The 9 million “dually eligible” people who qualify for both Medicare and Medicaid end up having to navigate two separate programs whose rules and incentives are often misaligned. The University of Pennsylvania’s Leonard Davis Institute of Health Economics recently hosted a panel of experts discussing policy pathways that could advance integrated coverage and care for dually eligible beneficiaries.
Earlier this year, together with Health Affairs, and with support from The SCAN Foundation and Arnold Ventures, Penn LDI convened a group of researchers, dually eligible individuals and caregivers, representatives from states, and policymakers to develop a policy brief and white paper with recommendations for improving care for dually eligible beneficiaries.
“Availability of integrated options varies widely across the states,” said Melanie Bella, executive advisor at Cressey & Company, a healthcare investment firm. “Some states have a lot of options; some states have a few options, and others, for very legitimate reasons, haven’t been able to do anything.”
Bella noted that the white paper discusses some of those challenges, but also offers concrete recommendations for how to get to a point that every state has at least one option where there is a single entity that’s administering both Medicare and Medicaid benefits and bearing some degree of financial risk for the Medicare and Medicaid spending.
Bella previously served as executive vice president of policy and duals strategy at Cityblock Health and is former chair of the Medicaid and CHIP Payment and Access Commission (MACPAC), a post she held from 2019-2024. She was also the founding director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services (CMS), where she designed and launched payment and delivery system demonstrations to improve quality and reduce costs.
She added that the white paper does a nice job of being very specific about where Congress could act, where CMS could act, and where the states could act.
For instance, the policy brief says that CMS should develop a menu of integrated program models, all of which should include financial integration. Each model should aim to integrate the coverage and care experience, and provide comprehensive benefits in each state, with features such as:
• A single set of enrollment materials and enrollee notices;
• A unified plan of care and a single care coordinator with access to information on all aspects of care and who can represent a beneficiary’s interests in reviews and appeals of coverage decisions;
• A core set of quality measures and targeted assessment of the dually eligible patient experience.
“The experience for people, unfortunately, is all over the place,” Bella added. “It is a very complicated system. We have seen growth in integrated products across the states, but still, the majority of duals do not receive Medicare and Medicaid services through the same organization, and we also still have a variety of non-integrated options out there. So when you are a person trying to make a choice about how to get your care, you’re bombarded with things, but the majority of them are very confusing. They don’t help you coordinate between the two programs, and there’s still a lot of cost shifting, which, at the end of the day, doesn’t usually end up in the individual’s favor.”
Matthew Behrens, Integrated Care Policy Supervisor for the Virginia Department of Medical Assistance Services, said one of the recommendations in the policy brief — seed money or planning grant money for the states — is incredibly important. “In Virginia, we started with a financial alignment demo, and we’ve moved to D-SNPs [Dual Eligible Special Needs Plans], so we’ve had a little bit of commitment to this. But it’s incredibly difficult for a state if you’re starting from scratch, trying to balance this with other priorities.”
Coordinating across the CMS data and the state data is incredibly difficult, he said. “It takes a long time to learn that. So any type of resources that can be given to the state to help them along that journey would be hugely beneficial.”
Behrens also said shopping for plans can often get confusing. “Yesterday I went into Medicare Plan Finder and pretended I was a dual,” he said. “There were 57 plans just in my zip code available for me. And if you go into Plan Finder, it took me to the fourth page before I found a decent one. All the ones that were ahead of that were non-integrated plans. So we’ve spent a lot of time working on providing an integrated product, and it’s not the first thing that pops up.”
Panel moderator Rachel Werner, M.D., Ph.D., executive director of the Leonard Davis Institute of Health Economics, noted that if dually eligible patients are confused about their options, providers are often equally confused and may not have incentives to get people into the integrated plans and can’t offer the support that people are looking for.
Toyin Ajayi, M.D., is co-founder and CEO of Cityblock Health, a tech-enabled, value-based healthcare provider for Medicaid, dually eligible and lower-income Medicare beneficiaries in underserved communities. She said that there are “foundational issues that stem all the way back into medical education and the administration of care delivery, which is that clinicians are not often taught about insurance, period. They don’t get immersive education about what the experience is from the member’s perspective, and that’s a real problem. That results in them optimizing for the ease of their daily work, so it creates a real onus on the plans to show the value and be discernible to the providers, and to ease their administrative burden, because that’s often one of the biggest challenges that they’re facing.”
Ajayi sees an opportunity to specifically target providers caring for these populations with nuanced and well-designed education so that they understand the implications of insurance and coverage type for the people whom they’re serving. “And then it creates the right incentive for plans to be differentiating and to be value-added, so that not only does the member and their family see the value of being in an integrated product, but so too does the primary care doctor who’s caring for them and making referrals for home health or for DME in the home. They’ve really got to be able to see that it adds value to them and to the patient that they’re caring for.”
The policy experts recommend creating new accountable care organizations (ACOs) in fee-for-service Medicare that are at risk for both Medicare and Medicaid spending; in the interim, phase in requirements that risk-bearing entities serving dually eligible individuals have a formal relationship with the states in which they operate.
Werner noted that Medicare Advantage plans can help develop integrated options, but nearly half of dually eligible beneficiaries are enrolled in fee-for-service Medicare. To improve and coordinate integrated care for those enrolled in traditional Medicare, one of the recommendations is that there should be pathways to enroll dually eligible beneficiaries in accountable care organizations that are specifically for dually eligible beneficiaries and that bear upside and downside risk for both Medicare and Medicaid spending.
The policy brief suggests that CMS should require that all risk-bearing entities (such as ACOs) serving a substantial number of dually eligible individuals have formal relationships with state Medicaid agencies, delineating their responsibilities to coordinate care and share information.
Ajayi noted that many of those people are enrolled in or are receiving care from a provider who is participating in some sort of an ACO arrangement. These are providers that, on the Medicare fee-for-service side, have opted into starting to do some of the work of care coordination and care management for a population of folks who are dually eligible, and not just Medicare beneficiaries. “This is a way to say, let’s create as many doors as possible, as many paths as possible, to ensure that a dually eligible beneficiary can benefit from integration. So if they are getting care from a provider who is involved in an ACO, how do we make sure that that provider can also provide that level of integration that that patient needs?”
One component, Ajayi added, is giving the provider a pathway to participate in Medicaid risk and to actually be accountable for that part of the benefit. “That means that we’re actually thinking about the way in which both of those programs play together. They’re not just focused on acute hospitalization reduction and the types of interventions that one might focus on in a Medicare ACO. They are also thinking about, how do we leverage home and community-based services, long-term care and supports. How do we understand and align across the continuum of care for that beneficiary so there is a single point of connection for them.”
