How do 'duals' (Medicare-Medicaid dual-eligible) influence payment policy and risk?

• A. They require special risk adjustment and can influence payment targets and quality measurement due to higher complexity and costs.
• B. They are excluded from risk adjustment and quality metrics.
• C. They always receive lower payments regardless of complexity.
• D. They do not affect measurement or targets.

Answer: (A)

Dual-eligible individuals have higher care needs and costs, so payment systems adjust for that reality. Risk adjustment is used to level the playing field by predicting expected costs based on factors like diagnoses, age, and dual-eligibility status, often incorporating Medicaid data alongside Medicare information. This means plans enrolling more duals receive higher baseline payments to reflect their greater complexity and resource use. The influence goes beyond payments: quality measurement and performance targets are often recalibrated for these populations to avoid punishing providers that care for sicker, lower-income beneficiaries, and to encourage appropriate care coordination. In short, dual status signals extra cost and complexity, so it drives more nuanced risk adjustment and changes to targets and quality metrics.