A Dual Dilemma

Updated on March 20, 2024

A 72-year-old woman is eligible for Medicaid and Medicare. She is currently receiving in-home care and has started exhibiting symptoms of a urinary tract infection (UTI). Her symptoms continually get worse, and she is taken to the emergency room with abdominal pain and confusion all while becoming physically weaker. After a short stay in the hospital, she was discharged and recommended home health for physical and occupational therapy to regain her strength. Her home health caregiver is new and does not know her history with home care. Her former in-home caregiver is unaware of the recent hospital stay and additional services needed. These home care and home health services may not be happening at the same time due to insurance. What important health needs and information are slipping through the cracks?

But what if the symptoms of her UTI were caught and addressed sooner and a home health episode had been implemented to maintain her physical strength? She could have avoided the ER and a stay in the hospital. What if she could maintain the same caregivers who know her and her needs? Is there a way for all of these needs to be addressed seamlessly while avoiding the ER visit and maintaining continuity of care?

These types of scenarios happen every day for individuals in our community. How do we successfully move these people through the continuum of care without losing consistency?

The Intersection of Medicare and Medicaid for Dual Eligibles

As if the American healthcare landscape was not complex enough already, a population representing particularly unique healthcare needs, and desperately in need of unique solutions to meet them, is growing: dual eligibles.

Dually eligible beneficiaries are generally described as low-income beneficiaries enrolled in both Medicare and Medicaid. While Medicare is a federal program available to eligible citizens and legal residents once they reach 65 or are disabled, Medicaid is administered at the state level and funded jointly by the federal government and the state. Medicaid is available to low-income individuals with a demonstrated need, regardless of age. Medicare pays first when a dual eligible receives Medicare-covered services, and Medicaid pays last, after Medicare and any other health insurance. The impact here is not marginal. 

As a general rule, Medicare does not pay for custodial care, if it is the only care you need. That is if you need assistance with activities of daily living like bathing, dressing, using the bathroom, etc. Medicaid will pay for these services if you are eligible and in accordance with state-specific programs. Medicare pays for acute care needs. This includes nursing and therapy needed to recover from an illness or hospitalization. The handoff, or rather lack of one, between these two services, is a perfect example of how our healthcare delivery system fails to coordinate care and why for dual-eligible individuals the issue is particularly acute. 

Coordinating Care for Dual-Eligible Clients

Recognizing the need to solve this lack of coordinated care for the dually eligible population is not new. Back in 2010, the Affordable Care Act made it a requirement that certain Medicare Advantage plans (those that focus specifically on the dually eligible) contract directly with State Medicaid agencies so that they can – among other things – coordinate care. That was more than 13 years ago. Except for instances where states have implemented fully integrated Medicare/Medicaid health plans, that coordination is limited at best. And even where fully integrated Medicare/Medicaid plans have been implemented only around 7% of the people who qualify have enrolled in them. 

And the challenge to solve for this is only growing. The number of dual eligibles is on the rise. They now include over 12 million Americans, representing approximately 3% of the US population. Factor in that the number of people over 65 will be around 100 million by 2060, and the potential for a genuine crisis becomes apparent.

Missed opportunities to coordinate care can result in healthcare complications for anyone. Not only is that risk amplified for dually eligible individuals because of their higher health risk status, to begin with, but the dual payment system between Medicaid and Medicare also increases the likelihood that opportunities to coordinate care are missed. As a result, dually eligible individuals are 3x more likely than non-duals enrolled in Medicare to need assistance with activities of daily living and 4x more likely to be food insecure. They are 2x more likely to use the Emergency Room and need Home Health services, and 1.5x more likely to be hospitalized. This results in worse health outcomes, increased difficulty in accessing care and higher overall spending.

Improving how we coordinate care offers benefits that include improved healthcare outcomes, reduced costs for both programs, higher client satisfaction, and consistency of care. It enhances communication across various healthcare settings and not only addresses immediate medical issues but broader societal factors that impact an individual’s health.

PurposeCare offers a promising solution to the challenges faced by dual-eligible clients by emphasizing the importance of coordinating care. Integrating coordinated home care and home healthcare services enhances the quality of life for a healthcare population that has been neglected, or offered services and benefits that are relatively inaccessible in the most practical sense. An approach that coordinates and delivers the most impactful services ensures that dual eligibles and their families seamlessly transition through different levels of care.

Caregivers are trained to spot changes of condition in their clients and refer them internally to the nursing team to ensure timely intervention and triage and, where appropriate, assess for home health care. We do this by recognizing and making use of arguably one of the most under-appreciated and under-utilized resources in our healthcare delivery system – the caregiver. That can be a Home Health Aide or Personal Care Aide. It can also be a family member. Educating, supporting, and empowering the caregiver to identify changes in condition as soon as they observe them and providing them with the support to coordinate care helps to reduce the total cost of care, increase the quality of that care, and certainly the satisfaction of our clients. When our clients do require skilled nursing or therapy in the home, we are able to keep their care within the PurposeCare team and maintain continuity of care and consistency with caregivers which results in more positive outcomes. 

Targeted support for dual eligibles addresses a crucial gap in the current healthcare system. By concentrating on a coordinated home care strategy, PurposeCare is continually refining and expanding services that increase visibility into an inefficient and unhealthy status quo for vulnerable populations. Simultaneously, it increases access to the full range of care and services that dual eligibles require and, in fact, deserve.

Richard Keller
Rich Keller

Rich Keller is the CEO of PurposeCare.