Planning for the Most Expensive Patients

September 24, 2013

By Callie Shanafelt

Some of the costliest care in the nation goes to the nine million people who are enrolled in both Medicaid and Medicare.

Dubbed dual-eligibles, these low-income seniors and younger people with disabilities qualify for the insurance program for seniors (Medicare) and the insurance program for the poor (Medicaid, called Medi-Cal in California).

Dual-eligibles often have complicated illnesses. But that’s not the only reason why their care is so expensive, with yearly spending for their care exceeding $300 billion.

Inflexible rules get in the way of efficient care, too. Neither insurance program, for instance, fully covers in-home care, which means that too many poorer patients end up in costly nursing homes. The majority of Medi-Cal funding spent on this population—59 percent—is spent on long-term care.

Medicare is meant to cover the majority of costs for these patients, with Medi-Cal filling in the gaps by paying for Medicare premiums, acute care, prescription drugs and long-term care. And dual-eligibles have to navigate complicated bureaucracies to get needed care, causing delays in treatment that only result in more expense and needless suffering for patients.

That’s why San Mateo and eight other California counties are piloting programs to provide better care. San Mateo created a special plan called Care Advantage to specifically serve dual-eligibles. Now, 8,700 clients on both Medicare and Medi-Cal are enrolled in the program, which started in 2006. The pilot project gives Care Advantage the discretion to decide what is beneficial for patients and how to best use funds.

“The theory is we save money because we keep people out of a nursing home or hospital and those savings accrue to us,” Maya Altman, CEO of the Health Plan of San Mateo said. “The ultimate reason we want to do this is that we think this will be a better system for people.”

One of those people is Willie Edwards. The 55-year-old now lives on his own in an apartment in Palo Alto, but that wasn’t always the case.

Edwards struggled with substance abuse for most of his life.

“It went from crack to meth to heroin- I did all of it,” Edwards said. “It was really bad for me.”
Eventually Edwards got clean and now he regularly attends meetings and has people who call him for advice when they feel like they’re going to use again.

But the years of substance abuse took a toll on his body. Through his IV drug use he contracted HIV. He had a stroke-like episode in 2008 and can no longer walk.

His Care Advantage caseworker helped when he needed a wheelchair that cost around $20,000 in 2008. Then she got him a bed to replace the air mattress he’d been sleeping on. Now he also has a home health worker provided by the county who comes every other day to help him bathe.

It’s a sharp contrast to when he first got sick and lived a long-term care facility in Burlingame.

“It was awful,” Edwards said. Between the lack of privacy and mediocre staff he couldn’t stand the place for more than a year.

He moved in with his aging mother but it was difficult for her to attend to him and awkward that his brother had to lift him into the bathtub each time he needed to bathe. Eventually, he moved to a Catholic nursing home, where he got better and free care.

But for the past eight years he’s been grateful to be living independently with all the modifications necessary made to his apartment. He didn’t find his home because of Care Advantage, but he said he’s been able to stay there because of their help.

It can cost $150,000 a year to house someone in a nursing home, which the plans cover. But if a client moves to a more independent setting like their own apartment, the reimbursement drops to $700 a month, which is not enough to cover expenses needed to live independently.

Enabling clients to live independently may not cost $12,000 a month but it does cost more than $700 a month Altman said.

“Under this program we’ll be able to pay for alternative services—for example if someone needs a ramp to keep them in their homes as long as possible,” Altman said. “There are a whole range of options.”

Another goal is to better integrate behavioral health and primary care. The county had already begun a program to more fully integrate both systems.

Patients with behavioral health issues die 25 years younger than average, said Chris Esguerra, Deputy Medical Director with San Mateo County Behavioral Health and Recovery Services. They struggle more often with behavioral issues like smoking, sedentary lifestyle and unhealthy diet—all of which lead to higher rates of chronic health problems like diabetes and heart disease.

The county started the Total Wellness Program to establish a medical home for dual-eligible patients at county mental health clinics. Clients in the program have a nurse care manager who helps to coordinate their care.

Nurses navigate complicated systems, different sets of electronic health records for primary care and behavioral health, and connect clients with useful programs such as peer coaches, smoking cessation groups or group exercise sessions.

The road to a healthy lifestyle is full of baby steps, Esguerra said. One client, for instance, took medications for her mental illness that led to weight gain. She had also been smoking for years.

The nurse connected her with a nutrition group and she started to change her diet.

“Then she got interested in a walking group because it looked like fun to her, “ Esguerra said.
Then her peer coach pointed out that she was out of breath while walking and suggested that she might want to quit smoking. So she started the smoking cessation group and has been tobacco-free for a couple months.

This is the third year of the Total Wellness Program and so far, many more clients are losing weight and getting their cholesterol and diabetes under better control.

ER inpatient psychiatric charges went down in the 2010-2011 fiscal year, while less-costly outpatient use went up, Esguerra said.

Still, the program serves only about 400 clients, with a goal to reach 600.

Altman wants to see this success spread, but 60 percent of the Care Advantage mental health clients access care through a private practice, not the county clinics.

Louise Rogers, Deputy Director of the San Mateo County Health System, points out that San Mateo is better positioned than other counties to help these patients because their system is already partially centralized. But it remains to be seen how jurisdictions nationwide could adopt their model, which has taken decades to streamline.

As Willie Edwards says of dealing with both Medi-Cal and Medicare, “It’s just one thing after another.”

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