Seeking High-Quality Care for Dual Eligibles

Who are dual eligibles?

Dual eligibles are those beneficiaries who are enrolled in both the Medicare and Medicaid programs. They are a population of nine million and includes some of the sickest and most vulnerable individuals covered by the two programs. Not surprisingly, they have on average, greater health and long term services and support needs than beneficiaries who have either Medicaid or Medicare coverage. For example,  2009 data of the Illinois dual eligibles population shows:

  • 338.582 individuals are dual eligible (3.6 percent of the nation's total),
  • 19% of the state's Medicare beneficiaries are dual eligible (21% nationally),
  • 28% of Medicaid spending in Illinois is generated by dual eligibles -- $12,684 per dual eligible (38% nationally),
  • 13% of the state's Medicaid beneficiaries are dual eligibles (15% nationally).

Since they disproportionately impact the total cost of both programs, improving health care delivery to dual eligibles would go a long way to addressing escalating federal and state health care expense. How to measure what high-quality care would look like for the dual eligible population is the subject of the fifth report authored by the Measure Applications Partnership (MAP), "Measuring Healthcare Quality In the Dual Eligible Beneficiary Population: Final Report June 2012".

What is MAP?

MAP is a public-private partnership that reviews performance measures for potential use in federal public reporting and performance-based payment programs. Its decision making process is consensus-based and MAP participants include many stake-holders (e.g. business, clinicians, researchers, labor, consumers, etc.) to ensure that it will provide varied and thoughtful input to the federal government. MAP is unique in the eldercare ecosystem and its reports inform the process of creating better, more affordable care and healthier people.

Findings:

In this report, MAP identifies a set of specific performance measures that are sensitive to the unique needs of the dual eligible population. Although the +100 page report contains too much detail to easily summarize in a post, it is worth noting that five "high-leverage opportunity areas" are identified where measurement strategies would have the largest impact: care coordination, quality of life, mental health and substance use, screening and assessment and structural measures. Although a core set of 26 measures ultimately emerged, there currently exists no single federal measurement tool devoted to monitoring quality of care for dual eligibles. Given the lack of a measurement tool,  the report does successfully identify the existing measurement tools (where possible), used by different providers in a variety of care settings which are relevant to some of the core set of 26 measures. However, MAP identifies a lengthy list of measure development gaps, which reveals that, "many concepts considered core to improving the quality of care and supports for dual eligible beneficiaries are not yet measurable." One of the most significant gaps is the lack of quality measures for dual eligibles receiving home and community based services (HCBS), despite the fact that two out of every three HCBS recipients are dual eligible beneficiaries. The explanation for why gaps exist are varied and complex and the report notes that resolving the gaps in data will depend upon short-term and long term-strategies involving many stake holders.

How do the finding relate to Illinois?

The Director of Healthcare and Family Services, Julie Hamos is currently supporting initiatives to create an integrated Medicare-Medicaid program (i.e. managed care) in Illinois by 2013. In managed care, dual eligibles would receive most or all of their Medicare and Medicaid services through a single entity that is accountable for the quality and cost of those services.

The conclusions of the the MAP report are as relevant in Illinois as they are on the federal level: measurements matter. They drive data collection and data drives policy. As Illinois embarks on implementation of mamanged care for dual eligibles it is critical that elders and their advocates ask policy makers to reveal how they will measure success. Currently in Illinois like other states, a variety of collection tools, forms and surveys are used and often the state is unable to gather, analyze and integrate all the relevant data. Insufficient funding and lack of resources presents other challenges to policy makers and regulators as they study this population. Just as MAP suggests, this report offers a framework for improving efforts to serve dual eligibles by developing benchmarks to understand what quality care would look like. This past week, the Jewish Federation of Metropolitan Chicago, funder of the largest social services network in Illinois, in a published statement called upon Director Julie Hamos to delay enrolling dual eligibles into managed care, until sufficient data is collected.

What does any of this matter?

Today's political campaigns are anathema to reasoned debate informed by experience rather then partisan political positions. For example, one should not present a plan which calls for the destruction of Medicare and simultaneously campaign on a platform articulating support for the program: it's intellectually dishonest and morally bankrupt.

MAP's report is an excellent example of the elder care ecosystem at work: diverse stake-holders empowered to determine how to understand current care delivery and by doing so, developing recommendations on how to improve the delivery of care.

What do you think? Have you ever considered this aspect of the elder care ecosystem? Learn more on Twitter @aginginchicago.

 

Click here to read the Illinois Medicare-Medicaid State Profile published by the Center for Medicare and Medicaid Services (CMS) in 2012.

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    Bruce Lederman

    Bruce Lederman has over 25 years experience in the senior care field as a direct care provider and thought leader. Bruce was CEO and president of his own firm that operated skilled nursing facilities in Illinois. He is a former nursing home administrator and has consulted to numerous elder care providers on planning for strategic growth as well as process improvement. Recently he served as board chair of CJE SeniorLife, a leading non-profit elder care provider in the Chicago area. Bruce is currently employed as chief strategy officer for a multi-facility skilled nursing facility company.

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