Editing Medicare (United States) (section)

==== Reforming care for the "dual-eligibles" ====
Roughly nine million Americans—mostly older adults with low incomes—are [[Medicare dual eligible|eligible for both Medicare and Medicaid]]. These men and women tend to have particularly poor health—more than half are being treated for five or more chronic conditions<ref name="ahipcoverage.com">{{cite web|last=Thorpe |first=Kenneth E.|title=Estimated Federal Savings Associated with Care Coordination Models for Medicare-Medicaid Dual Eligibles |url=http://www.ahipcoverage.com/wp-content/uploads/2011/09/Dual-Eligible-Study-September-2011.pdf|archive-url=https://web.archive.org/web/20111013072459/http://www.ahipcoverage.com/wp-content/uploads/2011/09/Dual-Eligible-Study-September-2011.pdf|url-status=dead|archive-date=October 13, 2011|date=October 13, 2011|access-date=June 15, 2019}}</ref>—and high costs. Average annual per-capita spending for "dual-eligibles" is $20,000,<ref>{{cite web|title=Dual Eligible: Medicaid's Role for Low-Income Beneficiaries|publisher=Kaiser Family Foundation, Fact Sheet #4091-07|date=December 2010|url=http://www.kff.org/medicaid/upload/4091-07.pdf}}</ref> compared to $10,900 for the Medicare population as a whole.<ref name=NationalHealthExpendData/>

The dual-eligible population comprises roughly 20 percent of Medicare's enrollees but accounts for 36 percent of its costs.<ref>Medicare Chartbook, Kaiser Family Foundation, November 2010, p. 55.</ref> There is substantial evidence that these individuals receive highly inefficient care because responsibility for their care is split between the Medicare and Medicaid programs<ref>{{cite web |first1=John |last1=Holahan |first2=Linda J. |last2=Blumberg |first3=Stacey |last3=McMorrow |first4=Stephen |last4=Zuckerman |first5=Timothy |last5=Waidmann |first6=Karen |last6=Stockley |title=Containing the Growth of Spending in the U.S. Health System |publisher=The Urban Institute |date=October 2011 |url=http://www.urban.org/uploadedpdf/412419-Containing-the-Growth-of-Spending-in-the-US-Health-System.pdf |access-date=March 13, 2012 |archive-date=June 14, 2013|archive-url=https://web.archive.org/web/20130614084117/http://urban.org/UploadedPDF/412419-Containing-the-Growth-of-Spending-in-the-US-Health-System.pdf|url-status=dead}}</ref>—most see a number of different providers without any kind of mechanism to coordinate their care, and they face high rates of potentially preventable hospitalizations.<ref>Jiang HJ, Wier LM, Potter DEB, Burgess J. Hospitalizations for Potentially Preventable Conditions among Medicare-Medicaid Dual Eligibles, 2008. Statistical Brief #96. Rockville, MD: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, September 2010.</ref> Because Medicaid and Medicare cover different aspects of health care, both have a financial incentive to shunt patients into care the other program pays for.

Many experts have suggested that establishing mechanisms to coordinate care for the dual-eligibles could yield substantial savings in the Medicare program, mostly by reducing hospitalizations. Such programs would connect patients with primary care, create an individualized health plan, assist enrollees in receiving social and human services as well as medical care, reconcile medications prescribed by different doctors to ensure they do not undermine one another, and oversee behavior to improve health.<ref>{{cite report |publisher=Medicare Payment Advisory Commission |title=Report to the Congress: Medicare and the Health Care Delivery System |date=June 2011 |chapter=Chapter 5. Coordinating care for dual-eligible beneficiaries |chapter-url=http://www.medpac.gov/chapters/Jun11_Ch05.pdf |archive-url=https://web.archive.org/web/20111113143043/http://www.medpac.gov/chapters/Jun11_Ch05.pdf |archive-date=November 13, 2011 |access-date=March 13, 2012}}</ref> The general ethos of these proposals is to "treat the patient, not the condition,"<ref name="ahipcoverage.com"/> and maintain health while avoiding costly treatments.

There is some controversy over who exactly should take responsibility for coordinating the care of the dual-eligibles. There have been some proposals to transfer dual-eligibles into existing Medicaid managed care plans, which are controlled by individual states.<ref name=jointcommitteereport/> But many states facing severe budget shortfalls might have some incentive to stint on necessary care or otherwise shift costs to enrollees and their families to capture some Medicaid savings. Medicare has more experience managing the care of older adults, and is already expanding coordinated care programs under the ACA,<ref>{{cite web |first1=Judy |last1=Feder |first2=Lisa |last2=Clemans-Cope |first3=Teresa |last3=Coughlin |first4=John |last4=Holahan |first5=Timothy |last5=Waidmann |title=Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead |publisher=Robert Wood Johnson Foundation |date=October 2011 |url=http://www.rwjf.org/files/research/72868qs68dualeligiblesfull20110930.pdf |access-date=March 13, 2012 |archive-url=https://web.archive.org/web/20120813045358/http://www.rwjf.org/files/research/72868qs68dualeligiblesfull20110930.pdf|archive-date=August 13, 2012 |url-status=dead}}</ref> though there are some questions about private Medicare plans' capacity to manage care and achieve meaningful cost savings.<ref>Families USA, "A Guide for Advocates: State Demonstrations to Integrate Medicare and Medicaid". April 2011. {{cite web |title=Report to the Congress: Medicare and the Health Care Delivery System |url=http://familiesusa2.org/assets/pdfs/health-reform/State-Integration-of-Medicare-and-Medicaid.pdf |url-status=dead |archive-url=https://web.archive.org/web/20120324164822/http://familiesusa2.org/assets/pdfs/health-reform/State-Integration-of-Medicare-and-Medicaid.pdf |archive-date=March 24, 2012 |access-date=March 13, 2012}}</ref>

Estimated savings from more effective coordinated care for the dual eligibles range from $125 billion<ref name="ahipcoverage.com"/> to over $200 billion,<ref>Robert A. Berenson and John Holahan, Preserving Medicare: A Practical Approach to Controlling Spending (Washington, DC: Urban Institute, Sept. 2011).</ref> mostly by eliminating unnecessary, expensive hospital admissions.