“Dual eligibles” are those beneficiaries who are eligible for both Medicare and Medicaid. They are among the sickest and most costly of all cohorts in the United States. To complicate matters, the coordination between Medicare and Medicaid is extremely poor, leading to not only excessive and unwarranted costs, but also extraordinary inconvenience and poor quality of care.
Some of the key features of this population:
- They make up 15% of the Medicaid population, but account for 40% of the costs.
- Hospitalization costs for this population are deemed to be unnecessary almost half of the time, at a cost of $3-4 billion annually.
- The directives for nursing home care and home care are under Medicaid’s auspices, while physician and hospital services are directed by Medicare.
It is clear that in a totally disjointed “system” that now exists for this population, there is an enormous amount of unnecessary and redundant care, much of which could be the target of CareCore’s programs to not only ensure that appropriate care was being delivered, but perhaps more importantly that coordinated care was at the center of the system. Eliminating duplicated high cost imaging studies would almost certainly save money not just from the studies themselves, but more importantly would provide continuum of care data to prevent unnecessary hospitalizations.
The Affordable Care Act has a provision to create an office dedicated to coordinate the care and reimbursement of care for “dual eligibles” and there are a number of demonstration programs in place in several states that aim to improve coordination of care for these beneficiaries.
Is another government “office” going to solve the problems with the cost and utilization?