June 2019
HHQI's Underserved Populations (UP) Network quarterly newsletter
Now Available
April 2019 UP Network Webinar Recording

Dr. Warren Hébert recently provided a wealth of information related to the changing role of caregiving in a value-based environment and relationship-centered care concepts during the Engaging Caregivers as Partners webinar. Free nursing continuing education credits are still available with the recording in HHQI University  
Who Are Dual-Eligible Patients

“Dual-eligible beneficiaries” generally describes individuals who qualify for both Medicare and Medicaid services. Each state determines the specific guidelines for Medicaid eligibility. Medicaid tries to provide needed services that Medicare does not offer like institution (e.g., nursing home) and community-based long-term services and supports (LTSS).
Full vs. Partial Benefits

  • Full-benefit dual-eligible individuals are Medicare beneficiaries who qualify for the full package of Medicaid benefits. They often separately qualify for assistance with Medicare premiums and cost-sharing through the Medicare Savings Programs (MSPs).
  • Currently 71.4% of dual-eligible enrollees have full benefit (see Figure 1 below)
  • Partial-benefit dual-eligible individuals are enrolled only in Medicare and an MSP.
Learn more about the various program categories & benefits in CMS’s Dual Eligible Beneficiaries Under Medicare and Medicaid MLN Booklet .  
Why Does that Matter?

According to Centers for Medicare & Medicaid Services (CMS), “Many of the 12 million dually eligible beneficiaries have complex healthcare issues, including multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. CMS and states spend over $300 billion per year on the care of dually eligible individuals, yet still do not achieve acceptable health outcomes” ( 04/24/19 Press Release ).

Who Are Your Agency’s Dual-Eligible Patients?

Often in home health agencies, that distinction is not easily accessible. These individuals often are referred to homecare for acute reasons where Medicare is the payer for services. It is difficult to gather the information from OASIS data, since clinicians often don’t include accurate responses for M0065 or agencies are unable to run reports to identify patients that have ID numbers for both M0063 and M0065. The OASIS-D Guidance Manual (2019) states:

  • (M0065) Medicaid Number – to include the Medicaid number, “whether or not Medicaid is the payer source for the home care episode.”

  • (M0150) Current Payment Sources for Home Care: (Mark all that apply) – limit identifying payers “to which any services provided during this home care episode and included on the Plan of Care will be billed by your home health agency.” [Note – if a dually eligible patient’s episode is being billed to Medicare, then Medicaid wound NOT be selected here.]

Some agencies capture dual eligibility data using fields in the patient demographics from their electronic medical record (EMR) at admission. Often a report can be generated from some EMRs.

What are the Issues?

Inadequate Care Coordination

Many patients who are dually eligible often have serious medical conditions that require complex coordinated care and assistance with functional limitations that result in high costs ( Bynum, Austin, Carmichael, & Meara , 2017). Additionally, this population is in the lower socioeconomic bracket, report poor health status, and often are placed in an institution like a nursing home ( Health Affairs , 2012). 

Care coordination is challenging when patients need both acute care under Medicare and long-term services through Medicaid services. The rules for care under each service differ and someone needs to coordinate the care. Dually eligible individuals have to navigate between two separate health programs:

  • Medicare for the coverage of most preventive, primary, and acute health care services and prescription drugs, and
  • Medicaid for the coverage of Long-Term Care Services and Supports (LTSS), certain behavioral health services, and Medicare premiums and cost-sharing.

( CMS , 2019)

Complex Medical Conditions

There are common dual-eligible sub-populations identified in the literature according to Bynum, et al. (2019) that require more intense care and have high costs including the following:

  • Multiple chronic medical conditions
  • Mental illness
  • Functional impairments or disabilities
  • Patients who are dying

Some of the top chronic conditions identified for dual-eligible community-based patients who are 65 years or older during 2010 (Bynum, et al., 2019) include:

  • Renal disease (54%)
  • Congestive heart failure (52%)
  • Diabetes mellitus (51%)
  • Chronic obstructive lung disease (38%)
  • Dementia (36%)

Many patients have more than one chronic condition and often have a mental health diagnosis. Table 1 shows that over 70% of this specific population has three or more chronic conditions (Bynum, et al., 2019).
Table 1 : Number of Chronic Conditions for Community-Based Patients who are Dually Eligible and 65 or older ( Bynum, Austin, Carmichael, & Meara , 2017).
Higher Care Cost  

Dual-eligible patients are a small portion of enrollees in either Medicare or Medicaid, but have high health care expenditures for each of the programs (see Figure 2 ). The majority of the costs are associated with inpatient care (e.g., hospitalizations and skilled nursing home). Home health and hospice care are only a fraction of the costs. CMS is offering new models of care to improve care coordination and reduce costs for dual-eligible patients. 
New Medicare & Medicaid Collaborative

CMS Administrator Seema Verma recently sent a letter to the Medicaid State Directors describing opportunities to improve care coordination and cost savings for dually eligible people ( 04/24/19 Press Release ). Ms. Verma stated, “Less than 10% of dually eligible individuals are enrolled in any form of care that integrates Medicare and Medicaid services, and instead have to navigate disconnected delivery and payment systems. This lack of coordination can lead to fragmented care for individuals, misaligned incentives for payers and providers, and administrative inefficiencies and programmatic burdens for all. We must do better, and CMS is taking action.”

Currently there are only nine percent of full-benefit dual-eligible individuals that are in an integrated care program to delivery of care and reduce costs ( CMS , 2019). Therefore, CMS is proposing several approaches to work collaboratively with state Medicaid programs including:

  • The Capitated Financial Alignment Model. Through a joint contract with CMS, states and health plans, this model option creates a way to provide the full array of Medicare and Medicaid services for enrollees for a set capitated dollar amount.
  • Managed Fee-for-Service Model. This model is a partnership between CMS and the participating state and allows states to share in Medicare savings from innovations where services are covered on a fee-for-service (FFS) basis.
  • State-Specific Models. CMS is open to partnering with states on testing new state-developed models to better serve dually eligible individuals and invite states to come to us with ideas, concept papers, and/or proposals.

Read more on the specifics offered to states to work with CMS related to dual-eligible patients.
What Can Your Organization Do ?

Here are a few ideas to get you brainstorming:

  • Check with your state Medicaid offices to see if there is current or projected collaborative approaches and how your organization can participate or utilize the programs.  
  • Develop a plan to ascertain data to identify dual-eligible patients.
  • Collect and evaluate data from this population.
  • Hospitalization rates, unachieved goals, key outcome/process indicators…
  • Common social determinants
  • Financial difficulties that effect health (e.g., medications, food, follow-up visits)
  • Transportation barriers for medical follow-up
  • Frailty and general poor health status
  • Mental health issues, including anxiety and depression
  • Chronic diseases and lack of self-management skills
  • Engage patient and family into self-care management
  • Try some motivational interviewing and teach-back skills
  • Identify their barriers and fears
  • Provide health literate teaching materials
  • Encourage and provide positive feedback with self-management activities
  • Include plans to coordinate with Medicaid at admission
  • Many patients may need further care under Medicaid after acute skilled needs for Medicare is complete – start early in the process
  • Work with Medicaid case managers to tap into community-based services as early as possible
  • Develop a Performance Improvement Project (PIP) to improve care
  • Select a specific problem area
  • Identify a key driver (cause) for that problem
  • Brainstorm on intervention strategies (evidence-based, if possible)
  • Test the change (Rapid Cycle Testing like PDSA)
  • Spread the change
  • Monitor and evaluate the change
  • Repeat, as necessary
  • And think out of the box on many other ways to address their needs!



HHQI Quality Improvement Resources

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. 
Pub. No. 11SOW-WV-HH-ADL-062119