- What are the needs of dually enrolled beneficiaries, and to what degree do their needs overlap with other high-cost, high-need individuals more broadly?
- What are the additional services health plans provide to dually enrolled beneficiaries or other high-cost, high-need beneficiaries?
- What is the range of added costs and resources needed to deliver these services and determine whether health plans found these services to be of value?
- What is the available evidence on whether such services were associated with better quality and outcomes?
Dually enrolled beneficiaries in Medicare and Medicaid are less likely to be enrolled in Medicare Advantage (MA) plans that perform well in the MA Star Rating program than non–dually enrolled beneficiaries. Some plans with a high proportion of dually enrolled beneficiaries, however, perform well in the MA Star Rating program. Through interviews with stakeholders and case studies of high-performing Medicare-Medicaid Plans (MMPs) and MA plans, the authors identify ways MA plans and plans participating in the MMP demonstration are working to meet the needs of their dually enrolled beneficiaries. The plans with high ratings in the MA Star Rating program reviewed in this study reported implementing multipronged approaches to address the needs of their complex member populations, including health-risk assessments, care management and coordination, referral or direct services, and better integrating Medicare and Medicaid. Reported outcomes associated with these plan strategies and interventions highlighted in case studies included reductions in emergency department visits and hospitalizations and other unplanned utilization.
To support organizations with MA contracts in their efforts to meet the needs of dually enrolled and other high-need beneficiaries, policymakers and other stakeholders can (1) use patient-centered performance measures relevant to the needs of dually enrolled beneficiaries; (2) account for clinical complexity and social risk in performance measures; (3) align care interventions and incentives in value-based purchasing programs, such as the MA Star Ratings; and (4) build a supportive environment through policy and by strengthening community resources.
- The challenges identified for dually enrolled and high-need beneficiaries were consistent with the author's previous findings and included a mix of complex clinical issues and social determinants of health risk factors.
- Across a range of high-performing MA plans serving a large proportion of dually enrolled beneficiaries, plans implement multipronged approaches to address the needs of their complex member populations.
- Findings from interviews with key stakeholders, including representatives of MA plans that serve a high percentage of dually enrolled beneficiaries, suggest that MA plans may seek to improve quality by addressing the nonclinical needs of members, including food and housing insecurity, transportation issues, low health literacy, and language barriers.
- Plan administrators reported typically performing some form of evaluation of their interventions to verify their benefit to health plan leadership.
- Although the plans reviewed perform well in the MA Star Rating program, the administrators were concerned that the MA Star Rating program is not aligned with the needs of dually enrolled beneficiaries.
- Plan administrators felt that the Chronic Care Act, which was implemented in the Bipartisan Budget Act, holds promise because of its increased flexibility to use supplemental benefits to pay for services thought to improve the overall health of beneficiaries with chronic conditions, but not directly related to a specific condition.
- Measure and report quality using measures and instruments relevant for dually enrolled beneficiaries.
- Set high, fair quality standards for all beneficiaries and consider stratifying or accounting for clinical complexity and social risk factors in performance measures sensitive to social determinants of health and clinical characteristics.
- Reward better outcomes through targeted financial incentives within value-based purchasing programs to reward achievement or improvement for beneficiaries with social risk factors.
- Support better outcomes by promoting rigorous evaluations to identify interventions to address social determinants of health and encouraging the sharing of best practices and interventions among Medicare Advantage plans to address social determinants of health.
- Support community resources and linkages on the local level, and implement supportive state and federal policies.
Table of Contents
Medicare Advantage Contract Structure
Case Study: SCAN Health Plan
Case Study: Commonwealth Care Alliance®
Case Study: HealthPartners
Case Study: UPMC for You
Summary and Conclusions
Interview Discussion Guide
Case Study Discussion Guide
Types of Additional Services Provided by MA Plans to Address SDOH