“This push toward home and community-based solutions was a turning point for us at Shea Family. The freight train had obviously left the station and it was our job to figure out how to make money on it or get run over by it.”

Kenneth Lund
President & CEO
Nosilla Relyt

Challenge

Over 9 million beneficiaries in the U.S. are dually eligible for both Medicare and Medicaid (duals). Underlying care for duals is still uncoordinated and disjointed, resulting in 1.8 times higher healthcare costs compared to non-dual Medicare patients.

Duals are an expensive and challenging population. Over half have three or more chronic conditions and have annual incomes of less than $10,000. Duals rely on Medicaid (Medi-Cal in California) to cover costs Medicare does not cover, like long-term nursing home care. Nursing homes are financially motivated to move duals in and out of hospitals in order to bill at Medicare rates for short-term care, which can be up to 3-4 times higher than Medicaid rates for long-term care.

The Bottom Line

Continuing down this path is cost-prohibitive for taxpayers. We believe continued pressure to control costs and improve care for all seniors will drive unprecedented entrepreneurial opportunity in this country, for those willing to stop fighting for preservation of the status quo.

This paper compares and contrasts the status quo with two innovative healthcare models for duals that lower the cost of delivering care while producing high-quality outcomes:

  • A cost-effective approach for assisted living (45%+ less than status quo)
  • A coordinated approach for home and community-based services (70% less than status quo)

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