Defining the Duals: 13 Things to Know for Population Health Management

Friday, April 12th, 2013
This post was written by Patricia Donovan

dually eligible Medicare Medicaid

A quarter of duals need help with three or more of their activities of daily living.

Who are the dually eligible? There are about 9 million individuals in the United States eligible for both Medicare and Medicaid, notes Timothy C. Schwab, MD, FACP, chief medical officer of SCAN Health Plan. And before developing a case management or population health management approach for duals, it pays to identify its characteristics.

Dr. Schwab shares 13 things to know about the dually eligible:

  • The two main criteria for eligibility are that they are financially challenged, and old or disabled.
  • Fifty percent of duals are below the federal poverty level, and 65 percent of duals are over the age of 65.
  • Of those under 65, about 6.5 to 7 percent are using nursing homes (long-term custodial stay, not Medicare skilled service use).
  • Almost 22 percent of those over 65 have had some long-term stay in a nursing home.
  • Of the total dual population, about 13 percent have spent permanent time in a nursing home.
  • Almost 20 percent use some sort of home long-term services and supports.
  • About 40 percent of all duals meet nursing home certifiable (NHC) status. California now uses the term ‘nursing facility level of care.’ (These criteria vary from state to state.)
  • In the under-65 group, nearly 66 percent have only a chronic condition and have no functional impairments.
  • In the next age band, age 65-74, there’s less frailty and a little bit more chronic illness, but you start to see healthy people show up in this age band — about 6 percent here.
  • In the over-75 group, you start to see a decrease in those that only have chronic conditions with no frailty. Over a third now have frailty and chronic conditions.
  • In the over-85 group, the healthy population has gone down to under 2 percent, and almost two-thirds of the population now has a frailty or functional impairment, in addition to a number of chronic conditions.
  • The duals population differs from the straight Medicare population in terms of both functional impairments and number of chronic conditions: 17 percent of the Medicare population — less than a fifth — are duals, but over a quarter or 28 percent of those duals have five or more chronic conditions.
  • A quarter of duals need help with three or more of their activities of daily living (ADLs) compared to only 6 percent of the Medicare population.

Models for dual eligibles care by SCAN and others have shown that you can reduce the long-term nursing home stay to less than 5 percent overall, Dr. Schwab notes. In SCAN’s population and nationwide, it is important to know which age bands you’re going to be dealing with. For example, Massachusetts’s new program serves only the people under 65, so that state will have to develop plans to focus more on these chronic conditions without functional impairment. Whereas if you’re dealing with the ‘old old,’ you need to incorporate a case management program that deals with a lot more people with functional impairments.

Due to the differences between the Medicare population and duals, Medicare models may not be effective, he says. “If you’re taking a case management program out of a straight Medicare plan, you see that both the volume and the focus is going to be quite different.”

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