Payers can thrive in dual-eligible market

Dual eligibles can be the most lucrative patient population if managed right

Although much of the focus has been on implementing health exchanges under the reform law, insurers can find bigger opportunity in states moving dual-eligible beneficiaries into private managed-care plans, industry leaders said Thursday at the New Health Insurance Business Models in Washington, D.C.

In fact, dual-need seniors--those simultaneously enrolled in Medicare and Medicaid programs--represent $200 billion to $300 billion in organic premium growth for health plans, said John Gorman, founder of the consulting firm Gorman Health Group in Washington, D.C.

No matter what happens in the November elections, he said the states already in line to implement the demonstration project will still move this patient segment into managed-care because of dire budget woes.

But payers beware: As a complete dual-eligible migration would be a "tsunami of the most complex and vulnerable patients," Gorman warned. However, duals also can be the most lucrative patient population if managed right.

Medicaid plans are best positioned to handle the complex needs of dual eligibles, according to Pamela Morris, president and CEO of 900,000-member CareSource Medicaid managed care plan in Ohio.

Louisville, Ky.-based Humana tapped into CareSource's knowledge of Medicaid beneficiaries by seeking out a partnership with the Medicaid managed care plan. Although it is a large Medicare managed care player, Humana has no Medicaid experience, Morris noted.


Dual-need seniors represent $200 billion to $300 billion in organic premium growth for health plans.

In addition to understanding the Medicaid population, what skills do plans need to manage these dual-need beneficiaries? Complex case management, medication therapy management, risk adjustment, as well as investments in home health and home monitoring, according to Gorman. "Because nobody uses more drugs than the duals, nobody is more complex," he explained.

To that list, Morris would add long-term care experience, social workers and navigators on staff, and stakeholder support. She also highlighted the need to be community-oriented to overcome advocate and stakeholder issues. In Ohio, disability, aging and long-term care advocates have been voicing concerns about the change to private managed-care. To address those issues, the state and its plans are reaching out to the community and holding stakeholder meetings.

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