Dual Eligible = Double Trouble?

Steve Peskin  0:03  
For the patient, it can be very tough because it's not entirely transparent and the level of beyond health literacy, which is an issue and a challenge, is insurance literacy, which people have challenges with health literacy, and then when you get into insurance literacy, it's even more stark. 

Terry Wilcox  0:25  
This week on the Patients Rising Podcast, we are using this one episode to talk about the ins and outs of having to benefit options in Medicaid and Medicare. On this episode, we speak with Steve Peskin, the CEO of SRP Advisors, and someone who has been in and around the insurance business for three decades. Welcome to the Patients Rising Podcast. I'm your host, Terry Wilcox, CEO of Patients Rising. I'm joined by my co host, who's been developing a new way to remove those dark circles under his eyes. He's Rob Goldberg, co founder of the Center for Medicine in the Public Interest. So Bob, I want to hear all about this breakthrough. Is it on goop?

Bob Goldberg  1:08  
It's not goop. It's in the Hadassah cookbook. It's called stuffed cabbage.

Terry Wilcox  1:16  
Now wait a minute, stuffed cabbage? Now how can that get rid of dark circles, Bob?

Bob Goldberg  1:21  
Well, it actually doesn't. But the smell moves people so far away that they can't notice.

Terry Wilcox  1:32  
Well, that's good, Bob, because one of your close friends is our guest today.

Bob Goldberg  1:39  
Well, Terry, I thought that was important to discuss the idea of dual eligibles on this podcast, because it's really complicated. And as you heard Steve Peskin say at the beginning of the show, to navigate any part of our health system, you pretty much need a doctorate. And now you're asking some people to navigate several parts at once.

Terry Wilcox  2:03  
Well, so let's break it down in its simplest terms, Bob. Peskin lays it out as straightforward as possible. What does it mean when you hear dual eligible? 

Steve Peskin  2:14  
Simply put, it means the person in government programs is eligible for both Medicare and Medicaid. So Medicaid is a program that provides health insurance for persons who have limited monies are unemployed or underemployed meet the threshold in their state for Medicaid, healthcare benefits, Medicare courses, primarily for persons 65 and over. There are exceptions for disabled persons for end stage renal disease and a few other criteria or exemptions for, so the dual eligible would be the person who has health insurance through both Medicaid which is jointly funded by the state in which the person is living and the federal government and Medicare which is funded by the federal government.

Bob Goldberg  3:20  
Now inherently, that doesn't sound too bad, right. But again, with the way our system is set up, it winds up being more confusing for the patient.

Steve Peskin  3:30  
The negative is that for the individual to for her or him to understand where each programs sort of begins and ends, and which pay or which bucket if you will, of money is responsible for what can be challenging at times to find clinicians. There are quite a number of clinicians that did not accept Medicaid assignment or Medicaid as a payer in the state in which they practice. The vast majority of physicians certainly not all, but the vast majority of physicians accept or will take Medicare patients. There are a few states that mandate that so the challenge for the patient might be to find physicians, ophthalmologists, cardiologist, orthopedic surgeons, primary care doctors that are accepting their situation as far as insurance goes.

Terry Wilcox  4:32  
With Medicaid being a state program, and Medicare being a federal program, the coordination between the two is where things can get really tricky.

Steve Peskin  4:42  
Coordination is more at the Medicaid level, that's a state program, that's where the person resides, and the state Medicaid program, most of them are in relatively difficult or challenging financial straits so there's an interest on the part of the state Medicaid program administrators to be able to have Medicare cover certain things for these dual eligible or dual eligible Special Needs plan persons. So that that coordination of benefits and coordination of financial responsibility for the patient, it can be very tough because it's not entirely transparent. And the level of beyond health literacy, which is an issue and a challenge is insurance literacy, which people have challenges with health literacy, and then when you get into insurance literacy it's even more stark.

Bob Goldberg  5:47  
Well Terry, the whole issue of health literacy is something that Patients Rising deals with a lot, not just through the advocacy work, but through the navigators. And, you know, someone who hears dual eligible doesn't know much about all, you know, to be a dual eligible takes a lot of fancy footwork.

Terry Wilcox  6:10  
Well, I also think you're getting the short end of the stick, because Medicaid is responsible for most of your plan. Mainly because Medicaid is a shared program, but it's managed by the states, right? So yes, the government does pay for a portion of Medicaid recipients expenses, it is managed by the state. And so it's obviously in the state's best interest to have the federal government cover as much as possible. Right? So this is where it can get really tricky for patients, because they can be put in limbo all the time and not really know how to get out. It takes a lot of management and a lot of literacy. And I don't think that's really the case with most of the folks that are dual eligible, that makes it even harder.

Bob Goldberg  6:58  
I think for anybody, I mean, I went through the dual eligible process, just to see what it was like and, you know, it's, it is very complicated. You do need either changes to the system or really good navigation. So, you know, as you'd expect, as a result all the complications in the system mean issues like access to care as well as cost effectiveness of the program continued to be larger problems that need to be addressed. So how do we solve them? Steve has a few ideas.

Steve Peskin  7:36  
Well, access can be improved through Value Based Payment Models, whereby the entity the Accountable Care Organization, clinically integrated network is contracted in a way that the Medicaid payments are not quite so low compared to Medicare and low compared to commercial insurers. So a Value Based Payment Model does attract increased participation or can has the potential to increase participation. Increasing the fee for service which we of course need to move away from and more toward fee for value, but in the short term, increasing fee for service would increase the number of physicians in certain areas, subspecialties to accept Medicaid patients.

Terry Wilcox  8:30  
And so what about the cost effectiveness?

Steve Peskin  8:34  
So cost effectiveness can be improved by constructs that I just mentioned, team based care, better coordination among the doctors and institutions that are attending to that person, sub specialists primary care, primary care to sub specialist sub specialists to sub specialist and ability to effectuate care management and care navigation, and we've seen that in certain organizations that have been highlighted for that, like Caremore and Oak Street, Ten Med among others, so that ability and some of the groups that I work with are quite good at that as well, bringing in the non clinical aspects, again, community services, community resources for persons who have or who are vulnerable and at risk and at need.

Bob Goldberg  9:37  
Just to follow up on what Steve said, Steve was a pioneer in developing patient centered care, as at the core of Medicare and Medicaid programs in horizon Blue Cross and Blue Shield. Part of that was coordination. The other part was is paying more for what they regarded based upon the data was high value care. As a result, you know, what's happened again, is there are now companies that are in the business of going at risk for coordinating that care. So we're beginning to make some headway in this area; I hope we continue to do so. Terry, you know, just from you know, your perspective, from Patients Rising perspective, you know, what are your thoughts about how we can make dual eligible situations more, not just palatable, but an opportunity to really deliver value based and high performing care?

Terry Wilcox  10:47  
Well, I think there's a lot of opportunities to try to streamline it. I think you need to take a look at the fact that it's a Medicaid Medicare program. And remember that we have to keep it in the confines of what Medicare is already doing, and figure out how to streamline it, if this makes any sense, to make it easier for decisions to be made quickly, to determine, you know, payments. This all has to do with the I agree with Steve on the things like Value Based Payment Models for care. But you have to simplify things in a way so that people really understand and why can't this particular situation, this particular medicaid medicare situation be streamlined? To where all the states are the same? Can it not be because of the situation?

Bob Goldberg  11:41  
Well, it certainly can that probably would take either a regulation issued by Health and Human Services are legislation. Because on the flip side, you know, we have the waiver program, which allows you to innovate. But at the same time, there's a way to say, hey, here's a broad framework for innovation, that, you know, we will pay more for, and it includes that streamlined approach.

Terry Wilcox  12:13  
If you can look at it in its totality, I believe that you can innovate and make it a better system for the patients who need it.

Bob Goldberg  12:21  
Yeah, make it more convenient. make it simpler, that's basically how you make something accessible.

Terry Wilcox  12:29  
Ironically I'm not saying cover everything, you know, it's like just set it up and put the parameters around it, and make it simple.

Bob Goldberg  12:40  
So, we have a link to some more information about dual eligibles in the show notes, and thanks to Steve for coming on the show.

Terry Wilcox  12:54  
This episode of the Patients Rising Podcast is brought to you by the Patient Helpline. Do you have questions about medical transportation or health insurance? What about caregiving? The Patient Helpline is a free service here to answer all of these questions and more. Call us or email us and one of our trusted Navigators will be there to help. These navigators have handled countless issues for patients and caregivers just like you. If you or someone you know has a healthcare question, challenge or issue, we are standing by and ready to help. To get in touch, leave us a voicemail or send us an email using the link in the show notes.

Bob Goldberg  13:32  
Before we go today, let's talk about some stories in the news this week that patients should be interested in.

Terry Wilcox  13:40  
Now earlier this month, the Biden administration announced that the administration for strategic preparedness and response will incorporate fair pricing provisions into contracts. Now, President Biden said and I quote, "American families will finally pay the same as people in other countries for many of the vaccines and treatments developed or funded through their own tax dollars in the first place." Oh my. So Bob, what do you think about this?

Bob Goldberg  14:14  
Well, as I've said before, we're already paying the same price in some cases less, because our out of pocket costs is less than what many people will pay for these products. It's virtue signaling for the election as part of this whole notion that we're going to have marchin rights on products that are developed with any NIH funding. This is all coming from patients for affordable dummies, that has been to become obsessed with patents, and you go after patents in a systematic way, you're not going to have investment in new medicines.

Terry Wilcox  15:00  
You're not, I mean, all this is going to happen with something like marchin rights and correct me if I'm wrong, but but it's just going to stop the investment in NIH research at all. I mean, is there anything that comes out of the NIH is just not going to be invested in. And the NIH will be the first to tell you if they're being honest, they can't do it without industry.

Bob Goldberg  15:22  
Of course they can't. I mean, we went through this a couple of weeks ago, we can't and we won't. I think this is a lot of lip service, for now. Of course we get fair prices, we negotiated fair prices during COVID.

Terry Wilcox  15:38  
No, I mean it is all these negotiations, I would argue, especially when you're looking at what some of the 340B prices are, Medicaid prices etc. that cause a list price to have to be what it is in this country. I mean, let's be honest, if we're being really honest, that's true. All the negotiation that's already taken place, is the reason for a high list price. 

Bob Goldberg  16:00  
That's right. And what people ignore deliberately is that the prices that are paid overseas are the negotiated prices that the PBMs is already get, in many cases, especially for regenerative or advanced therapies. There isn't a heck of a lot of difference in the prices between what Vertex negotiates with NHS, the National Health Service in the UK, and what they pay here. The differences is how the prices arrived, and who gets the money.

Terry Wilcox  16:38  
Well, and then I also think they're just trying to draw, I'll be really honest about an election year, I think they're trying to drum up another drug pricing issue. Because what they did in the IRA isn't really resonating with anyone it hasn't really lowered anyones costs. It hasn't really changed anything.

Bob Goldberg  16:54  
No, no. So that's all for today, but we have another episode right here for next week. Make sure to follow the Patients Rising Podcast on your favorite podcast player, so you can be notified as soon as a new episode is live. Plus 2024 is going to be an exciting year for us and we can't wait to have you with us each and every week.

Terry Wilcox  17:18  
Until next week for Dr. Bob and everyone at Patients Rising, I'm Terry Wilcox, stay healthy.