Medicare Advantage (MA) plans serving a high proportion of dually enrolled Medicare and Medicaid beneficiaries have lower performance and lower MA Star Ratings on average compared to plans serving a lower proportion of dually enrolled beneficiaries, according to a research report by the Assistant Secretary for Planning and Evaluation (ASPE) Office of Health Policy (OHP). A related report found that addressing social determinants of health (SDOH) plays a key role in improving overall health (Types and Costs of Services for Dual Beneficiaries by Medicare Advantage Health Plans, October 15, 2018; Addressing Social Determinants of Health Needs of Dually Enrolled Beneficiaries in Medicare Advantage Plans, October 15, 2018).
Meeting needs of high-cost, high-need patients. Dual enrollment in Medicare and Medicaid is a marker for living in poverty. Some MA plans serving a large proportion of dually enrolled beneficiaries are high performers, suggesting that, with appropriate strategies, it is possible to provide high-quality care in high risk populations. In the first phase of its study, the OHP found that the needs of dually enrolled beneficiaries largely parallel the needs of high-cost, high-need patients, as social and medical risks usually correspond with each other. The OHP also found that health plans, providers, and community partners adopt a variety of strategies to meet the needs of the dually enrolled and other high-cost, high-need beneficiaries. Evidence is still developing, but these actions seem to improve health outcomes and health care costs. These activities include:
- identifying needs and data analytics to target patients at high risk for hospitalization, readmission, and nursing home admission;
- addressing clinical needs through care management and coordination;
- meeting social needs of dually enrolled beneficiaries by referring them to existing programs to address housing, food security, and transportation needs or providing such services directly; and
- taking administrative action to better integrate Medicare and Medicaid, such as Fully Integrated Dual Eligible (FIDE) special needs plans, created under section 2602 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) which are required to coordinate care between Medicare and Medicaid.
The OHP found that little information exists regarding resources or costs required to implement and sustain strategies for meeting the needs of high-cost, high-need patients. Furthermore, there is a lack of strong, consistent evidence regarding the strategies, and questions remain about how the needs of the dually enrolled and other high-cost, high-need beneficiaries are met.
Addressing the social determinants of health. In a second research report, the OHP found that addressing the SDOH is an important key factor in determining overall health. In fact, some high-performing MA plans reported taking steps to address SDOH, including identifying clinical and nonclinical needs to provide better care and directly addressing needs for housing, food, and transportation. To inform CMS’s policies with a better understanding of the services provided by high-performing MA plans, the OHP characterized the needs of dually enrolled beneficiaries; identified the additional services health plans provide to such beneficiaries; identified the range of added costs and resources needed to deliver such services; and assessed the available evidence on whether the services are associated with better quality and outcomes.
The OHP found that the challenges for dually enrolled and high-need beneficiaries included a mix of complex clinical issues and SDOH risk factors such as low health literacy, poverty, lack of transportation, and food and housing insecurity—frequently paired with inadequate services in the community. It also found that a range of high-performing MA plans implemented multipronged approaches to address the needs of complex member populations. The findings were consistent with the strategies the OHP identified previously.
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