Dual Eligibles Demographics

When policymakers talk about duals, people who are eligible for both Medicare and Medicaid, they often talk about how costly they are. Oft cited statistics about duals point out that:

Medicare-Medicaid enrollees account for approximately $120 billion in federal and state spending – about twice as much as Medicaid spends on the 29 million children it covers. The Medicaid spending per Medicare-Medicaid enrollee was $16,325 in 2010 over five times higher than the comparable cost of a non-disabled adult covered by Medicaid ($3,025).

To understand the challenges faced by both the federal government and the states in trying to coordinate care for duals and hold down costs, it is important to understand who they are. The duals are anything but a homogeneous group. Many have multiple chronic conditions and need long term services and supports. Among the10.2 million duals, there are distinct groups with very distinct needs and preferences. They are poor seniors with and without chronic medical conditions, younger individuals with disabilities, and individuals with serious mental illness. All have very complex health care needs. Many also need long term services and supports.

Some people who are dually eligible for Medicare and Medicaid are people over 65 who are very poor. Most have several serious health conditions and many need long term services and supports. They see multiple health care providers and many take numerous prescription medications. Some dually eligible individuals have one, two, or multiple chronic conditions (66% have 3 or more chronic conditions), such as diabetes, heart disease, and chronic obstructive pulmonary disease which may require hospitalization. Some have cognitive impairments such as Alzheimer’s or dementia. Other duals have one, two, or more physical impairments that limit their activities of daily living (eating, bathing, and dressing).

About 41% of the duals are under age 65. But that figure varies greatly across states. In Massachusetts, Duals under age 65 make up 23% of the state’s Medicaid population; in New Hampshire and North Dakota, they comprise 58% of the Medicaid population. The “younger” Duals are more likely to have serious mental illness or intellectual and developmental disabilities. (It is estimated that approximately 7% of duals are individuals with I/DD.) Many duals have both physical and mental health needs.

About 16% of duals are in long term care facilities and account for about half of Medicare/Medicaid spending on duals. 70% of Medicaid spending for duals goes to long term care – both institutional and home and community based. Because they have multiple chronic conditions, duals tend to use more health care services, need to be hospitalized more frequently, make more visits to emergency rooms, have skilled nursing facility stays, use home health services, see specialists, and take many prescription medications.

State Demonstrations

In an effort to ensure seamless care for Duals, MMCO offered states the opportunity of test models in to align the financing of Medicare and Medicaid and integrate primary, acute, behavioral health and long term services and support for Duals. States will serve as laboratories and any models that are successful, especially those that result in cost savings, could result in nation-wide policy. Several states submitted proposals to MMCO for financial alignment projects.

  • Eight states have negotiated memorandum of understanding with CMS to test capitated models in which the state, CMS, and health plans enter into three-way contracts and the plans receive a prospective blended payment to provide comprehensive, coordinated care.
  • Two states have signed MOUs with CMS for managed fee-for-service models in which the state and CMS enter into an agreement that permits the state to share in Medicare savings for care coordination initiatives.

Integrating and coordinating acute care, behavioral health, and long term services and supports for people with I/DD who are duals is uncharted territory. Conceptually, the notion of integrating and coordinating care and services seems like an effective and efficient approach. It sounds like common sense. Practically, the idea may be fraught with peril for people with I/DD. There is virtually no research about integrated care models for people with I/DD. There may or may not be cost savings available through integrating and coordinating care for people with I/DD. The health care provider community’s record of providing health care to people with I/DD is not stellar. The system of long term services and supports for people with I/DD has taken years to develop and continually strives to improve. Despite these concerns, integrated and coordinated models of care may be inevitable. Allies of people with I/DD must get involved and be very vigilant.