CMS to address issues with data systems for dual eligibles

The CMS is preparing to overhaul the data systems that states use to coordinate care for the 10 million Americans enrolled in both Medicare and Medicaid.

Dual eligibles tend to be sicker than other Medicare and Medicaid beneficiaries—half suffer from three or more chronic conditions and six in 10 have cognitive limitations. They account for disproportionate levels of Medicare and Medicaid spending, costing the programs more than $300 billion a year.

The high cost and poor quality of the care they receive is attributed by many experts to a lack of coordination between the programs. Part of the problem is that the data collection and reporting systems for dual eligibles are disjointed, according to the CMS.

To address the issue, the CMS plans to hire a roster of consulting companies to help it develop guidelines for states to integrate multiple datasets, consolidate databases, and extract data used in care coordination, according to a search notice (PDF) issued in December. A representative for the agency confirmed the search is underway.

States are pleased that the CMS is working on the problem.

Accessing data on dual eligibles can be a bureaucratic and technical obstacle course, state officials say. “In a nutshell, you jump through a lot of hoops without clear instructions, receive a massive data dump and hope you can get your system set up to sort, match and verify what you have received, or else you end up with a lot of data that you are unable to use at all,” said Dana Northrup, a planning coordinator in Oklahoma Health Care Authority.

One specific challenge is that Medicare Part D delivers pharmacy data only once a month rather than daily, making it difficult to manage medications, said Beverly Court, a research manager in the Washington State Department of Social and Health Services.

Another issue is that Medicare often changes beneficiary IDs and states have trouble tracking eligibility. “Two common myths about Medicare beneficiary IDs are that once a person is eligible for Medicare, their ID stays the same, and they are eligible forever, from that day forward,” said Melanie Lawrence, a health information technology manager for the Oklahoma Health Care Authority.

Some states, including Colorado and Massachusetts, have taken matters into their own hands and have hired vendors to integrate data for dual beneficiaries.

“Access to readily available linked data could reduce similar work for other states pursuing integrated care models,” said Julie Kaviar, a spokeswoman for the Massachusetts Department of Health and Human Services. “It would also support capacity for closer to real-time care management for health plans and providers.”

The data project comes as the CMS is rolls out a large three-year demonstration program aimed at delivering coordinated care for dual eligibles. Some participating states are struggling to attract health plans willing to take on the financial risk to administer the coordinated benefits.

Follow Virgil Dickson on Twitter: @MHvdickson