“In Colorado we have approximately 71,000 individuals who are dually eligible for both Medicaid and Medicare. And those individuals actually represent 13% of our total Medicaid population. Those dual eligible individuals who are receiving Medicaid benefits account for 43 % of our Medicaid budget. That is about 1.2 billion dollars. It’s quite a large expenditure for a relatively small percentage of the population. Now that being said, these are very high need individuals. 60% of the individuals who are dual eligible are elderly, and 40% are actually individuals with some sort of a disability. So they have high needs and we want to make sure that we are serving them appropriately. 60 percent of those individuals actually have multiple chronic physical conditions and 20 % have more than one mental or cognitive condition. We want to make sure that we are coordinating care for them, making sure that they get all the services they need to deal with these intense physical and behavioral health conditions that they have.”
I’m aware that some states have started to design models for this Medicare/Medicaid integration. Which state would Colorado be modeling its design after and why?
“Now there are some states that are doing an excellent job in terms of redesigning their delivery system – with a focus on accountable care organizations and health homes and I’d say two of the leading states in the country are North Carolina and Vermont. Now they might not be specifically doing something around the dual eligibles but their work in coordinating care is so significant that that is really what we’re modeling ourselves after.”
In what way?
“Vermont has something called the Blueprint for Health and they have a very strong system they’ve designed that’s very integrated and systematic and has community healthcare coordinators who are very effective and work across different insurance products as well. So that’s one example. In North Carolina, their model is built on a very strong Medical Home model – and so that’s something we’ve built into our ACC for that very reason based on North Carolina’s success.”
What are the greatest challenges you foresee in creating this redesign of Medicaid and Medicare?
“I’d say some of the greatest challenges are making sure that we leverage the infrastructures we’ve already built and that they’re seamless connections. As I mentioned earlier, the idea that we do have a good PACE program in Colorado, we do have Medicare special needs plans, yet there are many people who are still in that uncoordinated fee for service system.We need to make sure we’re tying those things together and leveraging them appropriately. So that’s one challenge. I think making sure that we have an adequate provider network. Ideally, providers would take both Medicaid and Medicare so they can do a better job coordinating care for their patients.”