« March 2012 Issue

Better Care For Our Most Vulnerable

Anna* is a 65 year old woman with multiple sclerosis that led to paralysis in both legs, and this condition has been compounded by asthma and severe depression. Throughout her life she has lacked consistent primary care and has been bounced around from one doctor to the next. She has been hospitalized many times for predictable and preventable complications such as asthma attacks, urinary tract infections, pneumonias and for pressure sores caused by extended hours in bed and a poorly fitted manual wheelchair. Lack of care coordination among providers and a specific plan to meet Anna's individual needs has exacerbated her condition and left her in declining health. In short, the health care system has failed Anna: her care is inadequate and, as a result, unnecessarily expensive.

But major change is on the way for nine million of the most vulnerable Americans like Anna – the so-called "dual eligibles" whose care is divided between the Medicaid and Medicare programs. Dually eligible individuals like Anna are in very poor health – most are seniors who have chronic health conditions, and many have moderate or severe disabilities that make it difficult for them to care for themselves. Their care is often fragmented and uncoordinated with visits to numerous health care providers who do not communicate as a team. It is also disproportionately expensive: Dual eligibles represent only 18 percent of Medicaid enrollees but consume 46 percent of total program spending; they represent 16 percent of Medicare enrollees, but consume 25 percent of total Medicare spending.

This extraordinary level of public investment coupled with the widespread recognition that care for dual eligibles is inadequate has ignited a call for reform and pushed it to the top of the political agenda.

While change won't come overnight for dually eligible individuals, reform efforts are already underway, spurred by passage of the Affordable Care Act. Under an aggressive timeline, the Obama administration has launched initiatives to incentivize states to develop innovative ways to provide "integrated care," or better coordinated, comprehensive, high quality care to dually eligible individuals. The goal is to vastly improve services and care coordination for dually eligible individuals by minimizing the unnecessary and expensive practices that further impede their health.

Community Catalyst, which has a long history of advocating for improvements to the delivery of care for vulnerable populations, is working to ensure dual eligible individuals and their advocates are able to help inform and shape new reform initiatives. In 2003, Community Catalyst helped to incubate the Commonwealth Care Alliance (CCA) of Massachusetts, which is now recognized as a national leader for its efforts to better serve the dual eligible population.

According to Renée Markus Hodin, who leads Community Catalyst's Integrated Care Advocacy Project, the opportunity to improve care for dual eligible individuals and produce cost savings is great, but so too are the risks inherent in trying to change a complex system with many stakeholders seeking to influence the process.

"It's critical that dually eligible individuals and their advocates have the resources and knowledge base to be equal partners in developing these new initiatives," said Hodin. "With their meaningful involvement in the design and implementation, consumers will help to ensure the initiatives address the medical and long-term care needs of older adults and people with disabilities."

Community Catalyst is providing expertise on this issue to state advocates as they review and analyze proposals in their states and develop campaigns to advance good models of care, with a focus on what Hodin calls "leader states" that have the best potential to create models that can be replicated elsewhere.

"The details really matter. Given the unique needs of these individuals, there is no one-size fits all model," added Hodin. "The drive for savings shouldn't dominate the conversation – this has to be about improving care with a care model that's responsive to the specific needs of the people being served. It's only through better care that we will lower costs."

*Last name omitted to protect Anna's privacy.