Why are the dual beneficiaries unique to healthcare coverage?

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:
You mentioned this special population of beneficiaries that are both Medicare and Medicaid programs and have a great deal of impact on today’s healthcare system. What makes this member population so unique?

Nathan's Answer:

Well, there are a number of things. First of all, there is a direct correlation between income and health status in this country. It’s an issue of profound moral importance, I think, when we’re talking about health care. We can’t lose that dimension. The further down you are on the socioeconomic ladder, typically the more ill you are. Remember, of course, the important thing (and our audience surely knows this) is that the driver of costs in our health care system isn’t so much the funding of acute episodes of care (although it is important), but it is the management of chronic illness over a long horizon. By the time a Dual enters into the system and becomes Medicare eligible and, in some cases has perhaps not had Medicaid coverage over their life because they’ve had a lower middle class income and they haven’t qualified for their Medicaid benefit, they may not also have had consistent health coverage. So, by the time they come into the system they often have multiple chronic illnesses or co-morbidities that have a very complicated clinical interaction. 

You remember back a moment ago to your first question. Everything we know about the health care system is compounded with the duals. So, one of these is the duals who receive fragmented care because they’ve got multiple complex conditions. They can have clinical recommendations or pharmacy therapies that are at a cross purpose. So, it is a challenging population to manage because of the way they enter into the system. But, there are other challenges, as well. 

It seems like we see every extreme when you’re talking about the duals. In our practice at GHG, we work with quite a few Dual Eligible Special Needs Plans, which is a designation created by CMS. In the previous major health reform in the MMA, it grew out of a pilot that was created there. The Special Needs Plans that we work with, you see populations that are either virtually housebound, often in neighborhoods that don’t have a grocery store. The food comes from a corner bodega or they have, on the other extreme, extremely transient lifestyles. The most consistent thing about these beneficiaries is a cell phone, if they have one. 

So, they are incredibly difficult beneficiaries to manage from a model-of-care standpoint. They are in many cases (but certainly not always) at the lower end of the educational scale. So, communicating with them can be difficult. You think about what it’s like to come out of a hospital stay and have complicated discharge instructions. We know that hospitals and clinics are struggling to really get on top of the importance of discharge planning. We know it, but we don’t do a terribly good job of it. So, again, all of those things are compounded when you’re talking about serving this population. 

Whether it’s a plan or a state, historically as you’re trying to reach out to these folks you’ve got to do so in ways that can be profoundly different from how you manage the rest of your population. The average Medicare plan that got into a dual SNP was accustomed to a certain model of care for caring for these beneficiaries and it doesn’t quite apply or it certainly needs to be changed for the duals. They require from a regulatory standpoint, an independent model of care from the plan. 

And then your average Medicaid provider or payer, rather, is accustomed to perhaps moms and kids, blind and disabled, different populations. So, plans need to come into managing the duals with an expectation that everything from the operational model to