Reichert. “Clearly the issues that are affecting the health outcomes of disadvantaged beneficiaries need to be addressed to eliminate health disparities, and should also be taken into account when measuring the quality of Medicare managed care plans.”

While the CMS blog post commented on the success of integrated health plans through care coordination, the agency may need to consider how social determinants influence outcomes for Medicare-Medicaid beneficiaries.

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