3 Million PWD Eligible for Medicaid and Medicare: U.S. House Directs Focus Towards this Vulnerable Population

via AAPD (6.27.11):

Medicaid and Medicare Policy: U.S. House Focuses on Dual-Eligibles

by Julia Feinberg, AAPD Policy Intern

On June 21, 2011, AAPD learned that the U.S. House Energy and Commerce Subcommittee on Health held a hearing to discuss “Dual-Eligibles: Understanding This Vulnerable Population and How to Improve Their Care.”  This hearing focused on restructuring Medicare and Medicaid to be more effective and cost efficient for the 9 million Americans who qualify for both programs, beneficiaries commonly referred to as dual-eligibles.  

Of these 9 million dual-eligibles, one third, or three million are people with disabilities.  About two-thirds are elderly people.  43 percent of dual-eligibles have at least one mental or cognitive disability, while 60 percent have multiple chronic conditions.  AAPD is very concerned about the three million people with disabilities who are dual eligibles as current discussions focus on capping, cutting or otherwise limiting the amount of funds both these programs receive.

The House Subcommittee on Health is chaired by Joe Pitts (R-PA) and the Ranking Member is Frank Pallone (D-NJ).   Subcommittee chairman Pitts said, in his opening statement, “Dual eligibles are unique.  …. more than half of dual eligibles live below the poverty line … [and] nineteen percent of dual eligibles live in an institutional setting.” Pitts added that dual-eligibles “are also more likely to be hospitalized, to go to emergency rooms, and to require long-term care than other Medicare beneficiaries.” Citing to the Kaiser Foundation statistics he said “ ... dual eligibles – who make up only 15 percent of Medicaid enrollment – consume 39 percent of total Medicaid spending.”

Ranking Member Pallone said “Congress and this Committee are increasingly concerned about the rising cost of Medicare health care coverage for the 45 million elderly and disabled Americans and Medicaid’s 55 million poor patients. So what better place to explore, understand and address than the sickest and most expensive populations to cover.” Pallone also said, “But we mustn’t set a price tag on their care nor should we shape policy with the goal of only saving money.”

Melanie Bella, Director of the Federal Coordinated Health Care Office Centers for Medicare and Medicaid Services (CMS) said benefits were provided totaling $120 billion in 2007 and this is increasing. This amount is twice as much as Medicaid spent on the 29 million children it covered that year.

Bella explained that since Medicare and Medicaid were designed each as individual programs that is the cause of many problems today.  Since the two programs were not designed to be readily compatible, it is difficult for beneficiaries to navigate both sets of requirements, often resulting in fragmented and sub-optimal treatment, she said.

Bella said that CMS is working to make the two programs more user-friendly for dual-eligibles.  These initiatives focus on patient-centered medicine that would hopefully lower costs through preventing or avoiding costly interventions.  CMS hopes to do this through better state and federal coordination, learning from patient focus groups, and state-wide experimental initiatives that could be scaled to the national level if successful.

Four representatives from state and national programs that are currently providing medical coverage to dually eligible beneficiaries also spoke. These programs were presented as examples of how to solve the problems faced by beneficiaries who are dually eligible.   

Billy Millwee, Associate Commissioner for Medicaid/CHIP, from the Texas Health and Human Services Commission spoke about a Texas state program called STAR+PLUS.  The program features integration of acute care and long term support services, which Medicare and Medicaid currently do not provide.  Additionally, STAR+PLUS partners with medical providers that take full financial and well-being responsibility, using financial incentives to lower overall costs.

Robert Egge, Vice President of Public Policy from the Alzheimer's Association, discussed the need for more support of unpaid caregivers and simplification of the Medicare and Medicaid systems.  He urged the Subcommittee to remember that a large portion of the dual-eligible population has Alzheimer’s or dementia of some sort.  In order for participants to have cohesive and comprehensive care, they must be able to easily navigate the medical system, he said.

President and Chief Executive Officer, Shawn Bloom, from National PACE Association, or the Program of All-inclusive Care for the Elderly outlined how and why her organization was considered the “gold standard” by government and private evaluations.  Their programs are focused on community-based support that keeps the older population, above 65, out of nursing homes for as long as possible. She said that through patient-centered medicine -- as Bella advocated for -- PACE cuts costs while raising quality of care.  Significantly, Bloom asked the Subcommittee to provide resources for dual-eligibles who are under 65 years of age, such as people with disabilities, to participate in PACE programs.

Lastly, Denise Levis Hewson, Director of Clinical Programs and Quality Improvement from Community Care of North Carolina (CCNC), emphasized the importance of local, personal care.  CCNC functions by having the patient’s primary care physician direct all of his or her medical care.  By having the primary care physician at the center, care is cohesive and comprehensive.  Hewson stated her program “achieves ‘the triple aims’ of improving the health care of the dual population, improving the quality, access and reliability of care, and reducing the costs of care.”  This appeared to be the goal of Subcommittee and panel members alike.

Outlook: It is unclear how this hearing will affect future policy changes in Medicare and Medicaid although it appears CMS could sponsor more initiatives or make national some of the newer approaches.  However, disability advocates note that any federal entitlement programs that are expanding are being looked at very closely in the current conversations about the deficit, the debt limit and the budget for 2012.

To review the statements at the hearing and to see a video of hearing (not captioned), go to website at http://energycommerce.house.gov/hearings/hearingdetail.aspx?NewsID=8707

For more information on “dual eligibility” visit CMS website at http://www.cms.gov/medicare-medicaid-coordination/

Questions:  

1.      If you are, or know someone who is, a beneficiary of both Medicare and Medicaid and you are a person under age 65 with a disability, and have encountered problems with the two programs, please let us know about them, either by commenting in the box below or email to policy@aapd.com

2.      If you have had experience with any of the programs discussed above, such as in Texas or North Carolina, please tell AAPD more about this by commenting in the box below or email to policy@aapd.com

Comments

[Peg Meerkatz]

I receive both Medicaid & Medicare. I recently attended a meeting of the CDPAP program I am enrolled with. They are talking about EVERYONE being required to enroll in a managed care program this presents a BIG PROBLEM for many PWD.

The income threshold to be elligible for Medicaid (in New York at least) is ridiculously low. If you receive more money than the allowable amount you have a MEDICAID SPENDDOWN. Many PWD and their families establishes TRUSTS such as the SPECIAL NEEDS TRUSTS. This exempts the PWD from paying the spenddown instead allowing them (or their trustee) use the spenddown amount for other expenses. IF PWD were required to be in a MANAGED CARE PROGRAM then they COULD NOT have a special needs trust.

What are we to do?

[BHL]

I receive both Medicare and Medicaid and to say the two programs are not "compatible" is an understatement.

I am trying to return to work (I get Medicare as part of my SSDI benefits) and the Ticket-to-Work program is another government program that has its own rules that are often incompatible with Medicare and Medicaid. I feel like I'm navigating a minefield and while trying to meet the requirements of one program, I might inadvertently disqualify myself from another program, and thus, detonate a mine because not having health coverage would be catastropic for me.

For example, Medicaid has a low income cap for when you would lose eligibility. Medicare doesn't have an income cap but its premiums/deductibles are rather high so you would not want to take a job that wouldn't at least be able to cover that. Ticket-to-Work has a certain income limit called "Substantial Gainful Activity" which is set each year. So if you meet the Ticket-to-Work level, you'd lose Medicaid, but still have Medicare but taking away the deductibles and premiums and out-of-pocket amounts. . .you might not be making a 'living wage.'

Also, Maryland as a program called EID which allows you to buy-in to the Medicaid program but this program is dependent on being employed so if you lose your job or have to take a leave of absence due to an illness, you'd be without a paying job, without Medicaid, without employer health insurance and possibly still have Medicare but with premiums and deductibles you can no longer afford. It's a huge, huge risk for many people like me to return to work when we have to navigate such intricate rules/regulations and our very lives depend on our ability to navigate those rules/regulations successfully.

[Brenda Milewski]

I started a non-profit program to help facilitate dental care to low-income seniors who are on medicaid program. 90% of our dentist in Washington state does service those under medicaid because it does not cover the high cost of dental suppies needed to provide the care. Exmaple: an average upper and lower dentures cost estimated $3,500 - $4,500, medicaid is capped to pay $349 for upper and $349 for lowers. We have many denturist refusing to take on medicaid patients. By not providing a reasonable financial support to help in oral care many of our seniors (its happening now) will refuse to eat due to oral pain. This would lead into malnutrition or starvation. Oral cancer. Our organization assisted in the care for a senior who was diagnosed with oral cancer. This patient could not receive proper care to avoid this tradegy due to high cost of dental care. We have received many calls from speical need facilities such as Alzhiemer assisted living homes for assistance. The Medicare and Medicaid needs to be more realistic in financially supporting medical care for our seniors. We now we can't have an open wallet but there has to be a balance that can help our seniors who just don't meet state requirements.