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 $15,459 in 2007, over six times higher than the comparable cost of a non-disabled adult covered by Medicaid ($2,541).
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 the 9.2 million duals, there are distinct groups with very distinct needs and preferences. They are poor seniors, 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 38% of the duals are under age 65. But that figure varies greatly across states from a low of 29% in California to a high of 52% in Utah. The “younger” duals are more likely to have serious mental illness or intellectual and developmental disabilities. (It is estimated that approximately 8-9% of duals are individuals with I/DD.) Many duals have both physical and mental health needs.
About 17% 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
The Center for Medicare and Medicaid Services (CMS) Medicare-Medicaid Coordination Office (MMCO) awarded $1 million State Demonstrations to Integrate Care for Dual Eligible Individuals grants to 15 states to design new approaches to coordinate care for individuals who are eligible for both Medicare and Medicaid. The states will use the grants to design models that coordinate primary care, acute care, behavioral health, and long term services and supports. A summary of each state’s design is available on the MMCO website.
The 15 selected states are California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin. Each state is required to include the public in the development of the integration models. State and local Arc Chapters in those states, as well as other advocates for people with disabilities, should be included in the planning and design of the models to ensure representation by people with intellectual and developmental disabilities who are dually eligible.
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 be little to no cost savings available through integrating and coordinating care for people with I/DD. The 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.