Dual-eligible people

A major challenge in our healthcare system is taking care of the more than 9.6 million people who are eligible for both Medicare and Medicaid benefits, according to the Kaiser Family Foundation. These “dual-eligible” individuals often are some of most vulnerable members of our society. But with more opportunities to move toward integrated care, comprehensive care coordination, and enhanced support systems, dual-eligible beneficiaries can receive high-quality care that meets their health needs without driving up costs throughout the system.

The dual-eligible population consists largely of low-income seniors and younger people with significant disabilities. Dual-eligible people make up only 20% of the Medicare population but account for 31% of the program’s costs, the Kaiser Family Foundation found. For Medicaid, the disparity is even starker—they account for just 15% of the program’s population but are associated with roughly 39% of the costs, notes the Kaiser Commission on Medicaid and the Uninsured.

Unfortunately, the majority of these individuals continue to receive their care through separate fee-for-service systems that fail to provide any care coordination or guidance through the two very different programs. This traditional fee-for-service arrangement often results in poorer patient outcomes, unchecked costs and significant strains on caregivers. The effects of such inadequate arrangements cascade through the entire system, stretching state budgets and complicating federal entitlement program reform efforts.

Dually-eligible individuals must have access to the same types of coordinated, high-quality care that many others have through their employers, or from such programs as Medicare Advantage and managed Medicaid. By adapting proven care coordination tactics and support systems to care for a population that could benefit the most, governments can reverse the disproportionate strain posed by the current approach to care.

Officials at the Centers for Medicare & Medicaid Services understand the potential and are acting to realize it, building on language in the healthcare reform law that set up the Medicare-Medicaid Coordination Office. Communities that have started using innovative approaches to treating the population through the federal-state “dual demonstration” pilot programs resulting from the new CMS initiatives are starting to see the benefits of the investment.

Health plans have found success through innovations that are a perfect fit for such a vulnerable population, such as enhanced in-home care that allows dual-eligible individuals to stay in their communities and out of hospitals.

Through modern approaches to providing medical services, in-home and community-based care, nursing support, long-term care, and behavioral health, the system can bring high-quality, specialized care to the sickest members of our society in a way that avoids driving costs out of control.

January 1, 2017

To learn about how Humana is improving the system for dual-eligible people, check out this page.