Vulnerable Populations

Person-centered care for Medicare/Medicaid dually eligible individuals.

Improving care for people challenged by both complex health needs and economic disadvantage is a central challenge of healthcare reform. New payment systems covering individuals dually eligible for both Medicare and Medicaid set the stage for changes in how care is coordinated and delivered for many of our most vulnerable healthcare consumers.

WHO ARE DUALS?

Dually-eligible individuals are a diverse population that is generally sicker and more vulnerable than those covered under Medicare or Medicaid alone.

Duals include significant proportions of the population with:

  • Frail health
  • Multiple chronic conditions
  • Physical disabilities
  • Serious mental illness
  • Intellectual or developmental disabilities

The majority of duals are elderly, but nearly 40% are under age 65.  Duals are about 5 times as likely to use long-term care services compared to non-dual Medicare beneficiaries. One out of six duals lives in a long-term care facility.

WHAT MAKES CARE FOR DUALS CHALLENGING?

Duals often have complex needs, stemming from health, economic and social factors.

  • 20% of duals have 5 or more chronic health conditions
  • 56% have incomes less than $10,000
  • Duals are more likely to be isolated, suffering from depression, or homeless

Individuals with complex needs often are unable to find primary care providers who are experienced in serving them.  Specialty and behavioral health providers are hard to access, and frequently aren’t working in close coordination with a primary care team.  The fragmented incentives of Medicare and Medicaid deter coordination of care.

The result is a system that both underserves people with complex needs, and is very costly to our healthcare system. In 2009, spending on duals accounted for $300 billion of the roughly $900 billion spent annually on Medicare and Medicaid. Costs are driven by high rates of hospitalizations and institutionalizations that should be avoidable through better care and supportive services. Fifteen percent of duals are institutionalized, compared with 1 % of non-dual Medicare beneficiaries. It is estimated that for duals, 39% of hospitalizations are avoidable. Recent studies suggest that coordinated health plans can substantially reduce unnecessary hospital readmissions for duals.

Demonstration projects have shown that integration, care coordination, enhanced social support, and clinically appropriate care plans can improve outcomes and health status for this population in a cost effective manner.  However, at the time the Affordable Care Act was passed, only 1.5% of dual-eligible beneficiaries were in health plans that involve care integration and over 80 % of enrollment in integrated plans was concentrated in just 10 states

WHAT CHANGES ARE TAKING PLACE?

Established by the Affordable Care Act, the CMS Medicare-Medicaid Coordination Office (MMCO) provides incentives for states to coordinate care for dually eligible individuals. Under the State Demonstrations to Integrate Care for Dual Eligible Individuals program, 11 states are currently proceeding with demonstration projects to cover more than 1.25 million dual-eligible individuals. Another 14 states indicate they plan to implement care integration for duals.

Most, but not all of these State programs are adopting capitated models which provide a risk-adjusted fixed payment from both Medicare and Medicaid to care plans, which are then responsible for coordinating delivery of services.

For consumers and advocates, there is hope that these new initiatives will be high-quality models of integrated care, but also concern that new managed care models will respond to cost pressures in disadvantageous ways.

WHAT WE'RE DOING

Vital Healthcare Capital (V-Cap) is working to help strong community based plans gain the capital resources they need to provide excellent integrated care for duals.

Organizations that provide care and coverage for vulnerable populations have a critical need for access to flexible financing. V-Cap supports programs and plans that are committed to:

  • Delivering quality, cost-effective, person-centered care
  • Enhancing the roles of frontline healthcare workers

Vital Healthcare Capital, in conjunction with the Robert Wood Johnson Foundation, has provided a $10 million innovative loan to support Commonwealth Care Alliance (CCA), a pioneering participant in early demonstration projects that showed the promise of integrating care for duals. This loan gives CCA the ability to scale its pioneering model as the first of these new care demonstrations proceeds in Massachusetts.

V-Cap expects to finance additional organizations – both providers and plans – that focus services on quality coordinated care for vulnerable populations.