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BPC Calls for Aligning Medicare-Medicaid Services, Improving Care for Vulnerable, Chronically Ill Patients

Washington, D.C. – A new report released today by the Bipartisan Policy Center calls for policy proposals that would better integrate care for patients who are “dually eligible” for both Medicare and Medicaid. New data highlighted in the report show that these individuals who are admitted to the hospital for congestive heart failure or COPD are twice as likely to be re-hospitalized during the year compared to all other Medicare beneficiaries with the same conditions. This stark difference in re-hospitalization rates underscores the need for better coordinated care for our nation’s most vulnerable, chronically ill patients.

An estimated 10.3 million low-income, elderly patients and individuals with disabilities qualify for both Medicare and Medicaid, and many of whom must navigate between the two systems.

In extreme cases they may have two to five enrollment cards, two processes for coverage appeals, two or more sets of rules for benefits and cost-sharing, and two enrollment periods and deadlines for applications.

BPC’s recommendations call for revising existing payment models to better integrate care for dual-eligible patients; creating a new framework for providing health and health-related services to these patients; and consolidating the regulatory authority for dual-eligible policies within the Medicare-Medicaid Coordination Office at the Centers for Medicare and Medicaid Services. The intended result is a streamlined system that provides higher quality care.

“We should give plans and providers the ability to work with patients and their families to develop care plans that are specific to a patients’ needs, as opposed to what is covered under federal and state Medicare and Medicaid regulations,” said Katherine Hayes, director of BPC health policy.

Preliminary research shows that by removing the barriers to integrating the clinical and health-related social services in Medicare and Medicaid, and by eliminating unnecessary administrative complexities in the delivery system, providers and health plans can improve patient outcomes, enhance the patient experience, reduce hospitalizations, and address social determinants of health.

“While the Centers for Medicare and Medicaid Services, health care providers, plans, and states have made heroic efforts to better integrate care for dual-eligible beneficiaries, significant barriers to integration continue to exist,” said former Senate Majority Leader Tom Daschle, co-chair of BPC’s Health Project. “Improving the integration of services will take time as more states, plans, and providers gain experience in tailoring care for this diverse population. Creating a more patient-centered system for these vulnerable beneficiaries has the potential to greatly improve both the quality and value of care they receive.”

Based on 2011 Medicare and Medicaid claims and administrative data, BPC’s analysis compared cost and utilization patterns for full-benefit dual-eligible patients relative to all other Medicare beneficiaries. The results released today are part of BPC’s new report, Delivery System Reform: Caring for Individuals Dually Eligible for Medicare and Medicaid, which also includes proposals to better align and financially integrate health care programs for individuals with complex health needs.

“This new analysis confirms that high-need patients with low incomes are especially vulnerable to multiple hospitalizations and emergency room visits,” said former Senate Majority Leader Bill Frist, M.D., co-chair of BPC’s Health Project. “More importantly, the data show that better care coordination not only reduces these costly hospitalizations and ER trips, but in some states, has led to an expansion of home and community-based services that extend the time patients are able to remain in the comfort of their own homes.”

For more than two decades, health care providers and policymakers have sought ways to better coordinate care for dual-eligible individuals. BPC’s report points to the success of several programs around the country, including the Programs of All-Inclusive Care for the Elderly, Medicare Advantage Dual-Eligible Special Needs Plans, Minnesota Senior Health Option, and California’s MediConnect. BPC’s recommendations encourage CMS and the Department of Health and Human Services to improve and scale these successful programs as a way to launch a more patient-centered approach for this vulnerable population.

“CMS, states, plans and providers have learned important lessons about how best to treat high-need patients,” added Hayes. “Building on those lessons to better align Medicare and Medicaid benefits and payment incentives over time will allow providers to focus on their patients’ needs rather than on the need to navigate conflicting state and federal regulations.”

BPC will release a second report in 2017 to address similar issues in other Medicare reimbursement structures, including Medicare Advantage, the Medicare Shared Savings Program for Accountable Care Organizations, and Medicare demonstrations.

BPC’s report is supported by a grant from the Peterson Center on Healthcare.

Explore the full report and infographic