Who are the dual eligables for Medicaid?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

Today he answers the question:
To start off our conversation with the upcoming Medicaid Managed Care Congress in mind, when we talk about dual eligibles and the Medicaid’s programs role for the low-income Medicare beneficiaries, who are we talking about here? Who are the duals?

Nathan's Answer:

Right. It’s an important question, especially these days. The duals are low-income individuals who are entitled to benefits from both Medicare and Medicaid. There are roughly 9 million elderly and disabled duals in the system. These are the most vulnerable patients in the healthcare system. They are also among the most expensive patients in the system. To an average managed care plan they will generate almost $3000 per member per month in costs. That translates to a little more than $300 billion in annual health care spending.

The challenge here is that the Medicare program, which is financed and administered by the Federal government and the Medicaid program which, as our audience knows, is partially financed by the Feds but managed by the states, are generally not coordinated. There has been a fragmentation of care with respect to the Duals which really is an amplification of everything we see in the system. Anything we know about a beneficiary--whether they are a healthy 35 year-old commercial beneficiary or a 70 year-old Medicare beneficiary--everything we know that’s wrong with the system is doubled in the case of the Duals. They experience the fragmentation of the system more acutely. They suffer from the lack of coordination because their needs are greater and the lack of financial integration between Medicare and Medicaid is only the tip of the iceberg. More importantly with Duals, as for everybody, the much bigger deal is the lack of clinical integration. What we are seeing in the policy landscape is tinkering with the finances in order to get clinical things aligned and tinkering with the way we do clinical alignment and integrated care in trying to influence the way the program is financed. So, everything we know about the health care system really comes home to roost with the Duals. 

CMS, the agency that has oversight of the Medicare and Medicaid programs, the federal level has known this for some time. So, in 2010 they actually created a new Medicare-Medicaid Coordination Office. That Office is dedicated to trying to coordinate not just the finances, but the clinical infrastructure and the data flow and what have you around the Dual Eligibles. So, they’ve set a goal of enrolling one million Duals in coordinated care programs by the end of this year, 2012. That came out of a result of what was in the ACA. 

The Health Reform Act, which is now nearly two years old (hard to believe; it passed on March 23, 2010) is known in some quarters as ‘Obama Care’. From a policy standpoint, though, it is known as the ‘Affordable Care Act’. The ACA mandated better coordination and established a structure to accomplish that mandate. The other thing that the ACA did, though, which is of great importance to our audience is that it expanded the eligibility criteria for Medicaid. That meant that more beneficiaries were eligible for Medicaid and, therefore, more beneficiaries became duals. 

So, you have this double whammy demographically, one of which is just the overall aging of the population, right? You’ve got the Medicare beneficiaries increasing by 30,000 Baby Boomers a month to become Medicare eligible. It’s a big, big number. But now you’ve also got expanded eligibility on the Medicaid side. So, those two things have created an environment where the number of Duals is just absolutely exploding. 

Now, of those Duals about three quarters of them are what are known as ‘full benefit duals’ who qualify for full Medicaid benefits in addition to Medicare. And then the remaining quarter are partial duals. Partial duals qualify to have Medicaid subsidize their Medicare Part B premiums and the cost sharing, but they don’t receive the full spectrum of Medicaid benefits. 

Getting back to your question of who they are, there is a broad range of duals state by state. Eleven states have 25% or more of the Medicare beneficiaries also receiving Medicaid benefits. And these are highly populated states – California, New York, Massachusetts (a very sophisticated state from the standpoint of clinical infrastructure and, of course, a state that already has a mandate for coverage) and Wisconsin. The actual state with the highest proportion of duals (and this surprises many people) is Maine. And then you’ve got the deep South states of Louisiana, Mississippi, Alabama, Tennessee and then up into Kentucky. Very high proportions of duals. That’s over 25% of Medicare beneficiaries. 

The lowest state, by the way, is Montana. And you look out to those mountain states (Colorado, Utah, Wyoming, and Nevada). These are all states of generally low proportions of dual eligibles.So, it’s a national issue. The states are going to deal with this in different ways. CMS has shown itself open to experimentation on a number of different levels.