Fact Sheet

In 1996, The Robert Wood Johnson Foundation responded to the need for a better system of care for those individuals who are eligible for both Medicare and Medicaid (dual eligibles) by establishing the Medicare/Medicaid Integration Program (MMIP). The program seeks to end the fragmentation of financing, case management and service delivery that currently exists between the two government programs in serving this population.

People who are dually eligible for both Medicaid and Medicare are low-income and aged, blind or disabled. They are more likely than Medicare-only beneficiaries to need assistance with activities of daily living (ADLs) and to have multiple chronic conditions such as heart disease, diabetes and mental health and cognitive impairments.

Given the complex needs of these individuals and the exponential growth of Americans needing long term care currently and in the future, the director of MMIP believes that a strong imperative exists to develop efficient and effective systems of care to address their needs sooner rather than later. Research done by members of the MMIP also shows that effective care management for dually eligible beneficiaries is best accomplished when health plans have the ability to coordinate the service delivery and financing of the entire continuum of health and long-term care services. Consider the following facts and example:

• As of 2002, there are 6.2 million dually eligible individuals. They represent 17.2 percent of the Medicare population and 24% of Medicare costs. In addition, they represent 18.9% of Medicaid beneficiaries and 35% of Medicaid costs.

• Thirty-three percent of dual eligibles have three or more ADL impairments compared to 12% for Medicare-only beneficiaries.

• Cognitive or mental impairments are more likely to be found in people who are dually eligible than Medicare-only beneficiaries.

• The proportion of the US population 65 and older will increase to almost 20 percent over the next two decades. Those over age 85 are expected to grow to 7 million.

• The number of those needing long term care will continue to grow from 7 million in 1997 to 9 million in 2005 and 10 million in 2020.

Improving Care for Dually Eligible Beneficiaries: An Example

    Mary is a frail, elderly woman who has trouble handling most activities of daily living and whose income is considered at or near poverty level. In order for her to continue living in her own home, Mary's daughter arranged for home-based support services covered by Medicaid. However, Mary fell and broke her hip and was admitted to the hospital. When Mary came home, she needed additional health services in order to recover. Medicare paid for these post-hospitalization services, but her home health workers changed because there was no one coordinating her care. Mary was confused and upset because she had liked her previous aides. If Mary had been in a program that was responsible for integrating both Medicare and Medicaid services, she would have had a care coordinator who would have helped arrange for her care before, during and after she broke her hip. It's likely that Mary would have been able to keep the same home health workers before and after going to the hospital, saving time and money, ensuring continuity of care and ensuring Mary's satisfaction with her care.

The MMIP has provided 14 states with grant support and technical assistance to restructure the way in which they finance and deliver acute and long-term care. They are: Colorado, Connecticut, Florida, Maine, Massachusetts, Minnesota, New Hampshire, New York, Oregon, Rhode Island, Texas, Vermont, Washington, and Wisconsin.

Please visit the MMIP web site at healthresearch.gmu.edu/MMIP for more information about the program and to access a series of technical assistance reports on topics pertinent to creating more integrated delivery networks or coordinated systems of care for people who are dually eligible.

The Medicare/Medicaid Integration Program is a national initiative supported in part by the Robert Wood Johnson Foundation. The Foundation, based in Princeton, NJ, is the nation's largest philanthropy devoted exclusively to health and health care.