Funder: The Commonwealth Fund

July 21, 2015 | Webinar

Individuals eligible for both Medicare and Medicaid are increasingly served by health plans. Many dually eligible enrollees have a complex array of medical, behavioral health, and social support issues, often requiring tailored care management, housing, and social support services to address their needs. To best serve this population and use resources most effectively, plans need to target interventions for their highest-need, highest-cost enrollees.

This 60-minute webinar, made possible by The Commonwealth Fund, shared two plans’ approaches to identifying their highest-need, highest-cost Medicare-Medicaid enrollees and using targeted interventions to improve individual outcomes and quality of life. Speakers included representatives from Independent Care Health Plan (iCare) (Wisconsin) and Health Plan of San Mateo (California), both of which participate in PRIDE (Promoting Integrated Care for Dual Eligibles), a project to advance health plan strategies for providing high-quality and cost-effective care for Medicare-Medicaid enrollees.


I. Introduction

Speaker: Brianna Ensslin, Program Officer, CHCS

Ms. Ensslin provided an overview of the dually eligible population and introduced PRIDE and the webinar speakers.

II. Identifying High-Need, High-Cost Medicare-Medicaid Enrollees through Predictive Modeling for Targeting Services and Interventions

Speakers: Amanda Harcus, Lead Financial Data Analyst, and Lisa Holden, Director of Care Management, iCare  

Ms. Harcus introduced a new iCare initiative to identify and target the top 200 highest-need, highest-cost enrollees in its Dual Eligible Special Needs Plan and Fully Integrated Dual Eligible Special Needs Plan. She highlighted the predictive modeling tool iCare is using and its goals for the program. Ms. Holden discussed the interventions (e.g., care management approaches, health coaches, wellness programs, and tele-health) that iCare is implementing for Medicare-Medicaid enrollees and how they are tailored for each individual to improve outcomes.

III. Targeting Housing and Supportive Services to Promote Community Living and Independence

Speakers: Ed Ortiz, Director of Provider Network Development & Services, and Chris Esguerra, MD, Deputy Chief Medical Officer, Health Plan of San Mateo

Mr. Ortiz and Dr. Esguerra described Health Plan of San Mateo’s Community Care Settings pilot program to transition individuals from nursing facilities to the community through the provision of targeted housing and supportive services. They also reviewed criteria for identifying eligible candidates to move to the community and briefly describe successes of the program to date.

A moderated Q&A session followed each presentation.

IV. Closing Remarks

Speaker: Brianna Ensslin, CHCS