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The Dual Eligible Program: Better Coordination to Improve Access to Care


By Tom Standring
Vice President of Medicare
Molina Healthcare, Inc.

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Original Publish Date: May 06, 2014

With more than 10 million people in America now eligible for both Medicare and Medicaid, an initiative of the Affordable Care Act is connecting the two programs, to work together. This initiative is known as the Dual Eligible Program.

Dual Eligibles, also called Duals, are a diverse group of people, many of whom require complex care. Many have multiple chronic illnesses, battle substance abuse or depression. Most will need long-term care at some point in their lives. Dual Eligibles comprise 15 percent of all Medicaid enrollees, but account for nearly 40 percent of all costs. For Medicare, Duals represent 20 percent of all enrollees and more than 30 percent of costs.

Some states are contracting with managed care organizations to integrate the two programs. The goal is to improve access to health care while reducing cost. However, shedding the layers of complexity that a combined plan represents is a challenge and an opportunity on its own.

Advocates, health care industry leaders and state and federal officials alike agree that a personalized approach to each individual’s needs can improve the quality of life of those with the highest needs and the least ability to navigate the two programs.

With the new plan, all medical care, behavioral health, social support and long-term care is coordinated by one health care company like Molina Healthcare. Molina Healthcare, an expert in working with Medicaid and Medicare, has been selected to roll out Duals Demonstrations Plans in California, Illinois and Ohio this year, and has been selected to roll out similar plans in Texas, Michigan and South Carolina next year.

Although not all health insurance companies are participating, patients eligible for both Medicare and Medicaid can choose from several options, with benefits that vary from plan to plan. Molina, for example, offers experience managing services for seniors and people with disabilities.

To participate, Dual Eligibles need to be notified by the state where they live. Generally, the state sends letters monthly to those who are eligible with upcoming birthdays. People with birthdays early in the year have already been notified. Those with birthdays late in 2014 may be eligible without even knowing it. If patients want to find out if they’re eligible or not, they can be directed to an organization that is contracted with the state to handle enrollments and eligibility questions.

Once they are enrolled in the program, Dual Eligibles will get one card instead of two, a single plan with combined Medicare and Medicaid benefits and a case manager to coordinate all the aspects of their care – and this is key! The case manager will help patients personally and identify the resources that are available to help them.

One of the main concerns of many Duals is what happens to a patient after they leave the hospital, because in most cases, the best and most cost-efficient place for Duals to recover is at home.

To make the Duals model come to life, let’s use the example of one Molina Healthcare member, a 67-year-old woman who constantly had to be admitted into the emergency room. She suffered from depression, hypothyroidism, asthma, hypertension, congestive heart failure, osteoarthritis and had history of suicidal ideas.

The case manager arranged for a face-to-face meeting, and found that the member was afraid. There was gunfire and drug dealing in in the neighborhood, and recently a local person had been murdered. The first thing the case manager did was validate the information the member shared with her—and found that it was all true.

The case manager then got in contact with an integrated team who helped the member relocate to a different city, closer to her health care provider, by applying for Section 8 housing (subsidy housing for low-income individuals). Through a donation, the case manager was also able to obtain a laptop for the member.

Eventually, the relocation had a dramatic impact on the member’s health. She returned to being active in her church. She started taking needle point and crochet classes in the Senior Center, and she now pays her bills online. She has not been back to the emergency room since.

By solving a problem more social than medical in nature, and shifting the health care from reactive to proactive, the case manager was able reduce emergency room usage and limit unnecessary readmissions and other utilization, which are big cost drivers.

That’s why the program also focuses on preventive care, which might help chronically ill people avoid further deterioration of their health.

Integrating care for dual eligibles won’t be easy. Still, managed care companies like Molina will continue finding solutions that benefit vulnerable populations –populations Molina has been serving since 1980.

Visit Molina Healthcare at www.molinahealthcare.com.

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