Left Behind in the Era of Internet: Yet Another Challenge Facing Dual Eligible Beneficiaries

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AUTHOR – Allison Rizer

ATI Contributor: Allison Rizer 

Telehealth has been essential during COVID-19 to preserve access to care, mitigate social isolation risks, and meet the needs of individuals temporarily holed up in their homes. The provision of telehealth advanced about 10 years over the past 4 months, which wouldn’t be possible without the long list of policy waivers states and the Centers for Medicare & Medicaid Services (CMS) provided during the public health emergency.

However, the population most vulnerable to negative outcomes associated with COVID-19, individuals dually eligible for Medicare and Medicaid (“dual eligibles”), may be the least likely to access telehealth. A recent ATI Advisory analysis of the 2017 Medicare Current Beneficiary Survey (MCBS) found that among Medicare beneficiaries living in the community, dual eligible beneficiaries are considerably more likely not to use internet than Medicare-only beneficiaries, suggesting access issues related to internet-dependent telehealth. In fact, more than half of full dual eligibles (53%) use the internet rarely or not at all, compared with 27% of Medicare-only beneficiaries.

While this isn’t surprising given the socioeconomic circumstances of dual eligibles, it’s yet another data point to consider as the policy world develops integrated solutions for this population. Audio-only telehealth is an important alternative for dual eligibles, but even that becomes challenging when a person has limited cell-phone minutes (or doesn’t have a cell phone).

And this is about more than telehealth: internet access means easier access to medical and health plan information, and social platforms to connect with loved ones, and grocery shopping. Internet access also means safety: recent research coming out of the National Bureau of Economic Research[1] found that access to high-speed internet likely plays a significant role in whether an individual is able to stay home during the public health emergency. Add this to other COVID-19 risk factors facing dual eligibles (multiple chronic conditions, functional limitations, fragmented coverage), and you have a perfect storm. According to recent CMS data,[2] dual eligibles are experiencing COVID-19 at a rate over four times higher than Medicare-only beneficiaries, and this holds true across race, age, sex, and disability.

A little bit of good news: Beginning in 2019, Medicare Advantage plans can offer cellular data and electronic devices as a supplemental benefit, and CMS is allowing plans to make mid-year benefit changes due to COVID-19 (take a look here for a study we recently released on this topic), so potentially some dual eligibles who reported little or no access to internet in 2017 now have access as a result of policy flexibilities.

Now the bad news: There are significant limits on how Medicare Advantage plans can offer this “remote access technology” benefit, such as restricting cellular data and devices to health-related activities or to individuals with specific chronic conditions. And we’ve heard from plans that they’re hesitant to implement the benefit given its many restrictions and the resulting confusion (and potential complaints) among enrollees.

Where do we go from here? Health plans and risk-bearing primary care groups are well-positioned to create a bridge that re-directs resource flow to technology solutions for the most vulnerable individuals. Some have reported doing this during the public health emergency with the myriad state and federal policy waivers available – but as suggested above, many are concerned about what happens when the emergency declaration ends. To that end, Medicaid and Medicare policy (whether telehealth, benefit coverage, or payment) must evolve as our understanding develops around the drivers of health inequities, and in support of risk models that allow for the flexibility to address these inequities – especially in service of the dual eligible population.

[1] https://www.nber.org/papers/w26982.pdf

[2] Preliminary Medicare COVID-19 Data Snapshot, CMS.gov. Includes claims and encounters through May 16, 2020, received by June 11, 2020. https://www.cms.gov/research-statistics-data-systems/preliminary-medicare-covid-19-data-snapshot

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