A Path Forward for Medicare-Medicaid Enrollees

By Leena Sharma,  Center for Consumer Engagement in Health Innovation

Nearly 12 million individuals are enrolled in both Medicare and Medicaid. This “dually eligible” population has more significant health and functional support needs than either Medicaid-only or Medicare-only populations. At the same time, individuals who are dually eligible face significant challenges in receiving well-coordinated care that is aligned with their needs. Improving care for this population is an important priority for policymakers interested in achieving better health outcomes and containing health care costs.

On November 28, 2018, the Center for Consumer Engagement in Health Innovation (the Center), with the generous support of The Commonwealth Fund, The John A. Hartford Foundation, the Peterson Center on Healthcare, The SCAN Foundation, and the Valerie Wilbur Health Policy Fellowship Fund, hosted a symposium to reflect on the lessons learned thus far about caring for Medicare-Medicaid enrollees and the implications of those lessons for the future. Given our longstanding work with Medicare-Medicaid enrollees to build the leadership of consumers and to create person-centered care innovations, we were delighted to have a chance to bring together consumers, advocates, policymakers, providers, health plans, and researchers to address this important topic.

David Stevenson, PhD, from the Department of Health Care Policy at Vanderbilt School of Medicine summarized findings from the symposium, highlighting the following themes:

  • Humility and the Importance of Person-Centered Care - A key challenge that was articulated for integration efforts is to coordinate service delivery across disparate providers and settings and align these services and supports with each consumer’s distinct preferences and living situation. Asking consumers, “How can we help?” is one of the most effective ways for plans to meet the needs of the people they serve.
  • Optimism and the Role of Evidence - Despite the substantial challenges of integration, a sense of optimism permeated the symposium. Although comprehensive results have been slow to be released, reflecting the need for programs to break down silos in service and financing and to be responsive to the populations they serve, the Symposium highlighted the promising results achieved thus far through various integration efforts.
  • Savings and Why It Matters - For both the federal government and for states, the potential to provide higher-quality care more efficiently is a primary justification for integration initiatives. Symposium participants acknowledged the need to consider financial outcomes while also emphasizing that integration efforts should be judged on more than their ability to produce savings.
  • Implementation and the Challenge of Meeting Diverse Consumer Needs - A key strength of integrated programs is their potential to reduce fragmentation of services and consider the needs of individuals more holistically, which means taking a more expansive view of solutions. A unifying theme throughout the symposium was that achieving success relied on effective coordination across clinical disciplines and community partners.
  • Expansion and the Path to Sustainability - A majority of dually eligible individuals are not in any sort of integrated care arrangement. While there was robust discussion among symposium participants about expansion of programs and practices, ultimately, what happens next will depend on actions taken at the federal and state levels. Effective action will require strong leadership, political will, and advocacy.
  • Accountability and the Prioritization of Quality - Quality means more than simply avoiding negative outcomes. There are currently important gaps in measuring quality, related both to data limitations and to a lack of person-centered measures, particularly for long-term services and supports. Having robust quality assurance mechanisms in place to respond to complaints, as well as effective grievance and appeals processes, will be crucial as integration efforts are expanded.    

We are optimistic about the future of care for Medicare-Medicaid enrollees. We have seen in our work how integrated, person-centered care can be life-changing for consumers. At the same time, when designing programs for people with complex needs, the details are critically important and there are many gaps between good intentions and good implementation. The report from the symposium includes ten recommendations to help fulfill the promise of integrated care. We believe that consumers and advocates have a critical role to play in ensuring that a commitment to quality of care and the consumer experience remains at the forefront of care innovation.    

Editor’s Note: To learn more about the complete findings from symposium called “The Dual Imperative: What’s Next for Medicare-Medicaid Enrollees” on the Playbook, check out our resource summary.