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Maximize Value May 18, 2015

Managed Medicaid: The Dual Eligibles Opportunity

Global Head, Health Services, Oliver Wyman
Partner, Health & Life Sciences, Oliver Wyman
Partner, Health & Life Sciences, Oliver Wyman

In 2013, the Centers for Medicare & Medicaid Services (CMS) announced that it would be partnering with the State of New York to test a new model for providing individuals enrolled in both Medicare and Medicaid with a more coordinated, person-centered care experience. While recent reports have noted its slow start, Oliver Wyman’s Martin Graf, Jim Fields, and Parie Garg provide an update on the demonstration program – officially known as the Fully Integrated Duals Advantage (FIDA) program – and its potential:

As the most costly segment of the Medicare and Medicaid populations, dual eligibles represent a substantial opportunity for managed care organizations (MCOs) as States increasingly move to Managed Medicaid. At a PMPY cost of ~$30K (more than three times the average Medicare member), managing dually eligible individuals appropriately can drive significant savings for health plans.

A Big Apple Example

It’s not surprising that New York launched the FIDA plan to manage the integration of the behavioral and physical health needs of the dually eligible population: At ~700K full dual eligible beneficiaries, New York represents almost 10% of the total fully dual eligible population in the US. The FIDA program generated significant interest among New York MCOs – 22 plans originally signed up across eligible counties in New York to deliver services. The State has estimated enrolment in the region of 140K members across eight different counties. Interest was bolstered by the promise of passive enrolment (also known as auto-assignment) in FIDA, with the option for duals to opt out. However, enrollment has fallen significantly short of the target, driven by two major factors:

  • Rollout of the second wave of FIDA (across Suffolk and Westchester counties) was delayed indefinitely due to network inadequacies
  • More importantly, ~42K individuals chose to opt out of the program as of April 1, 2015

What does this mean for MCOs that are signed up for FIDA? Should they withdraw from the program (like Montefiore already has)? We believe that Medicare-Medicaid integrated Special Needs Plans (SNPs) like FIDA present a unique opportunity in the duals space. Moreover, as more and more states jump on the bandwagon of Managed Medicaid, integrated SNP programs (and similar holistic care programs for beneficiaries with complex care needs) are only going to grow. So, how does one get around the issues that are being experienced by the FIDA plans in New York?

  • Know your members: While the auto-assignment of members is a potential boon for health plans, knowing and managing members is still an important part of this program. As soon as someone is auto-enrolled, plans should be reaching out to establish a relationship with the member through a personalized member on-boarding process.
  • Have a field force at the ready: Finding the auto-assigned members (or any members for that matter) is a universally acknowledged problem with the dually eligible population. Having a well-designed field force on hand that can connect with individuals is an effective strategy for existing plans and those that will be launched going forward.
  • Address the opt-out issue head on: Market feedback indicates that the primary reason behind the opt out is fear mongering by the provider community. Plans that are able to talk to their members have reported success in reduction of opt outs. Additionally, it is important that plans engage providers in the process of managing care for these populations so the providers are engaged and incented to help the programs achieve success.

Finally, while we acknowledge that states like Massachusetts and New York are experiencing the pain of launching new models aimed at challenging, but high-need populations, we believe that these states will help define the path forward for managing duals. Now is the time to be running towards the opportunity, rather than away from it.

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