Managed Care and Dual Eligible

Last week we discussed dual eligible individuals; people using services under both Medicare and Medicaid and specifically “full” dual eligible. These are our friends and neighbors that use a large number of services under both programs. We noted there are 7.4 million full dual eligible citizens of the United States and that more than 168,000 of our fellow Missourians are considered full dual eligible.

Because of the cost and the need for better case management of the services provided dual eligible, the Affordable Care Act created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make the two programs work together more effectively. They are charged with testing new approaches to care coordination which permits states to keep any earned Medicaid savings but also share in the Medicare savings resulting from their management efforts. The biggest of these initiatives is the Financial Alignment Demonstration. In this demonstration CMS is testing predominantly two models to better integrate primary, acute, behavioral health, and long-term supportive services for full dual eligible.  The Medicare- Medicaid office wants 2 million of the 7.4 million full-dual eligible Americans enrolled in these demonstrations by the end of 2014.

The two models being tested by the Financial Alignment Demonstration are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

So what’s the difference? The Capitated model and the Patient Centered Medical Home model are both, equally, managed care models. Operationally, the capitated model, through capitation, transfers the risk of financial loss from the state and federal government to a private third party who administers the program to control cost and provider behavior. The Patient Centered Medical Home Model addresses cost and provider behavior by establishing a single point of coordination to design and manage care plans, case manage individuals, and coordinate all services. It then shares the total system savings with providers who meet its quality and cost benchmarks.

As of March 2013 26 states have submitted proposals and 5 have executed memorandum of understanding with CMS (California, Washington, Ohio, Illinois, Massachusetts). The other states remain in negotiations with CMS. Missouri submitted its proposal on May 31st, 2012. Missouri chose to submit a Patient Centered Medical Home Model. Of the currently approved five states, Washington State is operating a Patient Centered Medical Home Model. Iowa and New York like Missouri are expected to receive approval soon.

Home Healthcare, HCBS services and medication management services (MTM) provided through a community pharmacy can play a fundamental role in improving a dual eligible citizen’s health and reducing the cost of their care, regardless of the Financial Alignment Demonstration model chosen by a state.

To make a positive difference in an individual’s health you have to first have a relationship with the individual. To build a relationship you have meet the person where they are; and where full dual eligible are concerned that primarily consist of home or the hospital. It’s better and cheaper for everyone to meet at home.

Where the capitated model is concerned, effective use of Home and Community Based Services (HCBS), services like personal care and basic nursing, and MTM through community pharmacy reduces medical expenditures and can result in better beneficiary satisfaction and increased profit for the insurance company. There is no better return on investment for an insurance company than reducing costly hospitalizations and rehabilitation time spent in Skilled Nursing Facilities after acute events like falls or strokes.

The Patient Centered Medical Home Model likewise benefits greatly from a robust home care component. Where it’s difficult for many dual eligible patients in a Medical Home to get to their doctor’s office, a home health provider, like Pyramid Home Health Services, who provides fully interactive tele-health can bring their doctor into their home. In fact, at Pyramid Home Health Services we use Android tablets and multi-split screen technology to simultaneously case conference with a patient, our nurse in the home, the patient’s physician and the patient’s Pyramid pharmacist. If labs are necessary they can be attained on the spot. If medication regimen need to be changed home delivery can ensure those changes are made the same day. Most importantly everyone knows what’s going on real time and our patient does not end up in the hospital because they could not get to the physician’s office. Now that’s a health care home that can work for our dual eligible citizens.

Pyramid Home Health Services has been Missouri’s premium home care provider since 1972. We offer a full array of home health, HCBS, Hospice and Pharmacy services. We are also a leading provider of both tele-health and tele-monitoring services for individuals with chronic illness. If Pyramid Home Health Services can assist you, your family, patients or plan beneficiaries call us at 888-880-6565 or visit us at

Case Managing Dual Eligible

Medicare covers 46 million elderly and disabled Americans. 10.2 million Americans are also covered by Medicaid. They are in the parlance of public health, “Dual Eligible.” 7.4 million of these dual eligible, very often our poorest and sickest citizens, are considered “Full-Dual Eligible.” These individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. There are 168,229 full dual eligible in Missouri and Missouri Medicaid spends in excess of $2 billion annually on their healthcare.  

So who pays for what? Medicare pays for most acute care services like hospitals and physicians, but also prescription drugs and certain post- acute services like rehabilitation in a skilled nursing facility, home health, some outpatient therapy and some DME. Medicaid pays the individual’s Medicare premiums, cost-sharing for acute services, and for services not covered by Medicare, most notably long-term care but also medical transportation, case management, and in some states vision and dental services.

Because Medicare and Medicaid pay for different slices of a dual eligible’s care this group’s services have been largely uncoordinated. The cost of investments designed to lessen overall spending, if done, is often borne by the state and Medicaid with the benefits accruing to the Federal government and Medicare. For example, reducing avoidable hospitalizations is a direct benefit of better coordinated care. CMS says 45 percent of hospitalizations transferring from skilled nursing facilities last year we’re avoidable. To reduce those hospitalizations requires investment in programs like fall prevention and expanded HCBS services. The cost of expanding these programs is roughly 40% born by the state under Medicaid but the financial savings from those investments accrue to Medicare and the Federal government.

To address this inequality, The Affordable Care Act created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make the two programs work together more effectively. They are charged with testing new approaches to care coordination which permit states to keep any earned Medicaid savings but also share in the Medicare savings resulting from their management efforts. The biggest of these initiatives is the Financial Alignment Demonstration. In this demonstration CMS is testing predominantly two models to better integrate primary, acute, behavioral health, and long-term supportive services for full dual eligible.  The Medicare- Medicaid office wants 2 million of the 7.4 million full-dual eligible Americans enrolled in these demonstrations by the end of 2014.

Home Healthcare and especially Home and Community Based Services, those services that deliver long term care into the individual’s home, can play a very important role in helping the States better meet the care needs of their dual eligible citizens. These programs which include tele-monitoring, tele-health, personal care, homemaker chore and basic nursing services provide the single most affordable mechanism for early warning of impending health events that likely will result in a hospitalization. For example, if HCBS monitoring identifies an individual is experiencing increased restlessness at night and unusual weight gain in the short- term, with Doctor’s orders, a home health nurse can intervene with administration of a diuretic if necessary and increased teaching on diet. A personal care assistant can prepare in advance healthy meals and have them ready to go when it’s time for the individual to eat; making it easier to stay compliant with a lower sodium, lower sugar diet.

This is just one example of how home health and HCBS can, for the cost of a few hundred dollars under Medicaid, avoid many thousands of dollars of cost under Medicare relating to a a CHF hospitalization. When provided as a part of a broader Financial Alignment Demonstration this means increased revenue to the state by driving the Medicare savings associated with this dual eligible citizen’s care.

Pyramid Home Health Services provides Home Health, HCBS and Pharmacy services throughout Missouri. We’ve helped Missourians remain at home since 1972. Call us at 888-880-6565 if we can be of assistance to you.

The Future of Home Health Care

The issue of home healthcare has grown in popularity over the past few years. People have begun to speak out about the benefits of being able to age in the comfort of home versus in a nursing home or hospital. Much of this change is fueled by the fact that a large generation of people are reaching an older age. It is expected that just below 70 million people will be on Medicare by the year 2030. Many of these people would rather live out the rest of their lives at home, surrounded by comfort and family. This means there will be some big changes in home healthcare in the coming years.

Some companies have already begun to look into the future of healthcare by developing and creating new technology to assist patients at home.  GE is one such company that has been working to develop products that would help assist a person in-home. Some such aids include a mirror that reads vitals and kitchen appliances that make operation and food preparation much easier. Companies, like GE, have looked into what the future home should look like from a realistic point of view. Technology has the ability to offer some wonderful, easy to use home health solutions. They will provide a safety aspect for patients, where families can worry less about their elderly loved ones. Using technology to advance home healthcare is an industry that is growing quickly. Because of this, aging from home is beginning to feel like a much more attainable goal.

Technology is not the only thing driving the push for home healthcare. More and more organizations are beginning to understand the benefits to patients when they can be home. Companies and groups are working hard to bridge the gap between doctors and patients and provide options for more care around the clock, without hospitalization or nursing homes. This type of care is made possible by Accountable Care Organizations, or ACO’s. ACO’s are basically the care team for patients. The creation of these groups, along with the amazing organizations working to pair them with patients, will greatly improve home healthcare options.

Pyramid Home Health Services is looking forward to the future of home health care. We believe that the quality of life for someone aging at home can, and will be, improved in coming years.

The Benefits of a Home Health Care Model

Last week we covered the basics of the Patient Centered Home Health Model, but only briefly glossed over the benefits to patients and family caregivers. This week we would like to look a little more in depth into why home healthcare is advantageous to not only the patient and family caregiver; but what home healthcare can do to improve the monetary drain on Medicare and Medicaid.

Living with a chronic illness can be difficult for anyone.  It causes long hospital stays, inability to recover quickly, pain and discomfort, and, in some cases, premature nursing home living. All of those things can take a toll on the well-being of a patient and a family caregiver. With home healthcare services, some of that burden can be lifted. An easy example to use would be a man struggling with diabetes. Without the proper medication, nutrition, and counseling on how to handle the disease, that person would have difficulty controlling the diabetes and would probably end up hospitalized a few times over the course of his life. With home healthcare, diabetes can be handled much more efficiently with a team of individuals who cover the broad needs of the patient. The team can work to make sure medication is taken properly, the patient adheres to a strict diet, and any flares in the disease are handled quickly. This leads to a much better quality of life for the patient, and his caregiver.

Using home healthcare can also save money for both Medicare and Medicaid. Reducing the number of emergency hospital visits, as well as longer hospital stays, vastly reduces the amount of money spent by government funded health care. Basically, it is much less of a drain on the Medicare/Medicaid system. The reduction in spending for each patient means that the programs are more fiscally responsible. This will lead to a program that can be funded for a longer period of time. In fact, a study performed in Sacramento showed that reduced hospital visits can lower the cost of each patient by an average of $5,000.00. That is quite a bit of money when the number of people covered by Medicare and Medicaid are considered. Using home healthcare could be a useful, long-term solution to overcoming some of the funding issues that are currently present in the system.

All of us at Pyramid Home Health Services understand that this is a complex issue. If you feel you may benefit from home healthcare options, or just have unanswered questions, please feel free to contact us. Our staff would be more than happy to assist you in any way.

An Overview of the Patient Centered Medical Home Model

On May 31, 2012, Missouri submitted for approval a Patient Centered Medical Home Model for duel eligible Medicare-Medicaid residents. If approved, this proposal would reduce some of the monetary burden that falls on both Medicaid and Medicare. This Blog will give a brief overview of this proposed model and discuss a few of the benefits to patients and family caregivers.

As discussed previously, Home Healthcare can reduce the number of unnecessary hospitalizations and long term, premature nursing home care. The question here is how will it do this? The Patient Centered Medical Home Model works with individuals, who are elderly or disabled, to provide a “care team”. This care team is comprised of various individuals, including; nurses, pharmacists, nutritionists, physicians, and physician’s assistants. In some cases, it can also include; social workers, psychiatrists, behavioral heath consultants, diabetes educators, and labs. By bringing this team of people together, the patient receives comprehensive care that may not always be available without this program. It also helps to diagnose acute issues that, without the team, could lead to larger problems and hospitalization.

So, how does it work? Each team is led by a care coordinator, normally the primary physician or advanced care nurse. This care coordinator works to provide the rest of the team with information about the beneficiary and keep everyone connected. They are responsible for connecting the beneficiary with the help they need from specialists, and removing some of the burden from the family caregiver. This also gives the patient the ability to have more face time with each person on the team, faster response time for medical issues, and an unlimited ability to contact the care coordinator by a preferred contact method. In most cases this by email or telephone. There are no stipulations on being in contact with a physician during office hours only. Simply put, there is much easier access to health care for the beneficiary, while also offering the ability to live life independently while still in the home.

The Patient Centered Medical Home Model not only helps give comprehensive care for beneficiaries, but it also increases the quality of their lives. It works to establish relationships and provide unique care for each individual person’s circumstances. That is something that is often overlooked when discussing healthcare for the elderly or disabled. It also provides a plan for chronic illness, and in some cases, can help to control some of the issues and reduce hospital visits.

Pyramid Home Health Services provides a vast array of home based health services and care coordination. Please visit our website for more information, or to see if we can be of any help to you or a family member.

Care Coordination: Home and Community-based Services

There’s so much to discuss when it comes to home healthcare! We’d first of all, like to thank you for exploring our Blog site and being one of our first guests. Welcome!

One of the many goals of this Blog, will be to keep you informed of the weekly “goings-on” not only here at Pyramid, but within the industry as a whole. We’ll have a monthly topic, which in we’ll discuss multiple issues, offer statistical data, and talk about the pros and cons of home health service.

This month, we’re discussing the use of home and community-based services to avoid unnecessary hospitalizations, nursing facility placement and ensuring the highest level of customer satisfaction.

Not only is home health care a nice option for the patient, but it can also be a relief on the “system”.  Many patients that don’t have home care will use the hospital as their only means of staying on top of an ailment. Certainly, there are times when the hospital is the only option, but for the majority of patients, they simply need to be educated on how a home health service provider can improve their daily lives. Trips back and forth to the hospital are not only putting the patient at risk, but they’re expensive.

Home Healthcare facilities emphasize that care at home is designed to prevent avoidable repeated hospital stays that are costly for patients as well as government health programs such as Medicare. Such programs could become the model for millions of baby boomers that will rely on Medicare during their final phase of life. Hospitals are expected to reduce patient readmissions or otherwise face reimbursement penalties from Medicare. With a move towards home health services, the burden of payment into these systems is greatly reduced and the patient avoids unnecessary multiple trips to the hospital. There are several different kinds of home health services that we’ll discuss in future posts, but overall, In-Home Services provide individuals with assistance with activities of daily living and their families with a respite from the often intense demands placed on a family caregiver. In-Home Services are designed to allow individuals to remain at home as long as possible by bringing the custodial and nursing services often associated with a nursing home into the individual’s home.

Pyramid Home Health Services provides a full array of home and community based health services, including long-term-care, pharmacy, home health and hospice services. More than 4,000 individuals in 110 Missouri counties receive some type of home delivered health service daily from one of our Pyramid Home Health Services companies. These companies include Tri-County Group XV, Pyramid Homemaker Services, Tri-County Home Health, Pyramid Home Healthcare, Pyramid Home Health, Pyramid Home Health Services- Jefferson City, Tri-County Hospice Services and Pyramid Pharmacy.