Care coordination for dual-eligible Medicaid and Medicare members: a challenge and an opportunity

If there is one trend in healthcare that isn’t going to change soon, it’s the growth in America’s dual-eligible population. At last count, more than 10.7 million people are eligible for both Medicare and Medicaid.* Serving dual eligibles is a huge opportunity for managed care plans, but they also need to deal with some challenges.


Challenge 1: Greater needs, higher costs

Dual eligibles are often the sickest of the sickest. They have a higher prevalence of many conditions such as diabetes, pulmonary disease, stroke, Alzheimer’s disease, and mental illness compared to people who qualify for Medicare only or Medicare only, and their healthcare costs are four times greater than all other people with Medicare.* To meet this challenge, health plans need to have a range of care coordination services and a strong team of care managers.


Challenge 2: Connecting the neighborhood of providers

When it comes to serving dual eligibles, one of biggest issues is connecting the “whole neighborhood” – all of the healthcare providers who take part in a member’s care. It’s important to get the right people involved, including care managers at health plan. It’s even more important to get the right information to those people. They should have complete visibility about the care plan, test results, preventive care services, and anything else they need to keep members on track.


Challenge 3: Low participation in care management

Another issue is that it’s voluntary for the members to participate in care management programs. Some states have seen dreadfully low participation. Plans are working with the states to get more people engaged, but it has been an uphill battle. Why the low participation? Some suggest the opt-out form was confusing to beneficiaries, causing more people to opt out than necessary. A study in Massachusetts indicates beneficiaries were worried about losing access to services or providers if they participated.** To counter these issues, plans need to work with providers to reach out to members. Together, over time, plans and providers can get members themselves involved in understanding the care plan and agreeing to it.


Challenge 4: No clear leader with a working model

In healthcare we often look to one plan or one state as the model for success – and then everyone follows the leader. Unfortunately, there is no clear leader yet. The dual eligible care coordination models are too new, and no one has been doing it long enough for one place to claim success. Therefore, the industry is still making up its mind on best practices. That being said, we are seeing some best practices among our customers.


To increase participation in care management:

  • Ensure providers are aware of your member outreach methods
  • Supplement your provider outreach with community outreach methods
  • Make sure materials are simple, easy to read, and translated if appropriate for the population


To improve care for your dual eligibles:

  • Provide access to the care plan in the provider portal
  • Include member-specific reminders about needed care in the provider portal
  • Include member-specific reminders about missed services in the provider portal
  • Send automated outreach to members about needed services and self-management tools


The big opportunity: Mobile communications

Because dual eligibles are older and have lower income, many assume they are not good candidates for digital communications. That’s not the case at all. In fact, reaching these members on mobile is a huge opportunity. Several studies show the most reliable way to contact individuals on Medicaid is via smartphone. Why? For many, the phone is their primary link to the Internet – and they don’t necessarily have reliable home phone numbers, addresses. The people going in to Medicare now were raised on technology. The over age 65 group is one of the fastest users in terms of growth for mobile technology.


So as you look to coordinate care for dual eligibles more effectively, it’s crucial to engage providers. Work with them to reach members and get them on board. And don’t overlook the opportunity to use mobile technology to engage this membership.








Chuck Rolfsen is Chief Revenue Officer for Healthx. He helps Medicaid health plans, commercial health plans and other Healthx clients develop strategies to streamline administrative processes and improve the quality of care.