Dual-eligibles make up 20% of Medicare enrollees but account for 31% of Medicare spending, the authors wrote, citing data from the Kaiser Family Foundation. For Medicaid, dual-eligibles represent 15% of the population and 39% of Medicaid spending, as of 2008.
The measures could be used in the CMS' demonstration, which did raise the stakes for the effort, said Alice Lind, senior clinical officer at the Center for Health Care Strategies, and chairwoman of the dual-eligibles work group of MAP, a public-private partnership chosen by HHS as a result of provisions of the Patient Protection and Affordable Care Act, and convened by the NQF.
The MAP report highlighted seven measures that are the most ready for implementation right away, including measures related to care transitions, readmissions, and treating clinical depression and alcohol or drug dependence.
But some groups want the CMS to ease up on the gas. The Alliance of Specialty Medicine, an association of specialty medical societies, suggested in late May that the CMS delay its pilot for at least a year. The Federation of American Hospitals also urged the CMS to slow its implementation. States are moving too quickly and in too large numbers for a program that needs better definition, the FAH argued in an April letter to Marilyn Tavenner, acting administrator of the CMS.
The MAP report also included five core aspects of care that the authors believe provide “high-value signals of improvement over time.” They are: a continual need for follow-up care and the availability of support services; coordination of care; patient preferences, experience and engagement in care; the ongoing management and risks of chronic health conditions; and patient quality of life and functional status.
Still left unanswered, though, is the question of how to measure costs related to the dual-eligible beneficiaries, as providers for these patients are reimbursed in a variety of ways by their respective state Medicaid programs. There are esoteric aspects to measuring the cost of care that should be included if it's going to be done right, Lind said. The current set of available standardized measures won't work for the dual-eligible population, she said.
As a result, the work group report highlighted cost measures as an important gap to be addressed in the future, along with measures concerning person-centered care planning, connections between the healthcare system and community supports, beneficiaries' sense of autonomy and health literacy screening.
Something that went unexpectedly well, given the diverse interests of the representatives on the work group, was that the assembly for the most part kept its focus on the needs of the patients, Lind said. She said that it's typical among Medicaid stakeholders for discussions to include a lot of self-interested talk about different specific needs, “But in this group I was continually struck by how people would put aside their personal agenda.”