‘Dual eligibles’ pingpong between programs, getting stuck along the way

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

The phrase “dual eligibles” has always been a mouthful for describing people old enough (or disabled enough) to be on Medicare and poor enough to be on Medicaid.

M.C. Kim, a cardiac patient quoted in Anna Gorman’s nice Sunday  Los Angeles Times piece on the “duals,” comes up with a clear and easy-to-grasp alternative image: pingpong patients.

M.C. Kim had four heart attacks in as many years. Each time, he left the hospital not knowing why his heart had failed.

When he tried to enter a cardiac rehabilitation program to learn how to reduce the odds of having more heart trouble, the Medicare office told him to call Medicaid. The Medicaid office told him to call Medicare. In the end, he said, both denied coverage.

“I was like a pingpong ball,” said Kim, 51, who lives in Los Angeles. “Nobody wanted to take responsibility.”

So Kim kept returning to the emergency room, racking up expensive medical bills for taxpayers.

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Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

The “duals” get their doctors and hospitals paid for by Medicare, and their long-term care by Medicaid.  (That’s overly simplistic, but you get the main idea.) As they go back and forth between settings, they get caught between two systems that should mesh but often are more like mismatched gears that grind and jam and make noise and get stuck.

Care transitions, a weak point in the health care system in the first place, are particularly disastrous for this population. In fact, the mismatched incentives and insane amount of built-in levers to shift costs may increase the number of care transitions -which boosts costs and create all sorts of opportunities for mishaps and miscommunication that can harm patients.

Gorman’s story is a nice illustration, giving examples from both the elderly and the disabled.  She puts a face behind the red tape.

The health reform law takes some steps toward solutions – although this is a tough problem and it’s certainly too soon to say that the reform law will fix it.

A few pieces of a potential solution:

CMS now has a special office on the duals. I interviewed Director Melanie Bella for Kaiser Health News earlier this year. She  has testified at least twice before committees in Congress: On June 21 (PDF) she went before the U. S. House Committee on Energy & Commerce, Subcommittee on Health and on Sept. 21 (PDF) she was before the  U. S. Senate Committee on Finance. Her testimony can give you an idea of what steps her office is taking and which part is relevant to your state or community.

Medicaid managed care, advanced medical homes, ACOs, penalties for high readmission rates, payment bundling and other reforms may eventually provide better coordinated care for the “duals.” Some of the new programs for the elderly encouraged by the law, such as Independence at Home, may also help. There are more details about delivery system and the duals in this Kaiser Family Foundation brief.

The Alliance for Health Reform also did a whole briefing on this topic a few months ago. This link will take you to resources, an archived webcast, and a transcript (for those of you who would rather skim than watch the webcast)

The SCAN Foundation also has a lot of material on the duals on its website, including this report on state-based solutions.

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