There are nearly nine million individuals in the United States who are enrolled in Medicare and Medicaid--about 70,000 of them in Colorado.
These “dual eligibles” are considered some of the highest need and lowest income individuals in the nation and require a large amount of medical attention and assistance. Due to a mental or physical disability, they qualify for long term services and supports (LTSS) in Medicaid. Some LTSS include nursing facility care, home and community based services or assisted living. However, they receive their acute care, such as physician and hospital services, through Medicare.
Dual eligibles are a hot topic in health care reform. As a large vulnerable population that makes up a disproportionate amount of spending of Medicare and Medicaid, it’s important to better integrate and coordinate care for duals in order to reduce the growth of their medical expenditures, increase cost-savings, as well as improve their overall care.
Theoretically, dual eligibility should improve access to care for clients, offering them a wide range of services and programs to meet their needs. However, their large number of providers coupled with financing from two different payers can sometimes result in poor coordination and management and ineffective cost control.
So what’s happening to address the problem of providing coordinated and cost effective care to dual eligibles?
In 2011, the Centers for Medicare and Medicaid Services (CMS) funded 15 states - including Colorado - to develop demonstration proposals to implement state-wide programs to improve services and care for dual eligibles. The development is well under way for each state.
The proposals consisted of a detailed description of how the state would structure, finance, implement and integrate their model following CMS guidelines and standards.
Colorado’s proposal incorporates the existing Accountable Care Collaborative Program to improve dual eligible care. It outlines a managed fee-for-service finance model, as opposed to the previous traditional fee-for-service model. The proposed model incorporates quality and efficiency measurements to encourage payer-provider communication and performance. Under Colorado’s proposal, the Regional Care Collaborative Organizations (RCCOs) will be the primary coordinators of health support for the dual eligibles and will be compensated for coordinating their care. One of the main roles of the RCCOs is to ensure a strong client-provider relationship and to work with duals to accommodate their existing relationship with a health care provider.
Much of the funding and implementation will be determined by the path of the federal Affordable Care Act and whether it will survive November’s election. Either way, the “dual eligible issue” is well underway and on the minds of both national and state politicians.
Colorado and the other 14 states are waiting to hear from CMS to see if they can proceed with implementation. Decisions are expected by the end of this year.
CHI will continue to monitor progress on addressing the issue of dual eligibles, including best practices from other states and the progress of the national test.