With recent attention on programs for “dually eligible” beneficiaries, individuals who quality for both Medicare and Medicaid, it’s important to highlight health plans’ critical role in care delivery for these beneficiaries.
Health plans serve as a crucial safety net for approximately 1.5 million of our nation’s most vulnerable dual eligibles, many of whom have disabilities and chronic conditions.
By tailoring their benefits and services to address the unique needs of the specific populations they serve, these health plans are providing a high level of value to both beneficiaries and taxpayers. For example, an analysis of the MassHealth Senior Care Options (SCO) program, a Massachusetts initiative that works with fully integrated dual eligible special needs plans, found dually-eligible beneficiaries enrolled in these plans were “less likely to be long-term nursing facility residents… and more likely to have a history of community focused care.” Another study found health plans participating in the Texas STAR+PLUS program which includes dual eligibles reduced emergency room visits by 40% and inpatient admissions by 28% while promoting quality care. These data indicate that coordinated care provided by the health plans participating in the SCO program are successfully providing care in less intensive settings while producing cost savings for states by reducing unnecessary institutionalization.
Health care costs for dual-eligibles are disproportionately high. Using projections from the Congressional Budget Office, federal spending on dual eligibles will total nearly $3.7 trillion over the next decade. However, a recent AHIP study found that health plans are well-positioned to take the lead in coordinating the care of dual eligibles to achieve better health care outcomes and cost savings. These savings could potentially be as high as $125 billion to the federal government and $34 billion to states over ten years. Furthermore, The Lewin Group found that savings of 3%-6% can be achieved by transitioning the dual eligible population into a fully integrated setting offered by health plans.