Marsha Gold interview: dual eligibles

Marsha Gold is a Senior Fellow at Mathematica Policy Research who is an expert on Medicare, Medicaid and the care of the dual eligibles. She recently completed work focused on Special Needs Plans (SNPs) that I blogged about.[1] I asked her some questions about care for the dual eligibles via email that she has graciously answered in this, and two subsequent posts to be published later today. Dr. Gold’s responses are printed in full as I received them. Great thanks to Adam Coyne, who is Vice President and Director of Public Affairs for Mathematica, and who facilitated this interview.

What’s your take on why there is interest in dual eligibles?

Beneficiaries who are dually eligible for Medicare and Medicaid have diverse and typically complex health care needs. Compared to the Medicare population overall, dual eligibles are substantially more likely to be in poorer health, suffer from physical disability and/or cognitive or mental impairments, have low incomes and limited education, and reside in long-term care facilities.[2] They account for a disproportionate share of spending in both programs relative to their numbers. In addition, there is widespread concern over the quality of care these beneficiaries receive, because their needs are complex and care is financed through multiple channels.

 Do you think it is possible to reduce the costs of caring for dual eligibles while improving quality?

 Yes, I think it’s possible to do so, but not easily or quickly. We have a fragmented care system that is better designed to provide limited, short-term care in particular settings for particular conditions than to coordinate care over the long term for people who need a variety of medical, mental health, and social services provided by different systems. It’s hard to imagine that care for many dual eligibles cannot be improved or that such improvements would not generate some savings. Reconfiguring delivery to overcome these challenges will not be easy, particularly if it requires the systems and service providers to move out of their “comfort zone” and change the way they operate. Such change does not happen overnight, if it can be done at all. The fact that care for dual eligibles is financed through separate programs makes the challenges even greater, since it complicates the task of creating a consistent set of financial incentives and program requirements to encourage change.

What is the key to generating such change?

 Reaching out to the delivery system and finding ways to encourage and require it to become more focused on patients, families, and caregivers. We currently finance and provide services, instead of caring for people. Anyone with aging parents or an adult child or friend with special needs probably has experienced the frustration of knowing their care could be better, more humane, and less costly, “if only” more providers would talk to one another and focus on the patients, rather than their body parts, and then only “from 9:00 to 5:00.” To generate such change, expectations need to be modified, financial incentives overhauled, and care requirements configured to support new models of delivery. Ultimately, such change probably will be enhanced by capitation or per person payment but changing the payment approach is not a magic bullet for creating change unless the care configuration is improved. In addition, risk adjustment and other features that protect patients are essential to creating successful capitation payment programs that reward good performance rather than ways to game the system.

[1] Marsha Gold has been monitoring the evolution of the managed care marketplace for many years. She has written many seminal studies of Medicaid managed care and is recognized as a leading authority on the evolution of private plans in Medicare. The perspectives expressed here are those of the author only and do not necessarily reflect those of Mathematica or any of the agencies or organizations with whom it works.

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