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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;09;08
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil.
00;00;09;10 - 00;00;43;20
Alan Weil
People enrolled in both Medicare and Medicaid, often referred to as dually eligible, have some of the highest medical and social needs among enrollees in either program. Longstanding differences between how the two programs operate have led to repeated calls over decades to improve coordination between Medicare and Medicaid, with the goal of improving health outcomes and reducing costs. Now, the largest care management model for people who are dually eligible are Dual-Eligible Special Needs Plans.
00;00;43;20 - 00;01;07;14
Alan Weil
Commonly referred to as D-SNPs. They cover more than 4 million people. But there is a growing trend of enrolling tools into so-called look alike plans which could undermine efforts to coordinate care. What are the dynamics of enrollment by people who are dually eligible in integrated plans designed to meet their needs? That's the topic of today's episode of “A Health Podyssey”.
00;01;07;16 - 00;01;31;04
Alan Weil
I'm here with Yanlei Ma, a postdoctoral research fellow at Harvard University. Dr. Ma and coauthors published a paper in the July 2023 issue of Health Affairs, examining trends in D-SNP look alike plan enrollment. They found high rates of growth that raise concerns regarding efforts to coordinate care for this high need population. We'll discuss these findings in today's episode.
00;01;31;20 - 00;01;33;18
Alan Weil
Dr. Ma, welcome to the program.
00;01;34;21 - 00;01;39;28
Yanlei Ma
Thank you very much for having me, Alan. It's a pleasure to be here with you and your audience.
00;01;40;24 - 00;02;01;18
Alan Weil
Thank you. I I've been studying and working on the topic dual eligibles for decades, and this is one of those topics where if we don't sort of set the stage, you can jump to the findings and people sort of go so, so what? But this is really important what you found. And so I do want to start with a little bit of background.
00;02;02;08 - 00;02;16;23
Alan Weil
Tell us, if you would, just a little bit about the characteristics of people who are dually eligible for Medicare and Medicaid. Why is it so important that we think about care coordination and care integration to meet the needs of this population?
00;02;18;03 - 00;02;52;21
Yanlei Ma
Yeah, absolutely. Over 12 million people in the U.S. are dually eligible for Medicare and Medicaid. This is a fairly diverse population because it includes both low income people age 65 and above, and younger people with disabilities. While some duals are relatively healthy, many of them have complex health care needs, and these can include multiple chronic conditions, physical disabilities, behavioral health problems and cognitive impairment.
00;02;53;14 - 00;03;23;02
Yanlei Ma
In addition, many of them face significant social challenges such as homelessness, lack of transportation, or food insecurity. And because of their complex health and social needs, dual eligibles, on average, use more health care services than those enrolled in Medicare and Medicaid alone, even though duals only represent 20% of the Medicare population and 15% of the Medicaid population.
00;03;23;19 - 00;03;53;19
Yanlei Ma
They account for one third of spending in the Medicare and Medicaid programs. For duals, Medicare and the Medicaid each play a slightly different role. Medicare is the primary payor, so it covers inpatient and outpatient services as well as prescription medications. Medicaid is the secondary payor and provides wraparound for Medicare. It covers behavioral health care and long term services
00;03;53;19 - 00;04;20;25
Yanlei Ma
and the supports. Medicaid also pays for Medicare’s premium and cost sharing. Now, because Medicare and Medicaid were not originally designed to work together, duals have to navigate these two systems separately. Most duals have two insurance cards, they have to deal with two different enrollment processes and they have to navigate through two different provider networks.
00;04;21;14 - 00;04;49;26
Yanlei Ma
And these can cause a lot of confusion, unnecessary services and poor health outcomes. For example, the lack of data sharing between Medicare and Medicaid providers for duals in fee for service programs can limit the providers ability to coordinate care for these individuals. As another example, certain benefits covered by Medicaid and the Medicare overlap. But they are not exactly the same.
00;04;50;10 - 00;05;22;11
Yanlei Ma
So if Medicaid has more generous coverage than Medicare for certain services, but because Medicare is the primary payer, a dual may have to first get a payment of denial from Medicare before seeking coverage from Medicaid. From the patient perspective, this can be very confusing and inconvenient. And that in addition, because the financial incentives for Medicare and Medicaid are not fully aligned, duals may miss potential opportunity for better health outcomes.
00;05;23;02 - 00;05;49;20
Yanlei Ma
For instance, because hospital readmissions are covered by Medicare, Medicaid may not have enough of an incentive to provide additional services after a dual is initially discharged from the hospital to prevent their readmission. So all of this said, unfortunately, these days, the majority of duals still have to navigate their Medicare and Medicaid benefits separately.
00;05;50;15 - 00;06;19;17
Alan Weil
Well, that was an excellent description of both the challenges we face and the importance of meeting the needs of this population. Now, for decades now in both programs, we've turned increasingly to managed care with the idea that managed care plans can do some of the coordination that doesn't occur in a fee for service environment. So let's bring in the topic of your study, which is D-SNPs and D-SNP look alikes.
00;06;20;05 - 00;06;45;16
Alan Weil
Again, these are complicated regulatory, I should say, these are complicated terms that describe plans that operate under complex regulations. But can you give us just a thumbnail sketch here of what is a D-SNP and what's a look alike? And why might we want to have these SNPs to try to address some of the concerns you just described?
00;06;46;16 - 00;07;22;04
Yanlei Ma
So D-SNPs, which is Dual Eligible Special Needs Plans, is the largest integrated coverage model in the US. Basically, it is a type of Medicare Advantage special needs plan specifically designed to provide targeted care and to limit enrollment to dual eligibles. Now, because of this unique population it serves, D-SNPs are subject to many unique regulatory requirements in addition to the ones that apply to all Medicare Advantage plans.
00;07;22;22 - 00;07;49;27
Yanlei Ma
For example, D-SNPs are required to contract with the state's Medicaid agencies to provide or arrange for Medicaid benefits for their members. D-SNPs are also required to provide a periodic health risk assessment and to develop individualized care plans for their members. Currently, there are three types of D-SNPs of different levels of integration. They are fully integrated.
00;07;49;29 - 00;08;16;29
Yanlei Ma
This is known as FIDE SNP. Highly integrated D-SNP, known as HIDE SNP, and the coordination only D-SNP. The FIDE SNP is the most integrated version of the D-SNP. It covers virtually all Medicaid services, including both behavioral health care and the long term services and supports. And it fully integrates Medicare and Medicaid spending.
00;08;16;29 - 00;08;45;22
Yanlei Ma
HIDE SNP is less integrated than FIDE SNP, but still covers either behavioral health or long term services and supports. Coordination only D-SNP is the least integrated version of the D-SNP, they are still required to notify states when their enrollees are admitted to hospitals. Now, what about the D-SNP lookalike plans? The D-SNP lookalike plans are regular
00;08;46;07 - 00;09;22;09
Yanlei Ma
non integrated Medicare Advantage plans that appear like D-SNPs, but are not subject to any of the integration requirements for D-SNPs. In terms of similarities, like D-SNP, lookalike plans predominantly target and enroll duals. These plans also have similar benefits and cost sharing features as those offered by D-SNPs. They are attractive to duals because they provide a better coverage of supplemental benefits such as dental, vision, transportation services.
00;09;22;20 - 00;09;53;17
Yanlei Ma
Oftentimes, Medicare and Medicaid either do not cover such services or they cover it only to a limited extent. In the meantime, like D-SNPs, these plans require their members to pay high cost sharing for Part A, Part B services. They require a premium for Part D and a high deductible for Part D. All of these features are generally not attractive to those non dual Medicare population because of the high out-of-pocket costs.
00;09;54;04 - 00;10;40;06
Yanlei Ma
However, it doesn't really matter for the duals because Medicaid covers their Part A, Part B cost sharing and because duals are eligible for Part D low income subsidy, they also get covered for the Part D premium and deductible. So basically by design, these look alike plans are only attractive to the dual population. Now, in terms of the differences, as I said earlier, it is very important to keep in mind these plans are in essence regular non special needs plans, so they are not subject to provide the type of care coordination required for D-SNPs or other integrated care programs.
00;10;40;24 - 00;11;10;25
Yanlei Ma
For example, these plans don't all have to contract with the state Medicaid agencies, or follow any status of specific care coordination protocols to promote the beneficiaries experience. Neither are these plans required to meet the minimum integration requirements as laid out in the Bipartisan Budget Act of 2018. In reality, what happens is duals confuse the lookalike plans with D-SNPs
00;11;10;27 - 00;11;33;29
Yanlei Ma
because certain brokers of lookalike plans misrepresented the characteristics of these plans and made it sounds like a D-SNP. As a result, the duals thought they enrolled in a plan that coordinates their Medicare and Medicaid benefits when in fact the look alike plans have no such obligations.
00;11;35;23 - 00;12;22;26
Alan Weil
Well, so this sounds like a real threat to efforts to provide integrated care. And so your study examines growth in these look alike plans. I'd like to get into the results of what you found with respect to that growth and who they're attracting. We'll cover those topics after we take a short break. And we're back. I'm speaking with Dr. Yanlei Ma about rapid growth in enrollment among lookalike plans, look alike dual eligible special needs plans.
00;12;23;13 - 00;12;45;02
Alan Weil
Before the break, we were discussing how you can market these lookalikes to be quite attractive to people who are eligible for both Medicare and Medicaid, but then their needs aren't well met once they enroll in them. Let's turn to the findings that you report in the study. You found growth in the number of these plans and their availability.
00;12;45;24 - 00;12;52;02
Alan Weil
Can you just provide me with a little more detail? What were the findings with respect to growth in D-SNP lookalikes?
00;12;52;26 - 00;13;25;15
Yanlei Ma
Yeah, sure. Before sharing the findings, let me step back a little bit and explain how we identified the lookalike plans. Basically, in our study, we identified lookalike plans on an annual basis using Medicare enrollment data and the plan characteristics they'd have between 2013 and 2020. We defined lookalike plans as regular non integrated Medicare Advantage plans that had a percentage of duals exceeding a specific threshold.
00;13;26;00 - 00;13;53;20
Yanlei Ma
So we considered two alternative thresholds here. Why is there 80% dual enrollment? This is the definition currently used by the CMS in it's regulation for lookalike plans. And the other is a 50% threshold with all data would allow us to capture additional plans that enrolled duals to a level below the 80% threshold and therefore not subject to the CMS regulation.
00;13;54;18 - 00;14;34;15
Yanlei Ma
Now, in terms of our findings, we found that overall lookalike plans experienced the rapid growth among dual eligibles between 2013 and 2020. More specifically, the number of lookalike plans exceeding 80% enrollment thresholds grew from six plans in 2013 to 58 plans in 2020. The number of duals enrolled in these plans increased from 20,000 enrollees back in 2013 to about 220,000 enrollees in 2020.
00;14;34;24 - 00;15;10;20
Yanlei Ma
So basically it increased by almost 11 times and the geographical coverage of these plans also expanded quite a bit. Back in 2013, they were only in 50 counties within four states, whereas as of 2020 there are in 300 counties across 17 states. When we look to add lookalike plans using 50% enrollment to threshold, we also found similar rapid growth trends in dual enrollment.
00;15;10;22 - 00;15;46;10
Yanlei Ma
It is worth noting, though, the number of plans with duals between 50% and the 80% threshold is almost the same as the number of plans exceeding 80% threshold. What this tells us is there seems to be a sizable number of almost look alike plans that fall outside of the scope of the current CMS regulation. In addition to enrollment trend, we also analyzed the sources of new duals for lookalike plans.
00;15;46;12 - 00;16;18;09
Yanlei Ma
Among the duals newly enrolled into lookalikes, we found about 30% of them were previously enrolled in more integrated care programs such as D-SNPs. This suggests look alike plans do compete with the more integrated coverage models and they can have the potential to attract duals away from the programs that specifically designed to integrate Medicare and Medicaid services for these individuals.
00;16;18;12 - 00;16;51;08
Alan Weil
So that last finding seems particularly alarming. We set up a new program designed to integrate care for this population. People enroll in it, but then they get drawn out of that system into one that doesn't have as much protection for them and as many resources devoted to care integration. Can you say a little more also about the characteristics of the people who enroll in the D-SNPs versus the more traditional integrated plans?
00;16;51;11 - 00;17;27;29
Yanlei Ma
Of course, we found that the majority of duals enrolled in look alike plans were older than 65. Female Hispanic eligible for full Medicaid benefits and living urban areas and communities with a high social vulnerability compared to duals enrolled in D-SNPs in the same service areas, we found duals enrolled in these look alike plans were more likely to be older, male Hispanic living in rural area and the most socially vulnerable communities.
00;17;28;02 - 00;17;56;27
Yanlei Ma
This is concerning as the look alike plans seems to be targeting duals with low English proficiency and from underserved areas to the extent that the lack of integration in lookalike plans can lead to a lower quality of care. These disparity in enrollment may ultimately translate to a disparity in health care quality and outcomes. We also find that it is concerning that the majority of duals and look alike
00;17;56;27 - 00;18;07;20
Yanlei Ma
plans are eligible for full Medicaid benefits because these individuals could have benefited the most from integrated care programs.
00;18;07;22 - 00;18;42;14
Alan Weil
So these are just additional causes for concern and caution. And yet we do see continued growth. So the policy environment in which this occurs is very complex. These are all regulated plans under different regimes. Given the concerns that you raise about the possibility that the people most in need of care coordination are not getting the have not enrolled in the programs that might best meet their needs, what are some of the policy options available so that we have the right people in the right plans?
00;18;44;09 - 00;19;14;15
Yanlei Ma
Right, this is an excellent question. So first, I have to say, effective January 2023, CMS no longer contracts with any Medicare Advantage plans that do not fall under the category of special needs plans, but have 80% or more of its enrollees being dual eligibles. Our finding suggests that existing CMS regulations on look alike plans may not be sufficient. As mentioned earlier,
00;19;14;16 - 00;19;50;04
Yanlei Ma
our results show there is still a sizable number of almost lookalikes with high dual enrollment, but not a currently regulated. Now policymakers may want to consider further regulating these almost look alike plans using a lower dual enrollment threshold or a combination of a lower dual enrollment threshold and other factors to identify look alike plans. In addition, the policy makers may want to ensure the duals transitioned out of existing look alikes
00;19;50;06 - 00;20;24;28
Yanlei Ma
indeed get enrolled into more integrated care programs. While some look alike plans may have transitioned their enrollees into D-SNPs, other lookalike plans may have simply transferred their enrollees to another non integrated plan. For the duals in these latter plans they may have not truly benefitted from the CMS regulation because they were essentially shifted from one non integrated plan to another non integrated plan.
00;20;25;00 - 00;20;59;25
Yanlei Ma
And more broadly speaking, policymakers may want to further facilitate the roles in existing integrated coverage models, especially those of fully integrated data models. For example, the policy makers may consider allowing integrated plans to automatically enroll individuals when they first become dual eligible. And policymakers may also consider encouraging states to require more Medicare and Medicaid alignment beyond the minimum requirement.
00;20;59;28 - 00;21;28;11
Yanlei Ma
Finally, dual eligibles can also benefit from more education on the distinction between integrated and non integrated care products. Policymakers may consider, for example, providing more information on the non integrated Medicare Advantage plans with high dual enrollment or investing more resources to help duals actually select into the integrated care plans.
00;21;28;13 - 00;21;56;09
Alan Weil
You know, I'm particularly interested in that last topic. We put a lot of emphasis on what are your benefits, what are the covered services and certainly the marketing around MA plans in general, as you noted earlier, is around supplemental benefits, and that's very attractive. But coordination isn't something that's typically marketed. You don't say, oh, our product is highly coordinated, and theirs, you're not going to get that kind of coordination.
00;21;56;09 - 00;22;15;06
Alan Weil
I think it's sort of not part of our health insurance lingo. And yet it's such a critical need for this population. So maybe we really need to think about how we talk about what the insurance product represents. And it's not just what's covered, it's also how it's covered and how the parts fit together.
00;22;17;02 - 00;22;19;03
Yanlei Ma
Right, exactly.
00;22;19;05 - 00;22;42;01
Alan Weil
Well, I'm really interested in these results because as I noted at the outset, we've been working for decades on trying to improve coordination between two programs that, as you noted early on, were designed with very different structures in mind. They're operated one by the federal government, the other by states. And the list of differences goes on and on.
00;22;42;21 - 00;23;11;06
Alan Weil
It seems like here we found a model that can at least begin to make a difference. But we are also seeing that the market forces can create alternatives that may undermine that model. So it's a continuous effort to try to improve care for this large and high need population. I appreciate your time to take a closer look at what they face and for being my guest today on “A Health Podyssey”.
00;23;11;08 - 00;23;28;08
Yanlei Ma
Thank you all for considering our work. And I just wanted to say a special thanks to my coauthors on this study and to Arnold Ventures for supporting our work. And thank you again for having me here today.
00;23;28;11 - 00;23;32;02
Alan Weil
Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend
00;23;32;05 - 00;23;35;13
Alan Weil
about “A Health Podyssey”.