Medicare-Medicaid dual eligibles are often held up as a prime case for the need for better care management to reduce health costs and spending while improving quality.  But doing so can be challenging.  Most dual eligibles have multiple health conditions, whether a chronic disease, severe cognitive or physical disabilities, or some other condition or impairment that requires long-term care.  About 40 percent of dual eligibles have both a serious physical health diagnosis and a severe behavioral health condition, making care coordination and quality improvement all the more important and challenging.

Those interested in how current health insurance programs for dual eligibles measure quality can turn to a recent brief from the Center for Health Care Strategies (CHCS). You can read the full brief at the CHCS website – – but here are some highlights.

Special Needs Plans for Dual Eligibles (D-SNP):

D-SNPs, part of Medicare Advantage, account for more than 80 percent of, or 1.2 million, Special Needs Plan (SNP) enrollees. A report last year from Government Accountability Office (GAO) pointed out that the Centers for Medicare and Medicaid Services (CMS) does not require D-SNPs to report a standardized set of outcomes.

Nonetheless, the CHCS briefs pulls some helpful examples of different quality measures D-SNPs use:

Most of the data come from Healthcare Effectiveness Data and Information Set (HEDIS), though some come from the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS), or from CMS directly.

Quality in Financial Alignment Demonstrations for Dual Eligibles:

The Affordable Care Act (ACA) health reform law opened the door for CMS and states to launch integrated Medicare-Medicaid health plan demonstrations. Long-term care use, mental health service use, quality of life, and care coordination are of particular importance in measuring quality of care demonstration programs provide.

Examples of quality measurements for the managed care integrated dual eligibles demonstrations include:

  • Success managing complex cases, evaluating access to case management, individualized care plans, satisfaction with case management, and identifying members who would benefit from case management.
  • Easing Care Transitions, which looks at how well health plans manage and improve care transitions from hospitals to long-term care, for example.
  • Coordination of Medicare and Medicaid benefits, which includes service coordination and network adequacy assessments.
Business Briefings for Health Plans on Integrated Care Demonstrations:

Sellers Dorsey recently hosted two helpful webinars on dual eligibles: one is a basic overview and the other describes business opportunities and risks for health plans in the large and growing dual eligibles market.

In the later, Mike Fox and Kip Piper of Sellers Dorsey provide a 90-minute briefing for health plan executives on the new demonstrations to integrate Medicare and Medicaid financing and care delivery for dual eligibles. Mike and Kip describe the current $350 billion dual eligibles marketplace, state plans to contract with health plans, steps health plans should take in assessing the business opportunities and risks of serving this market, and key considerations for entering the integrated Medicare-Medicaid health plan business. Watch the briefing online for free here on Vimeo.

Read more Piper Report posts on dual eligibles issues here.