1. Meeting the Complex Needs of the Dual Eligible Population Jack Meyer Health Management Associates Prepared for Alliance for Health Reform June 3, 2011

2. What Drives Public Health Care Spending? Poorly managed, uncoordinated care for patients with complex medical needs Patients with multiple chronic illnesses Frail elderly Non-elderly patients with disabilities: physical, mental/emotional, or both MR/DD populations Cant just hand these patients a card

3. End the Federal/State Shoving Match Under the business-as-usual arrangements, feds have incentives to push costs to states, and vice versa Medicaid has incentive to transfer a high- needs patient to an acute care setting such as inpatient/SNF where feds pay – The longer the LOS, the better Medicare has incentive to get the person out of this setting and into long-term care scene

4. Examples of Perverse Incentives Dual eligible patient in NH who is hospitalized & returns to NH directly; Medicare activates a SNF-type benefit until exhausted e.g. 100 days If patient goes home for a period, then enters NH, Medicaid pays; thus, incentive works against sending the patient home w support NH also has incentive to get sickest patients into a hospital setting (and keep them there as long as possible) so that Medicare pays

5. Move away from Buckets The prevailing view is to put everyone into some bucket – Nursing home – Hospital – SNF care – Community setting – Hospice

6. Better Approach: Pool Financing and Manage Care Under One Roof Incentives change from pushing dollars onto other payers to finding the setting that is most appropriate for the patient and family This factors in the patients medical condition, prognosis, family support system, and personal preferences Whether patient has a spouse at home crucial Determine what can be managed at home

7. Focus on Better Care After Discharge Better discharge planning Home visits after discharge: telephone at least Dietary assistance Medication management Social service support Patient self-mgmt; early symptom spotting Access to physicians when problems arise Time-intensive, frequent, patient-ctred care

8. Beyond Muddling Through We need a new approach to long-term care Some mix of public and private insurance should substitute for our welfare-based, institutionally biased system This is a difficult sell in the current budget climate But long-term care will break Medicaid unless we go beyond waivers and restructure the whole system