- What are the needs of dually enrolled beneficiaries and the degree to which these needs overlap with those of high-cost, high-need individuals more broadly?
- What are the additional services that health plans and providers deliver while caring for dually enrolled Medicare beneficiaries or other high-cost, high-need beneficiaries?
- What additional costs and resources are used to deliver these services, and do health plans find these services to be of value?
- Does the available evidence suggest that such services are associated with better quality and outcomes?
Beneficiaries dually enrolled in Medicare and Medicaid are less likely to receive high-quality care and less likely to be enrolled in plans that perform well in the Medicare Advantage (MA) Star Rating program than those who are not dually enrolled. However, some plans with a high proportion of beneficiaries dually enrolled in Medicare and Medicaid appear to perform well in the Star Rating program. These findings suggest that some plans have identified effective ways to meet the needs of their dually enrolled beneficiaries. As part of a qualitative study on the types of services MA plans implement and the types of resources they use to meet the needs of dually enrolled and other high-cost, high-need beneficiaries, the authors conducted an environmental scan of the literature and key informant interviews, with the goal of developing a typology of the services that MA plans implement. The findings can be used to develop a series of case studies of high- and low-performing MA plans to further explore this topic.
The needs of dually enrolled beneficiaries largely parallel the needs of high-cost, high-need patients more broadly
- Social and medical risks are often intertwined.
- The different care needs among the heterogeneous subpopulations of dually enrolled members present a challenge for health plans.
Health plans, providers, and community partners adopt a variety of strategies to meet the varied needs of dually enrolled and other high-cost, high-need beneficiaries
- There are four categories of strategies: (1) identifying needs and data analytics to better target programs toward patients at high risk for hospitalization, readmission, and nursing home admission; (2) addressing clinical needs through care management and coordination; (3) meeting the social needs of dually enrolled beneficiaries by either referring them to existing programs that address housing, food security, and transportation needs or providing these services directly; and (4) undertaking administrative actions to better integrate Medicare and Medicaid.
Little information is available about resources or costs required to implement and sustain these strategies
- This is a major gap in the literature and proved to be difficult for interviewees to describe in detail.
A strong, consistent evidence base is lacking
- Long-term follow-up is still lacking, because many programs are new.
- Many studies examine only associations, and there are few randomized trials of such strategies.
- Many studies are of single programs or single centers.
- Care coordination for selected chronic conditions has the strongest evidence base.
Table of Contents
Medicare Advantage Contract Structure
Dually Enrolled Beneficiaries and Challenges to Obtaining Care
Strategies Used by Health Plans, Providers, and Community Partners
Resources Required to Implement Strategies
Evidence of Success
Unanswered Questions and Next Steps
Summary and Conclusions
Financial Alignment Demonstrations
Examples of Risk Stratification Used by Medicare-Medicaid Plans
Potential Targets for Case Studies Identified Through Environmental Scan and Interviews
Literature Cited in Chapter Seven, "Evidence of Success"