Caring for nursing home residents who qualify for both Medicare and Medicaid (known as dual-eligible) can be challenging due to the involvement of many different payers. However, by aligning goals, improving quality measures, and providing better tools for caregivers, nursing homes can offer better care for these residents.
The Complexity of Dual Eligibility
Dual-eligible residents receive benefits from both Medicare and Medicaid, but the rules between these programs can be confusing. Allison Rizer, Executive Vice President of Payer Solutions at ATI Advisory, describes it as a "tangled web of conflicting program rules" that makes it difficult for residents to get the care they need. Different networks of providers, varying enrollment periods, and different requirements for services add to the confusion, leading to poor health outcomes and higher costs for both programs.
The "Tug of War" Over Payment
Anne Tumlinson, the founder and CEO of ATI, compares the care of dual-eligible residents to a "tug of war" between Medicare and Medicaid over who will pay for what. This conflict often results in uncoordinated care in nursing homes. About 12 to 13 million people are dual-eligible, and nearly a million of them live in nursing homes. Unfortunately, about 40% of these residents are expected to be hospitalized at least once this year, compared to just 15% of the general Medicare population.
Diverse Needs and Disconnected Data
Dual-eligible residents vary widely in age and care needs, ranging from primary custodial care to more complex medical care. However, Medicare or Medicaid often collects data about these residents separately, which means the full picture of their care needs is not always clear. This lack of comprehensive data makes it hard to improve the quality of care for these residents.
The Administrative Challenges for Nursing Homes
Nursing homes face significant administrative challenges when caring for dual-eligible residents. Rizer points out that residents may be enrolled in multiple health plans, each with its own rules for submitting claims and getting services approved. This creates a heavy burden for nursing home staff and health plans trying to coordinate care for these residents.
The Need for Better Integrated Care
Better integration between Medicare and Medicaid is essential to address these challenges. During a recent webinar hosted by ATI, experts David Grabowski and Kate McEvoy emphasized that policymakers have been working on integrating care for years, but most efforts have focused on community settings, leaving nursing homes behind.
Barriers to Integration in Nursing Homes
McEvoy, who leads the National Association of Medicaid Directors, mentioned that while there has been some effort to improve quality in nursing homes, integrated care models for dual-eligible residents have not been a top priority. The complexity of aligning Medicare and Medicaid goals, combined with mixed results in quality measures, makes it hard to present a strong case for integrated care models.
Grabowski added that the current measures used to evaluate care for dual-eligible residents are only sometimes appropriate. He suggests that having consistent quality measures across both programs could help improve care. Additionally, because the needs of dual-eligible residents vary so much, states need flexible care options that can be tailored to their specific populations.
Moving Towards True Integration
More leadership and resources are needed in Medicaid programs to make real progress. Rizer identified three key elements for a successful integrated care model: clinical models tailored to the population, aligned quality measures, and efforts to simplify the care process for residents and their families.
"For us to really get a better quality of care experience for the resident, we have to change the incentives at the provider level," Tumlinson said. She also pointed out that changing the way nursing facilities are funded is crucial to solving the ongoing challenges in dual-eligible care.
The Way Forward
Creating integrated care models for dual-eligible nursing home residents is crucial for improving care quality and reducing costs. By aligning goals, standardizing quality measures, and simplifying administrative processes, the healthcare system can better meet the needs of this vulnerable group. As the industry moves forward, it's essential to ensure that nursing homes are included in these efforts, making them a vital part of the solution.
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