Measures for Dual-Eligibles

The lack of coordination between Medicare and Medicaid for people who have coverage in both programs is well documented. Because of the complexities of different coverage and program requirements, states and health plans are challenged to organize and deliver person-centered, coordinated care that people with dual eligibility need. With support from The SCAN Foundation, NCQA has developed a framework for evaluating integrated care for people with Medicare and Medicaid, and a draft set of structures and processes that could be a roadmap to developing an integrated care system. 

Current related projects include the following:

  • A March 2013 white paper, developed with support from The SCAN Foundation, describes a strategy for evaluating the quality and person-centeredness of integrated care. The strategy has two parts. First is a “roadmap” of structures and processes that describe capabilities needed by state, health plans and other entities responsible for integration of care and services. The second part of the strategy is a method of building on the structure and process measures to create outcomes and other types of performance measures for accountability and quality improvement.

  • NCQA is testing the feasibility and utility of the draft structure and process measures for integrated care entities (both managed care plans and states with managed fee-for-service arrangements). Results of the testing should be available by the end of March 2013.

  • NCQA is seeking collaborators and planning to develop new integrated care measures that address gap areas identified by The National Quality Forum’s Measure Applications Partnership, in its June 2012 final report to the Department of Health and Human Services, Measuring Healthcare Quality for the Dual Eligible Beneficiary Population. 

As a result of new opportunities generated by the Affordable Care Act combined with fiscal pressures and the recognition of current care short falls, many states are actively pursuing managed care initiatives to provide integrated care for people with Medicare and Medicaid. Managed care plans (including plans covering both general health care and long-term services and supports) and integrated delivery systems are candidates. 

Good integrated care holds the promise of eliminating the fragmented, medically-oriented care that often wastes state and federal dollars and leaves beneficiaries and their families feeling confused and overwhelmed. To achieve this promise, entities responsible for integrated care must demonstrate that they provide high quality care across the full range of services .

For more information, contact Jessica Briefer French