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11.23.22

Washington – U.S. Sen. Invoice Cassidy, MD (R-LA), member of the Senate Finance Committee, led a bipartisan group of senators soliciting suggestions from the healthcare and affected person communities as they develop laws to enhance protection for people collectively enrolled in Medicare and Medicaid , often known as the double eligibility. Senators Tim Scott (R-SC), John Cornyn (R-Texas), Mark Warner (D-Va), Tom Carper (D-D) and Bob Menendez (D-NJ) joined Cassidy to ask for particular data On the shortcomings of the present system of take care of twin eligibility, learn how to enhance well being outcomes for sufferers and the position of federal or state governments in twin eligibility care.

“…the present fragmented and disjointed system of take care of twin qualifiers can be a driver of spending. Most twin qualifiers immediately are lined by two separate Medicare and Medicaid plans that don’t coordinate care and don’t align with enrollment. This disagreement can result in poor affected person outcomes and inefficient healthcare system spending,” Senators wrote.

The COVID-19 pandemic has additionally uncovered the necessity for reforms to twin eligibility welfare techniques. Based on federal knowledge, throughout every demographic group, dual-eligible folks had been extra more likely to contract COVID-19. Much more troubling, dual-eligible folks had been thrice extra more likely to be hospitalized with COVID-19 than Medicare-only folks. The time to reform take care of the twin qualifiers is now, earlier than the following wave of COVID-19 or one other pandemic leads to increased morbidity and mortality charges for these weak people.” The senators continued.

Learn the total letter over here or beneath:

To whom it Could concern:

As Congress begins to contemplate methods to enhance protection for dual-eligible enrollees, we’re in search of extra detailed data on present knowledge and enhancing beneficiary care. Roughly 12.2 million low-income or disabled folks in america are collectively enrolled in Medicare and Medicaid. This inhabitants group, often known as “dual-habitation,” is a various group with a fancy and distinctive set of wants. Twin {qualifications} embrace people with a number of continual situations, bodily disabilities, psychological sickness, cognitive impairments comparable to dementia and developmental disabilities, and others who’re in comparatively good well being.

Twin eligibility, whereas accounting for a small share of Medicare and Medicaid beneficiaries, represents a disproportionate share of complete spending. For Medicare, 19% of enrollees are dual-eligible however account for 34% of spending. Equally, 14% of Medicaid enrollees are twin eligible however make up 30% of complete spending. Mixed Medicare and Medicaid spending on twin qualifiers rose to a complete of $440.2 billion in 2019, of which $164.3 billion was Medicaid spending.

Whereas the complicated set of situations introduced by this inhabitants contributes to this excessive price, the present fragmented and disjointed system of take care of dual-eligible folks can be a driver of spending. Most twin qualifiers immediately are lined by two separate Medicare and Medicaid plans that don’t coordinate care and aren’t suitable with enrollment. This disagreement can result in poor affected person outcomes and inefficient healthcare system spending. For instance, when a dual-qualified individual is hospitalized, the affected person’s Medicaid plan might not be conscious of such an occasion except the affected person requires long-term care or different Medicaid-covered providers after the affected person’s keep within the hospital. As well as, the Medicaid plan would don’t have any incentive to forestall a affected person from being hospitalized since Medicare would pay for the hospital keep. With no single payer liable for all Medicare and Medicaid providers, there are monetary incentives for payers to shift prices onto one another, which is a well-documented phenomenon.

The COVID-19 pandemic has additionally uncovered the necessity for reforms to twin eligibility welfare techniques. Based on federal knowledge, throughout every demographic group, dual-eligible folks had been extra more likely to contract COVID-19. Much more troubling, dual-eligible folks had been thrice extra more likely to be hospitalized with COVID-19 than Medicare-only folks. The time to reform take care of twin qualifiers is now, earlier than the following wave of COVID-19 or one other pandemic leads to increased morbidity and mortality for these weak people. By way of our analysis into the outcomes of twin eligibility, now we have come to grasp that any such reform needs to be guided by the next core rules:

  • Variety of wants in dual-competent populations: Any answer(s) should keep in mind the heterogeneity of this inhabitants primarily based on demographic traits comparable to age, ethnicity, gender, place of residence, severity and nature of continual situations, ranges of revenue and belongings, entry to group help, and so forth. This variance has a major affect on the care wants, outcomes, expenditure, and affected person expertise of dually eligible beneficiaries. Some twin qualifiers, comparable to those that reside in long-term care amenities from an early age, have nearly all of their care lined by Medicaid, whereas others who stay at residence and may go part-time obtain most well being providers below Medicare. This distinction is especially pronounced between the highest 10% of double spenders on Medicare and the highest 10% of double spenders on Medicaid.
  • Vary of States’ Capabilities in Bilateral Care Assist: States have various ranges of technical experience and administrative capability in relation to administering Medicare advantages. Proposed reforms should be primarily based on affordable expectations of what states have the willingness and talent to do. States should have the assets to know which coverage implementation pitfalls to keep away from, in order that missteps from the previous aren’t repeated. As well as, every state has distinctive elements of its dual-qualified inhabitants that you could be wish to prioritize inside any systemic reform.
  • Monetary incentives drive well being system behaviors when it comes to outcomes and effectivity: New options should realign monetary incentives to scale back inefficiencies in care supply and enhance affected person outcomes. Some research recommend that extra protection (i.e. protection by two payers) doesn’t translate into increased high quality care or higher affected person outcomes. Certainly, double protection could also be related to damaging outcomes when controlling for different elements. , , , Protection needs to be aligned towards attaining the very best outcomes for sufferers, not probably the most income for the well being system on account of poor coordination of care and/or integration of advantages.

To construct a long-lasting and efficient legislative answer primarily based on these rules, we want helpful suggestions and high-quality knowledge from sufferers, suppliers, payers and different stakeholders. Due to this fact, we invite you to reply the next questions:

  1. How will you individually outline built-in care, care coordination, and suitable enrollment within the context of take care of dually eligible beneficiaries? How are these phrases related and the way do they differ?
  2. What are the shortcomings of the present system of sponsoring twin beneficiaries? What particular coverage suggestions do you’ve gotten for enhancing coordination and integration between Medicare and Medicaid packages?
  3. In your view, which fashions have been notably profitable in integrating take care of twin eligibility, whether or not on the state degree, federal degree, or each? Please present knowledge, comparable to comparative analyses, together with particulars of end result measures and management group definitions, to help your response. (Examples of fashions embrace, however aren’t restricted to: totally built-in dual-qualified particular wants plans, extremely certified dual-qualified particular wants plans, Monetary Compatibility Initiative choices, or states which have taken steps to enhance the alignment of Medicaid and Medicare packages.)
  4. After reviewing these fashions, would you suggest constructing on present techniques in place (eg, enhancing suitable enrollment and/or coordination of care between two separate Medicare and Medicaid plans) or ranging from scratch with a brand new unified system that successfully assigns every beneficiary to a payer Mainly primarily based on their wants?
  5. If you happen to suppose a brand new unified system is critical, what are the primary enhancements we should always prioritize? What would such a system appear like? Please present particulars of funding and administration (eg federal versus state authorities), parts of profit design, whether or not such a system needs to be voluntary or necessary for states, shopper alternative and affected person security protections.
  6. How can disruption to present beneficiaries be minimized if any modifications are made to the present protection scheme?
  7. In your analyzes of information on twin eligibility, have you ever thought of persistence of enrollment standing or consistency of full and partial twin eligibility standing over a 12 months?
    1. Are there completely different protection methods that needs to be used for “partial” vs. “full” twin eligibility in relation to enhancing outcomes, comparable to MedPAC’s suggestion on proscribing D-SNP enrollment to solely “full” twin eligibility? And the
    2. Research present that frequent plan switching can have a damaging affect on well being outcomes for beneficiaries, particularly for twin eligible folks enrolled in managed Medicare and Medicaid merchandise. CMS and states have taken completely different coverage approaches to restrict extreme switching. Which of those insurance policies has the very best knowledge on enhancing cost-effectiveness, medical outcomes, and/or beneficiary satisfaction? Which of those approaches will be scaled up for broader utility throughout international locations?
  1. What’s the easiest way to make sure that this technique takes under consideration the variety of the dual-eligible inhabitants and is sufficiently focused to make sure improved outcomes throughout every subset of beneficiaries? How ought to these subgroups be outlined and the way ought to the info be categorized? Please present examples of methodology and evidence-based rationale for every instance.
  2. Does your knowledge establish subgroups of people for whom protection of two payers is ineffective or related to worse medical outcomes, as proven within the educational literature?
  3. There are people who can, or should, spend their belongings on Medicare with a purpose to financially qualify as dually eligible. Such spending might give these people entry to long-term care below Medicaid, which Medicare wouldn’t cowl. One other path to eligibility contains Medicaid beneficiaries who develop end-stage kidney illness (ESRD) and develop into eligible for Medicare.
    1. Is there cost-effective knowledge for offering choose supplemental advantages to Medicare Benefit beneficiaries that may assist them keep away from changing into Medicaid-eligible by means of increased Medicare spending?
    2. For Medicaid beneficiaries who’ve threat elements for creating ESRD, comparable to continual kidney illness, diabetes mellitus, hypertension, and so forth., for whom focused care methods have been proven to be efficient in delaying the event of ESRD (ESRD) And with that, Medicare eligibility till you are 65? Please share knowledge on the prices versus advantages of those interventions.
  1. How does geography play a task in twin protection? Are there explicit protection and care administration methods which can be simpler in city areas than in rural areas?

By offering complete solutions to those questions, you’ll inform our work to alter the standard of take care of this weak inhabitants. Please ship responses to [email protected] by January 13, 2023. Responses might be handled as confidential and won’t be launched publicly with out your consent. We look ahead to reviewing your submissions.

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