Coordinating care for the dual-eligible population.

Area of Science:

• Healthcare policy
• Health services research
• Public health

Background:

• Many patients qualify for both Medicare and Medicaid, known as "dual eligibles."
• Integrated Delivery Systems (IDSs) serving dual eligibles encounter challenges with conflicting federal and state regulations.
• Disparities in Medicare and Medicaid payment structures create financial incentives for IDSs to transfer patients inappropriately.

Purpose of the Study:

• To examine the challenges faced by IDSs in coordinating care for dual-eligible patients.
• To highlight the impact of differing Medicare and Medicaid payment rules on patient care settings.
• To advocate for the involvement of IDSs in designing state-led pilot programs for improved care coordination.

Main Methods:

• Analysis of existing federal and state laws governing Medicare and Medicaid coverage for dual eligibles.
• Review of financial incentives influencing patient placement decisions within IDSs.
• Examination of emerging state-level pilot programs for coordinated care.

Main Results:

• Conflicting rules and payment incentives create barriers to optimal care for dual eligibles.
• Financial incentives may encourage the transfer of patients from post-acute to acute care settings, even when not clinically indicated.
• Several states are initiating pilot programs to address these care coordination issues.

Conclusions:

• IDSs must be actively involved in the design of pilot programs to ensure coordinated funding meets care delivery needs.
• Effective program design is crucial for optimizing care for dual eligibles and ensuring adequate reimbursement for IDSs.
• Collaboration between IDSs, federal, and state entities is essential for successful care coordination strategies.