Delivering care to dual eligible nursing home residents can be complex with so many payers involved in the industry, but aligning incentives, quality measures and tools for providers can help operators serve this demographic.

Dual eligible residents, or those that can receive benefits from both Medicare and Medicaid, often find themselves in a “tangled web of conflicting program rules,” said Allison Rizer, executive vice president of payer solutions with ATI Advisory. There are different provider networks, different enrollment periods, different requirements for getting a benefit covered, and different coverage documents are needed, she said.

“It’s extremely confusing and overwhelming,” said Rizer. “This system fragmentation leads to poor outcomes and inefficient healthcare utilization, and higher costs overall for both the Medicare and Medicaid programs.”

Anne Tumlinson, founder and CEO of ATI, likens dual eligible care to a “tug of war” between who is going to pay for what and when, resulting in clunky care delivery in nursing homes.

About 12 million to 13 million people are dually eligible, Rizer said, and about a million of this population lives in nursing homes. Moreover, about 40% of dual eligible residents in nursing homes will have at least one hospitalization this year, she said, compared to 15% of the Medicare population.

The dual eligible population is heterogeneous as well – all ages, all levels of need, spanning both custodial and medical care. Quality and data collection tends to be siloed, with only Medicare or only Medicaid resident data captured. Meaning, the roadmap currently in place to inform quality improvement doesn’t take dual eligibles into account, Rizer said.

Administrative burden tied to dual eligibles is felt acutely in nursing homes, Rizer said. There may be a handful of residents enrolled across five to 10 health plans, and each claim might have its own credentialing or claims submission requirements. Health plans face administrative burdens as well when trying to develop a care model for this population.

The path toward integrated care models

Integration is needed with Medicare and Medicaid programs, panelists David Grabowski and Kate McEvoy said during a webinar hosted by ATI last week, which also presented findings from a study on dual eligibles, with support from Arnold Ventures. It’s something policymakers have been trying to do for decades, Rizer said, but efforts so far have been concentrated almost exclusively on community-based settings.

Grabowski is a professor of health care policy at Harvard Medical School, and McEvoy serves as executive director for the National Association of Medicaid Directors.

Care plan organizations that develop dual eligible models have way more patients living in the community, Tumlinson added, to the point where managing nursing home duals is a bit of an afterthought.

“At the same time, we have considerable policy attention on improving quality experiences and outcomes in nursing facilities, especially for long stay residents, as we see acuity increasing among residents and staffing shortages happening,” said Rizer. “We have these two conversations:, iIntegration for dual eligible people over here, nursing facility improvements over here.”

In the years devoted to creating a dual- care model in home- and community-based settings, nursing homes were acknowledged as an important part of the continuum but were not the predominant focus, McEvoy confirmed.

Integrated models for dual eligibles in nursing homes hasn’t seemed to make the short list yet among Medicaid experts, she said, with a significant “crowding out” effect happening due to the unwinding of the public health emergency (PHE) still affecting behavioral and maternal health.

Plus, presenting a value proposition for an integrated care model is difficult to do currently, McEvoy said. There are mixed quality results between Medicare and Medicaid, but aligning data on reduction of hospitalizations, falls, and overall care coordination is a place to start, she said.

“We often have the wrong set of measures for the quality of integrated care,” added Grabowski. If you look at how [special needs plans] are being evaluated relative to traditional [Medicare Advantage] plans, it’s kind of apples and oranges in terms of who they’re caring for and their needs.”

Uniform sets of quality measures across Medicare and Medicaid to rate dual plans is something the Centers for Medicare & Medicaid Services (CMS) can do, with most states having a limited budget.

McEvoy touched on the heterogeneity of the dual eligible population too, with Medicaid membership wanting a menu of choices for dual eligible care plans based on what works for each state.

Some models, including the institutional special needs plan (I-SNP), checks some of the boxes for dual eligibles, but the states aren’t playing in this space so it isn’t a true dual model Grabowski said.

“I think that’s a continuing source of frustration,” Grabowski said of unsatisfactory dual eligible models. “We have so much work to do here. NASEM came out with this set of recommendations. We need to better coordinate care.”

In terms of an evolution of the I-SNP, Grabowski said a truly integrated model would need to engage the states more, to convince state and federal players to buy in. The dual eligible special needs plan (D-SNP) model doesn’t have a big enough footprint among nursing homes.

“Even though from a state perspective, [D-SNPs] work well, I’m just worried that we’re ever going to get enough volume there for the nursing homes to really invest,” said Grabowski. “We need clinical services. The nursing home needs to be a part of this and sharing in the state, and they’re not today.”

The sector hasn’t really seen these two conversations come together, she said, despite 75% of long-stay residents being dual eligible.

A model for integration in nursing homes

In order to achieve integration, more leadership and resources in Medicaid programs is needed, ATI presenters and panelists said.

Three key elements of an integrated care model, Rizer said, involve population-appropriate clinical models, representative and aligned quality measures. The aim is to simplify resident and family experiences while reducing administrative burden.

“For us to really get a better quality of care experience for the resident, we have to change the incentives at the provider level,” Tumlinson said. “From a financing standpoint, we have to change the financing of nursing facility care…unless we change that at the provider level we’re just going to be struggling with this problem going forward.”

Getting paid for housing, food, and some ADL assistance from one payer, and then getting paid from a different payer for something akin to rehab and skilled nursing is very challenging, she said.