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Dual-Eligibles: A Group Whose Needs Cry Out for IT

June 5, 2012
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What research—and decades of experience—are indicating how best to treat a vulnerable, resource-intensive group of older patients


The June issue of Health Affairs carries a package of articles focused on the so-called “dual-eligibles”—individuals who are eligible for coverage under both the Medicare and Medicaid programs. In a featured study (“Dx For a Careful Approach To Moving Dual-Eligible Beneficiaries Into Managed Care Plans”), Patricia Neuman of the Kaiser Family Foundation and her colleagues emphasize the need for payment reform in order to optimize the right incentives around caring for these beneficiaries, whose care costs a total of $319.5 billion every year between the two programs. In 2008, dual-leigibles made up 20 percent of the Medicare population, but accounted for 31 percent of that program’s spending; similarly, they comprised 15 percent of Medicaid beneficiaries, yet accounted for 39 percent of that program’s costs. Neuman and her co-authors offer five principles with which to guide payment reform efforts on behalf of these patients, and stress the need to accommodate diverse patient needs and to build in sufficient time for thoughtful plan development and accountability measures.

So, who are the dual-eligibles? Put very simply and starkly, they are old and they are poor, and they tend to be quite frail, and to have multiple co-morbidities. I remember the first feature article I wrote about innovations in care management for dual-eligible beneficiaries, about 15 years ago, for a managed care-focused publication. It was eye-opening to talk to health plan medical directors and care management experts about this group of patients. Picture a very indigent African-American woman, 79 years old, who is extremely frail, very socially isolated, and has both diabetes and COPD—and has already fallen twice in her ramshackle home. That type of individual is a typical dual-eligible.

Yet it was heartening to learn that a small number of health plans were already back then creating some very helpful solutions to the challenges of care management for such Medicare/Medicaid beneficiaries. Fundamentally, health plans like the Minneapolis-based Medica were figuring out how to intensively care-manage their dual-eligible members, providing them with very regular phone- and in-person-based nurse care managers, and literally checking in regularly on those members and doing things like ensuring that particularly frail plan members had simple solutions such as handrails in their homes to prevent falls, as well as, of course, the right medications and other clinical interventions.

Nowadays, with an array of information technology available, from care management software to data warehouses to report-writing software to health information exchange, the potential exists as never before for health plans and providers to collaborate to improve the care of dual-eligibles and other patients like them. Indeed, if clinical and care management software were well-suited to any purpose, it would be to the intensive chronic care management of patients with co-morbidities, multiple medications, and complex socio-medical situations.

So, as our society begins to zero in on this group of patients, patients with very intensive care management and other needs, it’s very good to know that the information technology exists to provide the tools needed both to dramatically improve their care management and improve our cost profile.

Who knows exactly how all this will play out in the coming decade? What’s certain is that the need to address the care management of this population, both for profoundly humanitarian reasons, and because of the cost burden facing our society—is only going to intensify going forward.