Caring for vulnerable populations.

Acknowledgments The AHA Committee on Research would like to thank the following contributors who provided significant input in the committee's work:commercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publisher, or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please email [email protected]. Executive Summary Purpose The American Hospital Association Board Committee on Research (COR) annually studies a topic in depth to provide the hospital field with relevant recommendations for advancing health care. In 2011, the AHA COR examined emerging practices in effectively coordinating care for vulnerable populations. Since the breadth of the vulnerable population is large, the committee focused its initial efforts on the unique dual eligible population as a subset. While the alignment of financial incentives to provide care to this population will evolve at the federal, state, and local policy levels, hospitals are in the unique position to address the system, provider, and patient barriers impeding high quality care. This report summarizes the literature, highlights best practices, and makes recommendations for the field on important elements that should be included in any organized program to coordinate care for the dual eligible or any other vulnerable population. Background Approximately 9.2 million Medicaid beneficiaries are dual eligibles – low-income seniors and younger persons with disabilities who are enrolled in both the Medicare and Medicaid programs. Dual eligibles are among the sickest and poorest individuals, and they must navigate both government programs to access necessary services, relying on Medicaid to pay Medicare premiums and cost sharing to cover critical benefits not covered by Medicare. Fifty-five perecent of this population has an annual income below $10,000, and they are three times more likely than the rest of the Medicare population to be disabled, in addition to having higher rates of diabetes, pulmonary disease, stroke, mental disorders, and Alzheimer's disease. Although they represent a relatively small percentage of the overall Medicare and Medicaid populations, 16% and 15% respectively, dual eligibles account for $300 billion (approximately one-third) of annual spending between the two programs. Currently, care for dual eligibles is fragmented, unmanaged, and uncoordinated at the program level, based on an inefficient fee-for-service provider payment system. Different eligibility and coverage rules in Medicare and Medicaid contribute to …