Study indicates positive outcomes for new approach to Medicare/Medicaid dual enrollment

Navigating the complexity of either Medicare or Medicaid is challenging. Those challenges are compounded for people enrolled in both programs.

A team of researchers from William & Mary, Virginia Commonwealth University and the Virginia Department of Medical Assistance Services studied the potential benefits of integrating care for dually enrolled Medicare and Medicaid members. Their findings are published in JAMA Health Forum. William & Mary's Jennifer Mellor, professor of economics and director of the Schroeder Center for Health Policy, served as the lead author on the study.

People enrolled in both Medicare and Medicaid often face financial insecurity, complex health conditions and high rates of disability.

"Receiving some benefits through Medicaid and others through Medicare creates a number of challenges for this vulnerable group of people," Mellor said. "This has led to an intense policy focus on how to integrate the programs."

Integrating the programs has the potential to improve experiences and outcomes for dually enrolled members and reduce expenses for the state and federal agencies funding the programs. Integration can mean sharing member information and customer service systems between the two programs, and potentially, coordinating the care the member receives from each program.

One path towards integrating the Medicare/Medicaid programs makes use of Dual Eligible Special Needs Plans (D-SNPs), a type of private Medicare Advantage plan. For Medicaid members who are also enrolled in private plans for their Medicaid-covered benefits, D-SNPs can be used to achieve a high level of integration. This happens when the private insurer delivering a member's Medicare benefits is the same private insurer delivering the member's Medicaid benefits and D-SNPs include only members whose coverage is aligned in this way.

The alternative, where enrolled members are in different private insurance plans for their Medicare and Medicaid benefits, or in traditional Medicare and a private plan for Medicaid, can lead to confusion for the enrolled member and higher costs for the government.

In 2020-2021, several private insurers in Virginia decided to create more highly integrated D-SNPs. This change increased the variability in Medicare and Medicaid integration across the state. Some dually enrolled members gained access to the highest level of integration, while other dually enrolled members maintained lower levels of integration.

"This change created a unique opportunity for Virginia Medicaid to study the experiences that members have when they are in more integrated plans," Mellor said. Did members have greater access to health care, for example, or were they more satisfied with their health plan?

The study was a collaborative effort across Virginia universities and agencies. Matthew Behrens, a policy director at the Virginia Department of Medical Assistance Services (DMAS), helped design the study and identify comparison groups, consisting of members in less integrated D-SNPs and members in traditional Medicare. Peter Cunningham, professor and interim chair of VCU's Department of Health Policy, was the principal investigator on the contract and led the design of the sampling frame and the survey that the team mailed to members. Mellor, from William & Mary, contributed to the study design and led the complex quantitative analyses conducted on the returned surveys.

At the time of the survey in 2022, Virginia was one of only nine states where Medicaid members had the option to enroll in highly integrated D-SNPs. With relatively little research on the topic so far, the results of this study can inform other states' decisions to incorporate highly integrated D-SNPs in their Medicaid programs.

The research team's most striking finding was that being in highly integrated D-SNPs was associated with greater satisfaction with customer service.

"Members knew who to call if they had issues with getting access to a certain type of care. They were more likely to report being treated with courtesy and respect," Mellor said. "When you have multiple plans, knowing who to call and getting a resolution to that call can be challenging and frustrating. And we did see improvement in that."

The study yielded some positive results about highly integrated D-SNPs. But Mellor and the team already have future studies in mind.

Some members had been enrolled in the highly integrated plans for only six months at the time of the study. Mellor would like to see what experiences members have after being enrolled for a longer period of time, therefore increasing their number of interactions with the programs. The team is also exploring different sources of data. Self-reported survey measures, like the ones used in this study, are useful in ascertaining measures like customer service satisfaction, but their efficacy is limited by their smaller size.

"Along with DMAS, we are exploring ways to use administrative records of hospitalizations and physician visits that allow us to study larger numbers of members at later points in time," said Mellor.

The relationship Mellor has built with VCU and Virginia Medicaid has not only yielded opportunities for her own research but also opened doors for William & Mary students interested in health policy. In one class, she invited DMAS staff to virtually sit in on student presentations and offer policy feedback. She also recently matched a student with an internship at DMAS, fulfilling one of W&M's Vision 2026 strategic plan components to create meaningful pathways for student career success.

This kind of collaboration between W&M, VCU and DMAS is new and promising, said Mellor.

"This project is an example of how state institutions of higher education can partner to inform state agencies and public policy," Mellor said. "That's something I'm excited about with this kind of work."

Cunningham agrees, citing the role that the partnership plays in preparing Ph.D. students at VCU for roles as health policy researchers.

"The training and experiences that our students receive is invaluable to their education and career development, and as a result, these students are well prepared for academic and nonacademic careers. That is something very unique to both VCU and William & Mary."