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
0
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
$0.0
$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?
‐
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!