Posts Tagged ‘Dual Eligibles’

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Community Linkages Support HCSC’s Holistic Approach to Duals

September 25th, 2014 by Cheryl Miller

Meeting the holistic needs of the individual, and not treating them as a diagnosis has been key to Health Care Services Corporation’s (HCSC) work with dual eligibles. Here, Julie Faulhaber, HCSC’s vice president of enterprise Medicaid, describes the organization’s innovative use of community care connections to engage the unique challenges of this largely older adult and disabled population in population health management.

Question: What are some examples of HCSC community connections and how do these linkages benefit Medicare-Medicaid beneficiaries?

Julie Faulhaber: Our community connections are really critical to the success of our program. We work with a number of different community agencies in our state: the community mental health centers, the public health agency, and also with those types of agencies that deliver long term care services or have worked with those with mental health concerns.

We work across the board. All of these agencies catch our members, and we try to have relationships with them in order to gain access to our members, for example to better understand the types of services and support that our members truly need and where to access them. That’s been a key component of our program. We also look for community health workers who have backgrounds in the cultural needs of our members, which helps to engage them initially and maintain engagement.

HIN: What are the most common behavioral health issues your duals face and how has HCSC addressed these issues?

Julie Faulhaber: Our members have the full range of behavioral health issues that one would expect in a dual eligible population. Of course, the majority of individuals are experiencing depression and those types of concerns are often in conjunction with some physical disability. Referring back to the previous question on community linkages, we develop relationships with community agencies that support people with mental illness.

Other behavioral health concerns include those agencies that help people with recovery from addiction. We also worked with an integrated team in our own model of people with behavioral health backgrounds as well as our traditional physical healthcare model. That integration has been important for us in meeting the holistic needs of the individual and not treating them as a diagnosis.

dual eligibles care
Julie Faulhaber, vice president, enterprise Medicaid for Health Care Service Corporation (HCSC), a $52 billion health insurance company with 13.2 million members operating in five states, is responsible for the leadership and oversight of HCSC’s Enterprise Medicaid Business. This includes expansion of Medicaid programs across HCSC’s Blue Cross Blue Shield plans in Illinois, Montana, New Mexico and Texas.

Source: Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population

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5 Ways to Reach, Engage Dual Eligibles

May 15th, 2014 by Cheryl Miller

It takes a village — and more — to locate, stratify and engage dual eligibles, says Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC), especially when they can range from school-aged children to elderly Native Americans. Here, she discusses how to best engage the company’s diverse population.

Here’s an example of a Centennial Care outreach plan, which includes our dual eligibles. It has our Medicaid adults and children. There are not very many school-based children that are dual eligibles, but there are some, so working with the school-based clinics, the nurses’ association, etc., helps us engage.

In the New Mexico market, working with the Native American community is very important in engagement and sometimes actually for locating our members. Working with the tribal government and their leadership, some of the urban health centers, Indian health organizations, and other community organizations under the Native American groups can be extremely helpful. And some of our populations work with our behavioral health groups so again, those community mental health centers and other community organizations serving those with mental health and behavioral health concerns are of value to us.

We also work with community and public health outreach in this market. Promotoras or community health workers are critical elements for us to not only engage, but then also to maintain our relationship with members. With some of these outside agencies, we often have contractual relationships, and are able to share personal health information back and forth. That makes it much easier for us to locate members, and also have some of the staff in these organizations be part of our interdisciplinary care team.

Excerpted from Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population.

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5 Considerations for Developing a Dual Eligibles Program

February 5th, 2014 by Jessica Fornarotto

Congress has responded to the differences and unique needs of the dual population, states Dr. Timothy Schwab, former CMO of SCAN Health Plan, creating the Office of the Duals and the Innovation Center.

Dr. Schwab stresses the importance of defining the goals and the population when developing or participating in a dual eligible program.

If you’re developing or participating, you need to define your goals, which will ultimately lead to how you develop the care management program and the metrics. Everything relates back to the Triple Aim of better health, better care and better cost.

It’s important to get as much information about the population you’re going to serve as possible. You need to look at the age bands, which is relatively easy for most states. You need to also look at how many people are in each age band, and what the program is going to serve.

Third, it’s important to understand the functional status of this population. This may be a little bit harder to get from the state because they probably only have information available for the population currently being served by the long-term supports and services programs in the community. And we know that there are people who aren’t being served that the state is not aware of.

When it comes to the medical status, the state has very little information on this because Medicare is the primary payor and the state only secondarily gets any information on medical status.

Fifth, the social status is also critical: Where do they live? What is their caregiver status? What percent of them have caregivers? What percent live in their own home? Then, you must consider issues such as language, literacy, and culture: What percent of them are non-English speaking? What cultural improvements must you consider when serving certain parts of the population?

Excerpted from: Population Health Management for Dual Eligibles: Blueprint for Care Coordination

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Community ‘Feet on the Street,’ HRAs Improve Dual Eligibles’ Health

January 14th, 2014 by Jessica Fornarotto

A local approach — the integration of public health with managed care — is what a lot of states and CMS are starting to look for, explains Pamme Taylor, vice president of advocacy and community-based programs for WellCare Health Plans.

In HIN’s special report, Community Care Connections for Dual Eligibles: Closing Social Gaps to Improve Health Outcomes, Taylor describes some of WellCare’s efforts to connect its dually eligible population to health services, including making contact, identifying services for each member and assessing health status via health risk assessments (HRAs) that are part of these community services.

Question: What is WellCare’s strategy and practice for contacting dual eligible members and ensuring follow-through with recommended referrals to community support services?

Response: This question is two-fold; first, how do we reach the members and get them engaged? And second, how do we verify that services were rendered? For members, we have street teams that go out into the community investments. We also have community health workers on our interdisciplinary team. It’s their job to connect with our members on a face-to-face basis while also connecting them to community supports. It’s through that model that we heavily rely on engagement and connectivity, etc.

Our first line of outreach is through the phone; our second line is through the community health workers and the individuals that are ‘feet on the street.’ And then, how do we verify that services were rendered, and how is that data collected? We have a command center, which is the warehouse of all that information, and then the social service electronic health record (EHR), which bolts onto the member’s medical record. That process produces a provider roster that we then put into the hands of our field teams, who use that as part of relationship management, much like a provider relations representative would use in their engagement with the primary care physician (PCP). We meet with them on a regular basis to confirm that services were rendered, and review the successes.

The secondary piece to that is our case managers also reach out to the members that they have referred to services and activities. They verify through the members they received it and their level of satisfaction. So there’s two points of feedback: one from the provider themselves and one from the member.

Question: How do you identify community services to meet members’ needs?

Response: It’s similar to the United Way 2-1-1 directory. We did community health needs assessments, which identified a number of different needs. And using epidemiological information, we come at it in terms of identifying the need, and then determining the service model. Then we took it a step further and asked, ‘How do we define the services so it’s a blend between public health, social supports and managed care terminology?’

We use about 67 different categories of social supports. We turn that into research. We go ‘feet on the street’ to canvas the neighborhoods to make sure that we have all of the organizations represented. Then that’s put into a ‘pend’ status in our databases and it is vetted on a secondary level of review by our team of liaisons. Once it’s vetted and confirmed, it’s then put into the final database, which is used for searching by our case managers. It’s a combination of public health practice using both public health and managed care terminology.

There is no magic number of categories or organizations. No one’s ever systematically inventoried or catalogued the network of social services. That’s what we’re hoping to do — explain and quantify what organizations exist, then identify their service area, their reach, their service portfolio, and the volume of connectivity that the health plans have with these organizations for specific services. It’s an exciting time.

Question: What other components of the comprehensive health assessment are administered to the duals as they come on board?

Response: A number of different factors go into the HRA that’s completed. There are health factors, socioeconomic factors, living environment, and activities of daily living (ADL). What are their social needs, what are their social supports, etc.? There’s a whole number of different tiers of questions that we ask as part of the HRA. We use very specific tools that are either state-dictated or guidelines produced by the state or in partnership with CMS. It depends on which side of the equation that we’re being contracted for, and it depends on what’s already in existence.

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Healthcare Business Week in Review: Childhood Obesity, Dual Eligibles, ACOs, Patient Activation Measures

November 1st, 2013 by Cheryl Miller

Last year at this time we watched with disbelief as Hurricane Sandy pummeled our East coastline. Schools closed, power shut down, and Halloween was officially postponed until early November when it was considered safe for children to trick or treat.

Our own town is still recovering from the storm; scarred, vacant houses share the same block as rehabbed homes on stilt-like platforms; trailers double for once elegant restaurants and broken docks and abandoned boats patiently ride the crests of ocean waves.

It was a rocky year for healthcare as well, from an early surge in Medicare ACOs, to the embattled introduction of ACA-mandated health insurance exchanges during a government shutdown.

But many things remained the same; childhood obesity rates continued to climb , as did public health efforts to control it, including counseling and nutritional guidance, according to a new trends report from NCQA. Poverty continued to plague many Americans, particularly dual eligibles, but companies like Wellcare did their best to help them by closing social gaps with health-oriented community connections looking to “give back,” as its vice president of advocacy and community-based programs executive director Pamme Taylor demonstrates in this week’s featured book excerpt.

Organizations like HealthEast and Mercy utilized clinical analytics technologies from Optum to better understand and manage treatment for patients with chronic conditions, and advance performance for its newly formed accountable care organization (ACO).

And doctors’ policies toward accepting new Medicaid patients in the wake of expanded coverage will most likely stay the same, according to a study from Virginia Commonwealth University, Richmond. The decade-plus study found that physicians might be more likely to stop accepting those patients who remain uninsured, however, as our story details.

And lastly, self-management continues to result in better patient outcomes, according to researchers from the Boston Medical Center. Patient activation, or having the knowledge, skills, and confidence needed to manage one’s health, leads to better health following hospital discharge, and lower readmission rates. Screening for patient activation could not only help hospitals identify patients at risk for readmission, but also inform the development of tailored, cost-effective intervention plans.

How did your healthcare organization fare in 2013? And what plans do you have the future? Tell us by completing our ninth annual survey on Healthcare Trends for 2014 and you’ll receive a free executive summary of the results. One respondent will win a training DVD of the “2014 Healthcare Trends and Forecasts” webinar recorded on October 30, 2013.

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Healthcare Business Week in Review: Depression Management, Value-Based Benefits, Dual Eligibles

July 2nd, 2013 by Cheryl Miller

It takes a village to help those suffering from depression. Even a barber shop.

According to a new study from the RAND Corporation, when community-based support groups such as churches, substance abuse counselors, and yes, even barber shops, offered support to lower-income people suffering from depression, the patients’ mental health improved, their level of physical activity increased, and their hospitalizations decreased.

Researchers targeted lower-income neighborhoods because help is frequently unavailable or hard to find. Many suffering from depression also go undiagnosed; called the “silent monster,” it affects almost one out of five people from all cultural groups at some point in their lives. You can find more details in our story.

It takes a value-based benefits plan, and a disease management program, to help diabetics better control their health.

According to a new study from Truven Health Analytics™ and the Florida Health Care Coalition, patients enrolled in value-based benefit design in conjunction with a disease management program showed higher adherence to both brand and generic oral medications and a higher uptake of insulin over the three-year study period.

The study, Value-Based Design and Prescription Drug Utilization Patterns Among Diabetes Patients, which appears in the May/June issue of The American Journal of Pharmacy Benefits, examined the three-year effect of value-based design and disease management programs on diabetes patients. Value-based insurance design is a medical benefit plan design that reduces patient out-of-patient costs for treatments that are known to be effective, and increases out-of-pocket prices for lower value services.

It takes a combination of factors, including financial hardship and disability or old age to meet the criteria that defines dual eligibles, a population that nears 9 million in the United States.

You can find these facts and more in our new HINfographic, Defining the Dually Eligible: 16 Things to Know for Population Health Management, which illustrates a wealth of metrics on the dual eligibles population. Managing this population successfully is key to keeping healthcare costs low; and the HINfographic lists six keys to successful management of duals, including medication management and patient education.

Lastly, we’d like to ask you to take some time to fill out our third e-survey on Telehealth.

A clear majority of healthcare organizations are using telehealth in clinical and non-clinical settings, according to preliminary results from survey. Your response will be kept strictly confidential and will only be used in the aggregate.

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HINfographic on Defining the Dually Eligible: 16 Things to Know for Population Health Management

June 24th, 2013 by Jackie Lyons

There are about 9 million individuals in the United States eligible for both Medicare and Medicaid. Care coordination of these dual eligibles has been identified by PricewaterhouseCoopers LLP as one of the top 10 healthcare priorities for 2013.

Before developing a case management or population health management approach for this population, it is vital to first identify the group’s characteristics.

This HINfographic on dual eligibles illustrates 16 things to know for population health management, including criteria for dual eligibility, specific health and financial characteristics of the population, differences between the duals and Medicare population, and keys to successfully managing dual eligibles.

dual eligibles infographic

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You may also be interested in this related resource: Population Health Management for Dual Eligibles: Blueprint for Care Coordination.

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

April 12th, 2013 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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6 Keys to Successful Care Management of Dual Eligibles

December 10th, 2012 by Patricia Donovan

Applying a blanket care management approach to all dual eligible populations “is a waste of time and effort,” notes Dr. Timothy Schwab, chief medical officer, SCAN Health Plan.

Instead, care coordination for individuals covered by both Medicare and Medicaid should start with a strong risk stratification program, taking into account the age bands as well as the functional, medical and social status of the population.

Dual eligibles are a diverse group with different longterm-care needs; nationwide, about 40 percent of duals meet ‘nursing home-certifiable’ status, he explains. Additionally, about 35 percent of duals are under 65 years of age, Dr. Schwab said during a recent webinar on Care Coordination for Dual Eligibles: a Results-Oriented Approach. Nearly two-thirds of these duals have only a single chronic condition and no functional impairments.

The federal government has only recently begun to recognize some of duals’ unique needs, he explained. The ACA created both the Office of the Duals and the CMS Innovation Center to pilot new care delivery models.

Operating the only fully integrated dual eligible special needs plan (FIDE SNP) in California, SCAN has a history of successful care management of dual eligibles, who constitute about 9 million individuals in the United States.

The risk stratification should be followed by a very strong multifactorial assessment that goes beyond a traditional medical assessment of a population, followed by the development of individualized care plan, a process that requires buy-in from both the member and the significant caregiver, if one exists, Dr. Schwab states. Goals formulated by an interdisciplinary care team or other stakeholder, a fourth aspect of duals care management, should be meaningful to the member but also realistic to the care manager, Dr. Schwab emphasizes.

There should also be built into care management a reporting feature so that progress toward members’ goals can be tracked and adjusted if necessary.

Finally, inherent in the care management approach should be close attention to the member’s language, cultural norms, and health literacy, as well as their home environment, which impacts everything from a dual’s nutrition to transportation to compliance with care and medical goals.

States already focused dual eligible care management agree that a coordinated approach improves not only care of dual eligibles but also boosts satisfaction in this population, Dr. Schwab relates. However, little evidence has been gathered thus far on cost reductions associated with these efforts, although recent analyses by Avalere Health of SCAN’s care management model demonstrate its effectiveness in reducing readmission rates and inpatient hospital admissions and producing significant cost savings tied to the improvement in health status of members.

Click here for a live audio interview with Dr. Schwab, where he describes the composition of SCAN Health Plan’s Interdisciplinary Care Team for dual eligibles.

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Healthcare Delivery Advice for 2013: Shore Up Payment Before Shifting Model

October 23rd, 2012 by Patricia Donovan

Eying a move to an ACO or the patient-centered medical home model in 2013? First, adjust the payment structure to support it, advises Steven Valentine, president of the Camden Group. Shifting to one of the popular post-reform healthcare delivery models before changing the payment system is courting financial disaster, Valentine warned during HIN’s ninth annual Healthcare Trends & Forecasts strategic planning session.

Valentine charted anticipated trends for healthcare providers in 2013, while Hank Osowski and Dennis Eder, both managing directors for Strategic Health Group, covered business opportunities for health plans during the 60-minute webinar.

All of the analysts agreed that the outcome of next month’s presidential election would have little impact on healthcare reform.

“Regardless of who gets elected president, many of the things I’m talking about — bundled payment, patient-centered medical home, co-management agreements, clinical integration, accountable care organizations — are all going happen due to the economics of healthcare.”

“The reform train has left the station,” agreed Eder. “Folks who are waiting around to see what happens in the election, or who waited around for the Supreme Court decision on the Affordable Care Act, are too late.”

The election results will “likely influence the pace of change to the healthcare system, but probably not the direction,” added Osowski. The continued acquisitions and consolidations evident in the industry are proof in the market’s belief in the longevity of reform-based initiatives, he said.

Common ground across the industry continuum includes potential from collaborations — hospital-physician co-management service agreements on the provider side, and strategic partnerships in population health management on the payor side. Partnership opportunities are more plentiful now than at any time in recent healthcare history, noted Eder. “I was involved in the original integrated health world in the mid-1980’s when systems were buying both hospitals and physician organizations and starting health plans. The sincerity and the desire to work as true partners are unlike any time I’ve seen before.”

The speakers identified the strategic focus for each sector, with Valentine indicating that the key investment for providers should be on growing their population — getting as large a defined population base at the bottom of the pyramid as possible, which encompasses the access points and primary care, he said.

For payors, the industry’s increasingly population-centric, value over volume sensibility offers many opportunities in coordinated care, particularly for Medicaid-Medicare dual eligibles, said Osowski. “Duals comprise about 18 percent of the state Medicaid population, and yet they account for almost a little more than a third of the total spend on Medicaid,” he said.

Duals are a complex population with unique health concerns, requiring a strong behavioral health component. “Duals tend to be very costly because they’re typically non-compliant patients and don’t really follow what is being asked of them in terms of their healthcare,” said Valentine.

“The dual population is not just frail elders; the dual population is 40 percent people under 65,” added Eder. And the vast majority of the people under 65 are disabled because of behavioral health-related issues. So for organizations considering getting into the dual market, if you’ve just done frail elderly programs and you think you’re going to be working with that same cohort of members, it’s going to be a painful learning.”

In other trends, the industry should expect delays in implementation of health insurance exchanges (HIEs), which face significant funding hurdles, said Osowski.

Healthcare may also see the reemergence of narrow networks, in which health plan members or employers benefit from lower costs when staying within their own health systems. Individuals will still have the choice of going outside the system, but face much higher copays.

“We’re leaving choice in place, but we are getting much better at directing back to a smaller, more narrow network that will help to steer volume back to the providers, and reduce the total cost of care and the out of pocket cost for the employee,” concluded Valentine.

Listen to an interview with Dennis Eder, Hank Osowski and Steven Valentine.

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