Health insurers make progress in the hunt for dual-eligibles
Commonwealth Care Alliance, a Boston-based health plan found itself in a difficult position four years ago. It had signed up to participate in an experiment to improve care for people dually eligible for Medicare and Medicaid, but struggled to find beneficiaries who were passively enrolled in its plan. In all, 43% of those enrolled in CCA's duals demonstration plan were unreachable. The beneficiaries had provided the state with address and contact information, which was now outdated.
"It's been frankly pretty challenging, more than we originally estimated," said Chris Palmieri, CEO of the plan.
CCA wasn't alone in its struggle. Health plans in 13 states participating in the federal experiment known as the Financial Alignment Initiative were facing the same woes, potentially putting the initiative's future at risk. How could the plans better care for duals if they couldn't find them?
"The problem could seem unsurmountable," said Dr. Rafael Amezcua, medical director for L.A. Care Health Plan in California. "If we're going to have an impact on their health, we have to understand the context of their lives."
Payers have steadily overcome the challenge of finding enrollees, according to a CMS analysis released May 25. The CMS tracks whether health plans in the initiative have performed health risk assessments on dual-eligible beneficiaries within 90 days of enrolling in a demonstration plan. Health plans' success rate at conducting the assessments has jumped 20 percentage points from 2014 to 2016, from 69% to 89%, according to the study.
"CMS and states require plans to provide a more person-centered experience and that the care model promotes coordination of services for enrollees," the agency said in the notice. "Typically, the health risk assessment is the first step in a more comprehensive care coordination process."
Although the CMS didn't analyze what caused the health assessment rate increase, plans in the demonstration attribute the bump to a multi-prong approach that includes advanced data mining of pharmacy and hospital claims information.
These strategies have reduced costs for some plans, at least anecdotally. Within the first year of finding a hard-to-locate enrollee, CCA has seen a 7% drop on average in inpatient hospital claims and a 6% decrease in emergency room use, Palmieri said.
The improved health assessment rates come as more people actively enroll in the demonstrations. Early in the programs, beneficiaries were passively enrolled in plans if they did not opt out. Many enrollees were unaware they had been moved from Medicare fee-for-service plans to managed-care plans, according to Bridget Kelly, a spokeswoman for the California-based plan CalOptima.
That active participation makes it easier for plans to conduct health assessments, Kelly said.
In addition to claims data-mining, Molina Healthcare, which is participating in six demonstration states, relies on community partnerships and boots on the ground to search for beneficiaries.
Molina employees who hit the streets to find beneficiaries are called "Nancy Drew units," according to Lisa Rubino, the insurance company's senior vice president of duals strategy.
Payers say dual-eligible beneficiaries are a uniquely challenging population to serve, given the high percentage with multiple chronic conditions including physical and mental disabilities and substance abuse issues; also, a significant percentage are homeless.
"There are a number of attributes of individuals that are eligible for Medicare and Medicaid that don't exist in the commercial (insurance market) or in traditional Medicare," Rubino said.
Other plans have also found success with a boots-on-the-ground approach. "Knocking on someone's door with our well-trained community health outreach workers has made the biggest difference," said Scott Bluebond, a spokesman for AmeriHealth Caritas, which is participating in the demonstration in Michigan.
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