Exploring the Challenges of Integrating Care for Dually Eligible Medicare/Medicaid Individuals Using Human-Centered Design

More than 12 million people are dually eligible for Medicare and Medicaid. Because they tend to have greater health needs and lower incomes than other Medicare beneficiaries, dually eligible people often experience challenges with care delivery and integration between Medicare and Medicaid. With support from Arnold Ventures, AIR aimed to fill a significant gap in the literature by focusing on the views and experiences of dually eligible individuals and advocates and identifying strategies to improve Medicare and Medicaid program alignment.

AIR used principles of human-centered design (HCD) to conduct an exploratory study of how integration— or lack thereof— across the Medicare and Medicaid programs affects the care experiences of dually eligible beneficiaries. HCD provides a framework and set of tools for understanding complex, dynamic and ill-defined challenges, such as the complex health and health-related social needs of dually eligible individuals.

Key Findings

  • Although nearly half of the dually eligible individuals in the study were enrolled in integrated care plans, they experienced similar challenges with obtaining and coordinating necessary care and services as beneficiaries who were not enrolled in integrated care plans.
  • Their concept of care was oriented toward whole-person, comprehensive care. In their responses, individuals stressed that they desire and value care that is compassionate, collaborative and inclusive of all aspects of life and well-being.
  • Dually eligible individuals perceive integrated care as less of a continuum and more of an ecosystem that encompasses their personal circumstances, including family, health, social and logistical needs.
  • Integrated care begins with access to a network of high-quality providers.
  • Appropriate and timely prescribing and fulfillment of prescriptions are key components of integrated care.
  • Transportation was a frequent problem in accessing care. Without it, certain services are effectively out of network.
  • Telehealth mitigated certain challenges associated with receiving integrated care, such as arranging for transportation and getting timely appointments.
  • Individuals need help to understand, navigate and coordinate their benefits to receive integrated care.

State and Federal Policy Implications

The findings identify important considerations for designing integrated plans and systems:

  • Dually eligible individuals have a range of medical and behavioral health as well as social needs. Improving care for this population likely is not accomplished through plan design alone, but through hands-on approaches to identify their needs and get them and their families connected to care and services.
  • Individuals’ needs are closely tied to their personal goals and family circumstances. When plans and providers meet individuals where they are and understand these needs and goals, providers can collaborate more effectively to improve the individual’s health and well-being.
  • Provider networks play a key role in dually eligible individuals’ experiences of integrated care. Primary care physicians with a strong emphasis on care coordination, integrated health systems, and group practices with co-located services help individuals receive integrated care.
  • Dually eligible individuals need help identifying what benefits and services are available to them. Proactive, knowledgeable navigators or case managers who routinely communicate with dually eligible individuals can work with the individual in a way that respects and preserves their autonomy and preferences.