Delivering Improved Clinical and Financial Outcomes forDual Eligible Patients

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Delivering Improved Clinical and Financial Outcomes for Dual-Eligible Patients

Introduction

Caring for dual-eligible patients presents challenges and opportunities for home care organizations. Both federal and state agencies continue to focus on this group of beneficiaries due to the growing population and rising costs. Managed care solutions have the potential to change the landscape of healthcare delivery for these patients. Successful adaptation to the changes will come with understanding the payers' goals, using the right analytical tools, and robust revenue cycle awareness.

Attendees will better understand the categories of dual eligibility, demographic characteristics of the population, legislative landscape, and current challenges facing providers caring for this population of patients. Development and implementation of best practices both clinically and financially will align providers and payers to create better clinical and financial outcomes for the dual-eligible population.

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Medicare and Medicaid Definitions

MEDICARE• Title 18 of Social Security Act• Covers acute and post-acute care services• Consists of four parts

– Part A Inpatient– Part B Professional– Part C Advantage Plans– Part D Pharmacy

MEDICAID• Title 19 of the Social Security Act• Covers long-term and social support services• Administered by individual states

Medicare and Medicaid Growth

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10

20

30

40

50

60

70

80

90

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

MILLIO

NSB

ILLIONS

Medicare and Medicaid Growth

Medicare Spending Medicaid Spending Medicare Enrollment Medicaid Enrollment

SOURCE:  Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group.

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Home Health Expenditures

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$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

$90.0

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

BIILLIONS

Home Health Expenditures

Medicare Spending Medicaid Spending Private Insurance Spending Out of Pocket Spending Other Third Party Spending Other Ins Spending

SOURCE:  Centers for Medicare & Medicaid Services, Office of the Actuary.

What is a Dual-Eligible?

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 2

 4

 6

 8

 10

 12

 14

Millions

Dual‐Eligible Enrollment

Duals Full Duals

Partial Dual-Eligible• Medicaid plans assist in Medicare

premium paymentsFull Dual-Eligible• Beneficiaries receive benefits from both

Medicare and Medicaid

SOURCE:  Centers for Medicare & Medicaid Services, Office of the Actuary.

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Dual-Eligible Characteristics

• Full Dual-Eligibles make up 13% of Medicare/Medicaid enrollment

• Full Dual-Eligibles account for 34% of Medicare/Medicaid spending

• Half of Dual-Eligibles qualified for Medicare dueto disability

• 20% have 3 or more chronic conditions• 40% utilize long-term care and social services• 85% of Dual-Eligibles live outside of nursing

homes.• Average healthcare spending per Dual-Eligible is

$33,400

Medicare65 & Older

End‐Stage Renal Disease

Disability

MedicaidLow incomeChildren <1965 & Older

BlindDisabled

Nursing home

Dual EligibleLow IncomeDisabled65 & Older

Social Characteristics

Dual-Eligibles are impacted by social determinants impacting health:• 61% female• 43% minority• 76% living in an urban area• 56% less than $30,000

household income• 64% with no college degree

Characteristic

Dual‐eligible BeneficiariesNon‐dual Medicare

Non‐dual Medicaid

AllUnder 65

65 & Older

Full Benefit

Partial Benefit

Gender

Male 39% 48% 32% 39% 40% 47% 53%

Female 61% 52% 68% 61% 60% 53% 47%

Race/Ethnicity

White 57% 62% 54% 55% 62% 85% 52%

African American 20% 24% 18% 20% 22% 8% 31%

Hispanic 16% 11% 19% 17% 13% 5% 13%

Other 7% 3% 10% 8% 2% 2% 4%

Residence

Urban 76% 74% 77% 78% 70% 77% 78%

Rural 24% 26% 23% 22% 30% 23% 22%

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Dual-Eligible Health Characteristics

Top Diagnoses• 29% diabetes• 17% COPD• 15% Congestive heart• 14% Dementia• 10% Osteoporosis

4%

1%

8%

13%

16%

9%

13%

13%

21%

26%

1+ Days in a SkilledNursing Facility

Long‐Term CareFacility Resident

1+ Days of HomeHealth Care

1+ Emergency RoomVisits

1+ Inpatient HospitalStays

Medicare Beneficiaries Who ReceiveAssistance From Medicaid

Other Medicare Beneficiaries

Source:  GAO analysis of CMA data.

Chronic Conditions

3.01

2.08

1.76

1.77

1.382.11

1.40

4.62

1.55

9.36

1.49

0

5

10

15

20

25

30

35

40

Percentage

Non Duals

Duals

Source: https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/Chronic‐Conditions/CC_Main.html

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Clinical Considerations

Dual-Eligibles are usually:• High need, High cost, High utilization• Disabled• Have multiple common chronic conditions• Disabilities to include ESRD• Depression (2.3x)• Alzheimer’s disease (2.4x)• Diabetes, asthma, heart failure and stroke (all ≥

1.5x).

Utilization of health services including:• Emergency room visits (2.8x)• Drug fills (2.2x)• Hospitalizations (1.8x)• Observation room visits (1.7x)• Unique medications (1.5x)• Outpatient visits (1.5x)

70% higher costs overall• 2.7x higher Part D drug spending• 2.8x higher spending on durable medical

equipment• 1.5x higher inpatient hospitalization costs• 1.3x higher spending on physician services and

tests

Dual-Eligibles perform worse on most quality outcomes:• 70% greater use of high-risk medications• 18% higher rates of potentially avoidable

hospitalizations overall

Issues and Concerns

“Federal and state policymakers have growing concerns about the

high costs of dual-eligible beneficiaries-”

Congressional Budget Office-”Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies”

Concerns identified by both Federal and state agencies: Fragmented or ineffective care Lack of care coordination Two distinct public programs Separate rate structures Financial alignment Multiple conditions and complex care required Chronic conditions Eligibility and enrollment Social determinants Shared outcomes Rising costs

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Federal Coordinated Health Care Office(FCHCO)

Section 2602 of the Patient Protection and Affordable Care Act of 2010 created the Federal Coordinated Health Care Office (FCHCO).

Goals of the FCHCO:• Full access to benefits from Medicare and

Medicaid• Simplify the process to access services• Improve quality of services• Increase understanding of and satisfaction

with coverage• Eliminate conflicts between Medicare and

Medicaid• Improve care continuity• Eliminate cost-shifting between programs• Improve the quality of provider performance

The FCHCO is charged with more effectively integrating Medicare and Medicaid benefits and with improving the coordination between the Federal and State Governments for dual-eligible beneficiaries.

Legislative Timeline

2003-Medicare Prescription Drug, Improvement and Modernization ActSpecial Needs Program (SNP) created by Congress as a type of Medicare Advantage Plan. No formal relationship with state agencies.

2006-First Dual-Eligible Special Needs Program (D-SNP) began.

2008-Medicare Improvements for Patients and Providers Act (MIPPA) extended the SNP program. NCQA contracted to develop strategy to evaluate quality of care provided by SNP’s.

2011-Patient Protection and Affordable Care Act (ACA) created the Federal Coordinated Health Care Office with the purpose to integrate benefits and improve coordination. Requires SNP’s to submit Models of Care.

2013-All D-SNP’s are required to be contracted with state Medicaid plans to coordinate care.

2018-Bipartisan Budget Act permanently authorized D-SNP’s and set minimum requirements to integrate Medicare and Medicaid benefits.

2021-Implementation of Final Rule.

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What have we learned so far?

Challenges• Disrupting the status quo• Making the case for integration

– to both beneficiaries and policymakers

• Limited state capacity/bandwidth

• Locating and engaging beneficiaries

• Increasing provider buy-in & appetite for financial risk

• Integrating LTSS, BH and other non-medical services

• Cost shifting and gaming• Scaling

Successes• Positive beneficiary experiences

and outcomes• Critical learning about

assessments, care plans and care teams

• Integration of LTSS, BH and other non-medical services

• Unprecedented level of investment in infrastructure, people and community supports

• Meaningful risk adjustment and payment change

Types of Dual-Eligible Plans

Full Dual-Eligible• Qualified Medicare Beneficiary

(QMB) plus• Specified Low-income Medicare

Beneficiary (SLMB) plus• Full Benefit Dual-Eligible

• Chronic Condition (C-SNP)• Institutional (I-SNP)• Dual-Eligible (D-SNP)

Partial Dual-Eligible• Qualified Medicare Beneficiary

Program (QMB)• Specified Low-Income Medicare

Beneficiary Program (SLMB)• Qualifying Individual Program

(QI)• Qualified Disabled Working

Individual (QDWI)

Benefit Category % of Duals Medicaid Benefits

Full-benefit dual-eligible 72%

QMB plus 51%Medicare Parts A & B premiums, cost-sharing, other Medicaid benefits

SLMB plus 3%Medicare Part B premiums, cost-sharing, other Medicaid benefits

Other FBDE 18%Medicare Parts A & B premiums, cost-sharing, other Medicaid benefits

Partial-benefit dual-eligible 28%

QMB only 13%Medicare Parts A & B premiums, cost-sharing, other Medicaid benefits

SLMB only 9% Medicare Part B premiums

QI 5% Medicare Part B premiums

QDWI <1% Medicare Part A premiums

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States with D-SNPs

SOURCE: Centers for Medicare & Medicaid Services. SNP comprehensive report. (2017a).

Integrated Plan Designs

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Programs of All-inclusive Care for the ElderlyPACE

Similar to D-SNPs Medical and social services

to frail and elderly individuals (most are duals)

Operates through a “health home” type model

Interdisciplinary team of healthcare providers

Care in homes or in the community

Avoid nursing homes or other long-term care institutions

Must be 55 or older Need nursing home care

PACE covered services include:• Adult day primary care• Dentistry• Emergency services• Home care• Hospital care• Laboratory/x-ray

services• Meals• Medical specialty

services• Nursing home care• Nutritional counseling• Occupational therapy• Physical therapy• Prescription drugs

States with PACE Programs

Source: Integrated Care Resource Center (ICRC). July 2018. See Program of All‐Inclusive Care for the Elderly (PACE) total enrollment by state and by organization.

Programs of All-inclusive Care for the ElderlyPACE

“As PACE programs grow faster and reach out to more communities, it will be unlikely that they’ll be able to just hire their own in-home staff to meet those needs.”Robert Greenwood, Vice President of Public Affairs at the National PACE Association

Opportunities• Integrated care delivery models will

improve efficiencies• Improved outcomes by integrating

behavioral health and medical models

• Development of next generation home health aides for improved functional status

• Improved care coordination to allow aging in place

“Now a fall may land a homebound patient in the emergency department, and eventually in a nursing home, just because neither Medicare nor Medicaid was paying anyone to arrange accessible toilet facilities for the person. Elderly patients admitted to the hospital once under Medicare may end up back in the hospital later just because no primary care provider ever helped them reconcile their new medication regimen with their previous one. The future is ours to determine.”

Why CMS’s Final PACE Rule Spells Opportunity for At-Home Care ProvidersJoyce Famakinwa, May 29, 2019

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Changing Healthcare Assumptions

• Treatment of Symptoms• Specialized silo care• Emphasis on

eliminating/controlling disease• Preventive care focus on

medical• Primary based care• Improved comorbidity• Skilled care• Behavioral health specialty

programs

• Search for a cause• Holistic care• Emphasis on wellness• Preventative care focus on

lifestyle & behaviors• Community interdisciplinary

based care• Improved function• Non-skilled care• Behavioral health integration

Illness-Wellness Continuum

Pre‐Mature Death

High‐Level 

Wellness

Comfort Zone(FALSE WELLNESS)

DISEASEMultiple medicationsPoor quality of life

Potential becomes limitedBody has limited function

POOR HEALTHSymptoms

Drug therapySurgery

Losing normal function

NEUTRALNo symptoms

Nutrition inconsistentExercise sporadic

Health not high priority

GOOD HEALTHRegular exerciseGood nutrition

Wellness educationMinimal nerve interference

OPTIMAL HEALTH100% function

Continuous developmentActive participationWellness lifestyle

0          1            2            3            4            5            6             7           8           9          10

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Creating Positive Health is More than a Risk Reduction

Pre‐Mature Death

High‐Level 

Wellness

WELLNESS PARADIGMWELLNESS PARADIGM

TREATMENT PARADIGMTREATMENT PARADIGM

Disability Symptoms Signs Awareness Education Growth

Neutral Point(No discernable illness or wellness)

Illness‐Wellness Continuum

The Nursing Process

ASSESSING

DIAGNOSING

PLANNING

IMPLEMENTING

EVALUATING

ASSESSMENT• Collect data• Organize data• Validate data

DIAGNOSING• Analyze data• Identify health problems, risks & strengths• Formulate diagnostic statements

PLANNING• Prioritize problems/diagnoses• Formulate goals/desired outcomes• Select nursing interventions• Write nursing interventions

IMPLEMENTING• Re‐assess the client• Determine the nurse’s need for assistance• Implement the nursing interventions• Supervise delegated care• Document nursing activities

EVALUATING• Collect data related to outcomes• Compare data with outcomes• Restate nursing actions to client goals/outcomes• Draw conclusions about problem status• Continue, modify, or terminate the client’s care plan

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Integrated Model of Care Design

Models include• Health risk assessment• Interdisciplinary care team• Care management team• Individualized care plan• Care coordination• D-SNP Benefits• Provider role• Staff role

Goals• Improve quality• Increase access• Create affordability• Integrate and coordinate care across specialties• Provide seamless transitions of care• Improve use of preventative health services• Encourage appropriate utilization and cost

effectiveness• Improve member health

Health Risk Assessment

• Identifies members with most urgent needs• Part of Care Coordination• Contain self-reported information• Helps create the individualized plan• Completed telephonically• Initial completed with 90 days of enrollment• Repeated annually

Assess the following needs: Medical Functional Cognitive Psychosocial Mental Health

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Health Risk Assessment

Interdisciplinary Care Team

Member & Care Manager

SNP Management Team Primary 

Care Provider

Specialists

Family/Caregiver

Social Services

Pharmacies

Vendors

Home Health

Determine each member’s goals Coordinate care Identify problems Educate members about

conditions/medications Coach members Refer members to resources Manage transitions Coordinate benefits Identify and assist with changes in

eligibility

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Individualized Care Plan

An individualized care plan is the mechanism for evaluating the member’s current health status. These plans contain specific problems, goals, and interventions.

Individual care plans use the following:• Health risk assessment• Laboratory results, pharmacy,

emergency, and hospital claim data• Interdisciplinary care team input• Member preferences and personal

goals

Plan of Care

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Care Coordination

To improve coordination of care:• PCP can be utilized as a gatekeeper.• Care Manager can coordinate with PCP, member and interdisciplinary team.

To improve transitions between care settings:• Communicate with PCP prior to transition.• Share care plans with PCP, hospitalist, facility, member and

caregiver (if applicable).• Provide communication and education to member prior to

transition.

To improve post-hospitalization care:• Follow up communications with member.• Reinforce discharge instructions and follow ups.• Assist with additional services such as home health and DME.• Ensure medications are obtained.

Provider Participation

• Participate in Interdisciplinary team• Focus on member’s special needs• Deliver care management programs

designed to assist with member’s medical and non-medical needs

• Support member’s plan of care

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Billing Options

Secondary Billing

•Medicare coverage

• Secondary responsibilities

•Primary must be filed first

• Secondary claim filed with Primary information

•Crossover claims

Split Billing

•Same claim

•Not covered by Medicare

•Medicaid coverage known

•Medicaid only services

Consolidated Billing

•FIDE SNP’s

•MA paid by both

•Coordination of authorized services

•One claim

Improper Billing

Causes of improper billing:• Providers may not understand or be aware of the prohibition on billing of QMBs

or other FBDEs.• Many states apply the “lessor of” rule to reduce cost-sharing.• Remittance advices or EOP may not clearly show that beneficiary is not

responsible.• Providers may not know they can bill Medicaid or how to bill Medicaid.• D-SNPs may not provide beneficiary’s plans or allow access to Medicaid

program details.• Plans are not able to monitor balance billing activities.

Balance billing is the practice in which Medicare providers seek to bill a beneficiary for Medicare cost sharing. Medicare cost sharing can include deductibles, coinsurance, and copayments.

Federal Balance Billing Statute: 42 U.S.C. 1396a (§1902(n)(3)(B) of SS Act). Medicare Managed Care regulations: 42 CFR 422.504(g)(1)(iii) CMS Medicare Managed Care Manual,  https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/Downloads/mc86c04.pdfMLN Mathttps://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/downloads/se1128.pdf

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Identifying Dual-eligibles

Identify Dual-eligible• HIPAA Eligibility Transaction System (HETS) data• Medicare Remittance Advice

• Crossover claims• Remittance Advice Remark Codes (RARC)

N781/N782• Contact the Medicare Advantage Plan• Medicaid eligibility-verification systems

Summary

Dual-eligible numbers and spend continue to increase and lawmakers are focused on finding a solution.

Commercial insurance appears to be the best solution to coordinate care and align financial incentives.

Specialty programs designed to treat chronic conditions and address social determinants will provide value to these programs.

Home care is well situated to coordinate care, deliver value, and improve outcomes for this population.

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Thank You!