Understanding the Economics of Dual Eligible Consumers in Healthcare

JUL 31

There are approximately nine million Medicare and Medicaid jointly eligible consumers in the United States. These “duals” are typically low-income, elderly, or disabled persons who qualify for both Medicare and Medicaid programs, and caring for them has become an unsustainable cost burden for the U.S. economy. The Centers for Medicare and Medicaid Services (CMS), federal and state policymakers, and many governmental and private healthcare organizations are acutely aware that we need to rethink how the healthcare system addresses the care needs and benefits coordination across Medicare and Medicaid programs to better serve this vulnerable and costly population.

A lesser known part of the Patient Protection and Affordable Care Act (PPACA) addresses duals by establishing a coordination office within CMS to trial various programs, including creating capitated models and shared savings for managed care plans. These demonstration projects are to shift the majority of duals into capitated managed care programs within five years of the Act’s passage.

Many health insurers have shown strong enthusiasm toward capturing their share of the $300 billion spent annually to manage duals. In particular, payers with strong capabilities for managing seniors and Medicaid beneficiaries project significant revenue growth and profitability as these dollars move out of state or federally managed Medicaid or Medicare programs and into managed care. In addition, many insurers have quickly built out their seniors and Medicaid capabilities via both acquisition and infrastructure investments in the hopes of winning a large share of the demonstration projects, members, and dollars. This began in 2012, when CMS began lining up large-scale demonstration projects, and several payers forecasted positive revenue impacts regarding the massive dual eligible managed care opportunity.

While many of the Medicaid managed care plans are still bullish about revenue upside from their dual demonstration projects, it has taken longer than initially envisioned for many of the states to setup their programs and align with their payer partners. Still, there remains a tremendous opportunity for the health plans in managing this population, for the states and federal government to seek better cost savings models, and ultimately for this population who frequently needs better services that they can get from a fragmented system.

Some of these managed care organizations recognize the investment needed in care management infrastructure and the uncertainty of shared savings benefits. Additionally, many states are bidding out their Medicaid contracts as they shift from fee-for-service (FFS) to a managed care approach to Medicaid medical management, and this represents a more immediate opportunity for many of the managed care companies.

TripleTree believes that managed care companies can offer meaningful improvements in care and cost. Even though CMS is slow out of the gates with its demonstration projects with delayed project start times and smaller beneficiary participation than first envisioned, these demonstration programs will provide long-term program savings and care benefits within the dual population. States are learning how to contract with CMS and payers for shared savings contracts, and payers will have more time to build competencies and capabilities in care management for the most complex and chronically ill within their populations.

In our view, the duals are a good opportunity for plans with the right capabilities or who can, in understanding the needed areas, make the investment. The duals opportunity however, is not the ‘pot o’ gold’ at the end of the rainbow that it may seem. The challenges in the models are many and the financial incentives are not clear. Rather, plans already are preparing for Medicare Advantage (MA), community based care, bundled payments, and other models that better align the payer and integrated care/PCP system will likely (and are perhaps unknowingly building the needed capabilities for duals).  In that case, they may look to leverage investments already made in Medicare, Medicaid, and even in their commercial platforms.

We’re spending a lot of time in this important area of healthcare and welcome your questions.  Until then, let us know what you think.

Scott Donahue
Like most websites we use cookies here, but we don't share your information. By continuing your visit, you accept the use of cookies. Find out more