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Managing Care for Adults with Chronic Conditions

Managing Complex Populations

Some elderly Americans as well as some disabled persons under age 65 are eligible for both Medicare and some form of Medicaid benefit. These dual eligibles have a higher proportion of chronic, disabling, and complex conditions than all Americans. Forty-four percent of Americans have a chronic condition and 87 percent of dual eligibles have a chronic condition. In addition, 63 percent of dual eligibles have activity limitations compared to 14 percent nationwide. Care coordination for this population is often complex and difficult to achieve and is made even more complicated by that fact that they receive benefits and services through two programs.

Fueled by cost pressures, quality concerns, and the Olmstead decision (which mandates that people with disabilities be served in the least restrictive and most integrated setting), efforts are underway to integrate Medicare and Medicaid services for these dual eligibles. Massachusetts' Senior Care will be the first statewide Medicare/Medicaid integration project.

Numerous difficulties complicate these integration efforts. Planning and implementation of waiver-based programs take a long time, typically one to three years. Florida, Arizona, and Colorado have dropped integration efforts because of this long lead time. Conflicting Office of Management and Budget (OMB), Medicare, and Medicaid rules make establishing appropriate rates difficult.

The Centers for Medicare & Medicaid Services (CMS) has created the Medicare and Medicaid Technical Advisory Group (M+M TAG) to improve Federal-State coordination of policies, procedures, and regulations and to provide an integrated health care delivery system for dually eligible individuals. The TAG group is also meant to enhance the ability of CMS and States to support individuals in community-based settings through innovations in chronic care management. It has developed a framework for analyzing demonstration programs and created a forum for moving forward on common issues (data integration, budget neutrality, etc.).


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