兰德-Types-and-Costs-of-Services-for-Dual-Beneficiaries-by-Medicare-Advantage-Health-Plans_-An-Environmental-Scan_65页_4mb

Summary of "Types and Costs of Services for Dual Beneficiaries by Medicare Advantage Health Plans"

Core Content

This report presents a qualitative environmental scan and key informant interviews to identify the types of services and resources used by Medicare Advantage (MA) health plans to meet the needs of dually enrolled beneficiaries (those enrolled in both Medicare and Medicaid) and other high-cost, high-need patients. It explores the effectiveness of these strategies and the associated costs, aiming to inform future quality-improvement efforts and the design of care models for vulnerable populations.

Main Findings

1. Performance Disparities in MA Plans

• MA plans with a high proportion of dually enrolled beneficiaries tend to have lower performance and Star Ratings compared to those with fewer dual beneficiaries.
• Dual enrollment is often a marker for poverty and social vulnerability.
• Despite this, some high-performing MA plans exist, indicating that quality care is achievable even for high-risk populations.

2. Strategies to Meet Needs

• Four main categories of strategies were identified:
  1. Identifying and Targeting Needs: Using data analytics and health risk assessments to target high-risk patients.
  2. Managing and Coordinating Care: Implementing multidisciplinary care teams and individualized care plans.
  3. Addressing Social Needs: Referring or providing services such as transportation, housing, and food security.
  4. Integrating Medicare and Medicaid: Streamlining administrative processes and benefits for dual beneficiaries.
• Similar strategies are being adopted by other health systems and community organizations, not just MA plans.

3. Resource and Cost Considerations

• Limited data exists on the costs of these strategies, except for staff involved in care teams.
• Costs vary depending on the plan type, approach, and worker involved.
• The Financial Alignment Initiative and other demonstration programs are exploring integration of services and benefits, which may provide insights into cost structures.

4. Evidence Base for Success

• The strongest evidence is found in care coordination for selected chronic conditions.
• Few randomized trials exist, and most studies focus on associations rather than causation.
• Long-term outcomes and cost impacts are not yet fully understood.

Key Information

• Dually Enrolled Beneficiaries:

  • More likely to be under 65, disabled, in poverty, and report poorer health.
  • Average six chronic conditions, compared to four for non-dual beneficiaries.
  • Often face challenges in accessing care due to complex needs and limited resources.

• Challenges in Care:

  • Coordination of services between Medicare and Medicaid.
  • Socioeconomic barriers, such as housing insecurity and food insecurity.
  • Limited access to social services and communication between payers.

• Strategies and Interventions:

  • Care Coordination: Used in managing chronic conditions, reducing hospital readmissions.
  • Social Services: Transportation, housing, food assistance, and social work.
  • Administrative Integration: Streamlining processes and benefits for dual beneficiaries.

• Costs and Resources:

  • Costs depend on the type of service, plan, and workforce.
  • No comprehensive cost data is available, but ongoing evaluations may help.
  • Resources include staff, data systems, and partnerships with community organizations.

Unanswered Questions and Next Steps

• Prevalence of Services: How widespread are these identified services among MA plans?
• Costs: What are the associated costs for these services?
• Community and State Roles: How do community organizations and state agencies influence the delivery of social support services to dual beneficiaries?
• Future Research:
  • Conduct in-depth case studies of high- and low-performing plans.
  • Explore the impact of these services on care quality and outcomes.
  • Investigate the role of socioeconomic factors in service delivery and effectiveness.

Conclusion

The report highlights the potential of MA plans to improve care for high-risk, high-cost beneficiaries through targeted strategies and integration of services. However, more research is needed to understand the full impact of these approaches, the associated costs, and the role of external factors such as community resources and state policies. This knowledge can support the development of more effective value-based payment models and care delivery systems for dually enrolled beneficiaries.

Structure of the Report

• Chapter 1: Introduction and background on MA and dual beneficiaries.
• Chapter 2: Description of the study approach, including environmental scan and interviews.
• Chapter 3: Overview of MA contract structure and integration with Medicaid.
• Chapter 4: Characteristics and challenges of dually enrolled beneficiaries.
• Chapter 5: Strategies used by health plans, providers, and community partners.
• Chapter 6: Resources required to implement these strategies.
• Chapter 7: Evidence of success from existing studies and programs.
• Chapter 8: Unanswered questions and future research directions.
• Chapter 9: Summary and conclusions.

Appendices

• Appendix A: Discussion guide for key informant interviews.
• Appendix B: Financial Alignment Demonstrations.
• Appendix C: Risk stratification approaches used by Medicare-Medicaid Plans.
• Appendix D: Candidate health plans for phase 2 case studies.
• Appendix E: Literature cited in Chapter 7.