By Maureen Hewitt
As managed care organizations (MCOs) continue to enroll dual eligibles, those who qualify for Medicaid and Medicare, it’s become clear that while they are good at doing a great many things, managing the elderly with multiple complex chronic conditions is not something they have done before.
In an effort to reduce costs for the 9.6 million people in the United States who are dual eligibles, many of these low-income and generally elderly adults (59 percent are 65 years old and older) began receiving healthcare from MCOs. While the premise is sound—control costs and improve health—most managed care organizations simply aren’t always equipped to deal effectively with this population.
Perhaps the biggest difficulty MCOs face is providing consistent care coordination. An AARP study of four MCOs, found each plan suffered from overlapping roles in the care management area. The issue is the potential lack of communication among the MCOs and the other organizations providing care coordination services to the patient. While many times this lack of communication doesn’t pose a significant risk for the patient, other times contraindicated medications may be prescribed along with duplicative procedures or tests recommended multiple providers.
Age = Issues
As one ages, her health typical declines. While everyone ages differently, dual-eligible adults face particularly difficult “golden years” as they grow older and suffer from a number of issues:
- Up to 56 percent of dual eligibles 65 years old and older have limitations on 1-6 activities of daily living or ADLs. This ranges from the ability to take a shower independently to fixing meals.
- Many members of this group live alone (29 percent), with a spouse (17 percent), in an institution (29 percent), or with children or others (24 percent).
- They are poor. Fifty-three percent have an annual income of $10,000 or less.
When compared to the general Medicare population, dual eligibles have higher rates of chronic conditions, including diabetes, COPD, mental illness and Alzheimer’s disease.
Everyone agrees dual eligibles typically have low incomes and are susceptible to a lack of care coordination because they are poor, sick with multiple chronic conditions, and often have serious disabilities and other significant challenges. And, for a relatively small group, they account for a large portion of expense. Dual eligibles 65 years old and older are the highest spending age group, accounting for $175.1 billion in costs in 2010.
For older adults, care coordination is one of the most important aspects of their medical care. Without it, a multitude of significant issues may arise without providers taking notice until the problem becomes critical.
With the help of care coordinators, the patient can customize the care she receives. This is most effective when she receives these services through a single entity with a hands-on multi-disciplinary care team able to coordinate the care.
Care coordination is enhanced through the use of data collected by the care coordination organization. When the data is shared across caregivers, it makes it possible to deliver to the patient the best healthcare experience possible.
As Baby Boomers continue to age and join the ranks of Medicare participants, many also will become dual eligible. It will be even more important to keep pace with the influx and contend with the health issues from which this group will inevitably suffer. (The number dual eligibles grew from 8.7 million people in 2007 to 9.6 million people in 2010—a cumulative growth of 10.4 percent over the period and an average annual growth rate of 3.3 percent.)
A program I know quite well can help alleviate the issues found in a well-meaning, but fragmented healthcare system. PACE, or Program of All-inclusive Care for the Elderly, is sponsored by the Centers for Medicare and Medicaid Services. Available around the U.S., PACE provides medical, dental and rehabilitation services under one roof. PACE has built in care coordination, which benefits those who participate in the program.
“A few such programs, such as the Program of All-Inclusive Care for the Elderly (PACE), have successfully integrated Medicaid and Medicare services and raised the quality of care provided to dual eligibles,” according to the Center on Budget and Policy Priorities, which also reveals fewer than 1 percent of dual eligibles are enrolled in PACE programs.
To improve care coordination for dual eligibles, we must consider increasing enrollment in PACE programs from the less than 1 percent that exists today. For those not eligible to participate in PACE, independent care coordination is an option to meet the needs of this vulnerable group.
Maureen Hewitt is the President and Chief Executive Officer of InnovAge, a Denver-based provider of comprehensive healthcare services for older adults in California, Colorado and New Mexico. Hewitt has held this role since 2006 and has led for-profit and nonprofit health care organizations for more than 25 years. Hewitt’s experience includes leading skilled nursing/sub-acute care facilities and acute care and rehabilitation hospitals, as well as serving in volunteer board positions. http://MyInnovAge.org.