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Why Those Interested in Population Health and ACO Development Need to Think About the Dual-Eligible Population

December 15, 2015
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My interview with United Healthcare’s Dr. Deshpande at iHT2-Houston offered insights into care management opportunities going forward

It was excellent to be able to interview Salil Deshpande, M.D. last week, during the final session of the Health IT Summit in Houston, sponsored by our sister organization, the Institute for Health Technology Transformation (iHT2). I was hoping that Dr. Desphande, chief medical officer of the Houston-based United Healthcare Community Plan of Texas, a division of United Healthcare of Texas, might be able to offer some insights on some of the populations that United Healthcare serves in Houston and across Texas, and he indeed was able to do so.

I was particularly interested in Dr. Deshpande’s insights around the Medicare/Medicaid dual-eligible population. That is a population with very intense needs and extremely difficult situations, with many elements that are not strictly clinical, but rather, involve socioeconomic and other factors. I’ve been writing about care management for dual-eligibles for nearly 20 years now, and it is in fact the combination of clinical issues and often very intensive social determinants of care and care management, that makes it so challenging to care for these health plan members/patients.

As Dr. Deshpande told our audience last Wednesday, “[T]o step back for a moment, that emphasis on dual-eligibles, it is something that is a priority for the health plans. I think the focus and the eye on healthcare will continue for the country as a whole. It is obviously an issue that the payer industry is also very focused on. There’s been increased access to healthcare for the past several years. We expect that additional people will continue to move into the insured category. There are still continued pressures around healthcare costs in general, of course, but of those reasons will underlie why we are continuing to focus on healthcare as a society.”

He added that, “In terms of the cost pressure, that issue is particularly relevant among the dual-eligible population. They are among the sicker people, and are either elderly or have qualified for SSI by virtue of some other disability, and also are likely to be living below the poverty line. And they likely have a history of lack of access to care, that has caused their chronic conditions to be under-diagnosed. And for all those reasons, that patient population tends to be an expensive one, but with opportunities for healthcare improvement. That is the reality for any population,” Dr. Deshpande noted, “but more dramatically in the elderly population and among relatively poor populations; in both cases, a relatively small percentage of members are driving the expenses. So to the extent that we can drive care management, we will both improve outcomes and lower costs, and thus, the focus on dual-eligible members makes eminent sense.”

What’s interesting for me about my discussion at iHT2 with Dr. Deshpande is how for years, health plan care management of the dual-eligible population was seen as something very specialized, something very difficult and challenging, and not even something that most health plans expended a lot of energy on. Certainly, few providers were focused specifically on that high-needs group.

And yet now, as healthcare costs in the U.S continue to increase, and as American society ages and chronic illness continues to explode, what is really interesting is this: I believe that the health plans whose success in managing the care and health status of their dual-eligible members—people who are usually elderly and impoverished and very often in quite poor health—will be able to help show the way for everyone with regard to how to manage the care of all types of populations, in the emerging health care system—one in which providers and plans will have to work with relatively fewer resources while managing more complex, challenging health status, care management, and patient care situations.

Indeed, the forward evolution of accountable care organization (ACO) and population health management development, is beginning to make what has been learned so far in the care management of dual-eligibles quite timely and relevant—even though some health plans began working more extensively with that population years ago.

I remember researching and writing an article 20 years ago for a managed care-focused publication about the innovations then taking place among a smallish number of health plans around the care management and case management of its dual-eligible members. It was fascinating, in doing the interviews for that article, to speak with one of the care management executives at one health plan that had made considerable strides with the care management of that plan’s dual-eligible population. She noted that going into the homes of members and checking for hazards, including fall hazards, was one of the things that was absolutely necessary to do, in working to support her organization’s dual-eligible population. In some cases, she and her colleagues were even having handrails installed, in order to avert potential falls that could lead to hip fractures, for example.