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As North Carolina’s Medicaid program prepares for changes, a group of policymakers is wrangling with how to care for the most difficult patients.

By Rose Hoban

A small group of people making decisions about big sums of money is getting close to wrapping up their work in Raleigh.

The Dual Eligibles Advisory Committee has been meeting monthly for the past six months to determine how to handle one of the most difficult populations to care for in North Carolina’s Medicaid program.

Dually eligible patients often end up living out their lives in expensive institutions, when many of them would rather stay at home. Image courtesy of Ava Lowery, Flickr Creative Commons

The group was created after the General Assembly ordered a study of the best way to move forward toward covering a special Medicaid population – dual eligibles. It’s a population that costs more than a billion taxpayer dollars to care for annually.

Dual eligibles are those people who are sick enough and poor enough to qualify for coverage under two large government health care plans: Medicare and Medicaid.

Medicare, paid for wholly by federal dollars, usually covers seniors and some people with disabilities. Medicaid, paid for with a combination of state and federal dollars, pays for care for low income infants and children, some of their parents, low-income seniors and people with disabilities.

While there are relatively few “dual eligibles,” these folks often have multiple needs, multiple diagnoses and multiple medications, and managing their care can be a thorny problem.

“There are a very complex stew of issues associated with dual eligibles,” Bob Atlas, a consultant hired by the Department of Health and Human Services, told the advisory committee during their meeting at the McKimmon Center on the N.C. State campus Tuesday.

Atlas spent three hours discussing the issues around dual eligibles with about 35 people – advocates, health policy experts, representatives of managed care companies, doctors and others. Their goal: To boil down the complicated needs of this complicated population for a legislative report due Jan. 31.

It’s complicated

At the end of last year, North Carolina had about 319,000 dual eligibles, about 17 percent of the state’s Medicaid population.

In the last fiscal year, the state spent about $1.1 billion, which is a third of the state’s $3.6 billion Medicaid budget.

Dual eligibles – also referred to as the “aged, blind and disabled” – have their care paid for by a complicated combination of the two government programs, which can differ for different subgroups of people.

For example, someone who is dual eligible might have been born with a disability and qualifies for Social Security Disability benefits, meaning they also qualify for some Medicare payment. Medicare only pays a portion of the tab, and the state Medicaid programs picks up the balance. Or, an 86-year-old widow who has exhausted all of her savings and who is sick enough to live in a nursing home is also dually eligible. In her case, Medicare pays for hospitalizations and acute needs, while state Medicaid dollars pay for the skilled nursing facility.

When the legislature passed its Medicaid reform plan in late 2015, lawmakers decided to punt on the dual eligibles issue, because of the complexity of the issues involved. Instead, they ordered the formation of the advisory committee to hash out what would be needed to manage the costs of dual eligibles in a way that makes sense.

In some states, similar groups of stakeholders have taken more than a decade to iron out the details for managed long-term care.

The draft report discussed this week is 35 pages of single-spaced type, with another 35 pages of Powerpoint presentation. The details are dense enough to make even a policy wonk’s eyes glaze over, but billions of dollars are at stake.

Why so expensive?

“We… have to understand the array of folks,” said Atlas, who has been working as a consultant for DHHS off and on for more than three years. “They’re not all supremely ill, they’re not all in a facility.”

Atlas pointed out that the best way to manage the care for dual eligibles is to help them stay healthy and to stay in the community in their own homes.

But life, and fate, can sometimes get in the way.

“Someone, might be a Medicare-only beneficiary. They fall at home, end up in an acute care hospital, they’re sent to a rehab or a nursing facility and things develop where they don’t recover,” he said. “Maybe the rent isn’t getting paid at home, they lose their apartment, next thing you know, they have to live in the nursing home.”

Those costs quickly add up. According to the latest data from the annual Genworth Cost of Care survey, a semi-private room in a nursing home costs upward of $6,500 a month. It’s far cheaper to help these folks stay in the community, where having a home health aide to assist a patient is only about half that cost.

In the past, North Carolina would simply pay for these people’s care, with the federal government putting in two dollars for each one spent by the state. But in the future, lawmakers want to move to a “managed care” system, where the state gives an insurer a set amount of money to provide care, while working with parameters for quality of care and patient outcomes.

“The idea here is to create an incentive to put people in the least costly setting where they get good quality care, and have a good outcome and have a good quality of life,” he said.

For now, the earliest duals who will roll under the new Medicaid managed care program would be in 2021, two years after other Medicaid beneficiaries such as children and low-income pregnant women are moved into managed care.

But due to the complexity of the issue, it could take years longer.

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Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...