(Last Updated On: March 1, 2019)
Dual eligible patients (those on both Medicare and Medicaid programs) are one of the most challenging patient groups to manage. In addition to their clinical needs, most of these patients have a variety of social needs that can greatly affect their clinical outcomes. A recent big-data study by Inovalon comparing outcomes between dual eligible and Medicare only patients found that sociodemographic factors explained 30% of the difference in outcomes between dual eligible patients when compared to the Medicare only group.
Care coordination, especially the services provided through a Chronic Care Management (CCM) program under CPT 99490, is one way to help bridge this sociodemographic gap. In June 2016, a report around the Minnesota Senior Health Options (MSHO) program, a joint pilot between the Center for Medicare and Medicaid Services (CMS) and the State of Minnesota, was published reporting outcomes on a dual eligible population. The MSHO program is a joint Medicare/Medicare program aimed at delivering truly integrated care to the individual patient. Each patient is assigned a care coordinator, just like CCM, to manage both their Medicare and Medicaid funded services. The study found that, when compared to the control group, patients on the integrated plan using the CCM-like care coordinator were:
- 48 percent less likely to have a hospital stay, and those who were hospitalized had 26 percent fewer stays
- 6 percent less likely to have an outpatient emergency department visit, and those who did visit an emergency department had 38 percent fewer visits
- 13 percent more likely to receive home and community-based long term care services
CMS issued a statement after the studying stating:
“Integrated care is improving the lives of some of the most vulnerable Americans. These new findings from Minnesota affirm the promise of integrated care and reinforce the urgency with which we need to continue to develop, test, and scale successful models for better serving dually eligible individuals.”
Although more models using care coordination to integrate care for these dual eligible patients are on the horizon, CCM can be used today. CPT 99490 provides a sustainable revenue stream by which providers can give dual eligible the extra support they require – especially relating to social needs. The Inovalon report referenced earlier found that “Living in a poor neighborhood” contributes 18.1% to the higher readmissions rate of dual eligibles vs non-dual eligibles (see graph below), underscoring the need for coordination of community resources for dual eligible patients.
Using Chronic Care Management and CPT 99490, a practice can fund the care coordination effort required to arrange for these community resources for the patient. One of the barriers to billing CPT 99490 is the patient copay. For many dual eligibles, specifically those that meet the requirements of the Qualified Medicare Beneficiary (QMB) designation, there is absolutely no copay. For QMBs, the State Medicaid agency is obligated to cover their Medicare copays up to the amount it would pay under its state plan for the same service – making CCM completely free for the patient. If CCM is not covered under the State plan, the state must create a rate at which it will pay. Although there are still many ways that healthcare can improve for dual eligibles, CCM is a great first step for any practice looking to provide extra care coordination support for these patients in need.
Sources: An Investigation of Medicare Advantage Dual Eligible Member- Level Performance on CMS Five-Star Quality Measures. Inovalon. 2015; https://blog.cms.gov/2016/06/16/better-outcomes-for-dually-eligible-older-adults-through-integrated-care/