Reducing Costs and Improving Care Among Dual Eligibles

San Antonio—As of 2009, there were 9.2 million dual eligible beneficiaries in the United States. This population is among the sickest and costliest, accounting for a disproportionate share of federal and state spending, according to Mary Ptacek, RPh, CGP, Pharmaceutical Strategies Group, LLC. Full dual eligible beneficiaries account for 36% of total Medicare spending and 39% of total Medicaid spending. The average annual cost for a dual eligible member is $33,300, compared with $8300 for a non-dual eligible member. Almost half of dual eligibles (44%) use long-term care (LTC) services and support, and this use of LTC services rather than episodic care is one of the many challenges associated with dual eligibles.

However, managed care can help, according to Dr. Ptacek. By offering one payer simplification, utilizing case management to coordinate care, and expanding access to home/community based services these challenges can be alleviated. The challenges for managed care are the same issues seen with any Medicaid population (eg, cultural and language barriers), but with the added burden of having 2 separate regulatory agencies to work with.

The Centers for Medicare and Medicaid Services (CMS) is awarding contracts to states for demonstration projects to integrate care for dual eligibles. There are 2 demonstration models: the capitated health plan and managed fee-for-service. So far, 26 states have submitted letters of intent; 15 states have proposals pending; 6 states have signed contracts with CMS; and 5 states have dropped out.

The Affordable Care Act has established 2 federal entities to assist with efforts in studying and improving care for dual eligibles, said Cynthia Pigg, BSPharm, MHA, FAMCP, Magellan Pharmacy Solutions: (1) the Center of Medicare and Medicaid Innovation; and (2) the Federal Coordinated Health Care Office (Duals Office). The first of these duals projects is the Massachusetts Duals Demonstration (One Care). Key objectives of this program include:

·      Improving the beneficiary experience in accessing care

·      Delivering person-centered care

·      Promoting independence in the community

·      Eliminating cost shifting between Medicare and Medicaid

·      Achieving cost savings for the commonwealth and federal government through improvements in care and coordination

Expected outcomes of this duals project, she continued, include reduced overutilization of high-cost hospital and long-term institution care and reduced underutilization of outpatient and community-based service and support, as well as an increase in the use of evidence-based practices.

Addressing Medicare-Medicaid Plan (MMP) formulary issues, Julie Howard, PharmD, MBA, Catamaran, explained, “One of the goals of the development of these formularies is to simplify the process for dual eligibles to access the medications they are entitled to under both the Medicare and Medicaid programs. The MMP formulary is an integrated formulary that meets the requirements of both Medicare Part D and state Medicaid requirements.”

“Although the coordination of these benefits makes it easier for beneficiaries,” Dr. Howard continued, “the development of the formularies comes with its own set of challenges for the plan sponsors and pharmacy benefit managers. Some of these challenges include complexity of the tier model, the ability to identify drugs for the Additional Demonstration Drug (ADD) supplemental file, differences between CMS guidance and state guidance, and the continuity of care ‘transition’ period for non-Part D drugs.”

Specifically, tier models can consist of 2 to 6 tiers, but the more tiers a formulary has, the more complex it is, thus making ADD file preparation, submission, and maintenance more complex as well. Each ADD file is state-specific, and the CMS has requested that states provide guidance on the drugs to be included. This level of guidance differs among states, making it difficult for plan sponsors to ensure all drugs are included on the ADD file. The CMS has also been very specific that ADD file drugs include only non-Part D drugs.

Additionally, the transition benefit for non-part D drugs is a separate benefit from the part D transition benefit and involves a continuity of care plan. “There is no clear guidance about what drugs should be involved in the non-Part D transition benefit,” Dr. Howard concluded. “It is a definite challenge for the plan sponsor to decide what drugs should be part of this benefit.”