Profile of Older Dual-Enrollees Living in Areas with Managed Long-Term Services and Supports

OBJECTIVES

Nearly half of all state Medicaid agencies in the United States have implemented managed long-term services and supports (MLTSS). Data gaps have inhibited our understanding of MLTSS experiences to date. We draw on a national survey with novel data linkages to develop a profile of older dual-enrollees with significant LTSS needs by MLTSS program presence.

DESIGN

Cross-sectional observational study using the 2015 round of the National Health and Aging Trends Study (NHATS), a longitudinal study of a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING AND PARTICIPANTS

The sample comprised 275 participants who self-reported Medicaid enrollment and met our definition of significant LTSS need as defined by receiving help with 2 or more self-care or mobility activities (eating, bathing, toileting, dressing, bed transfer, indoor mobility).

METHODS

Bivariate analyses were used to comparatively examine differences in demographic, health, and care circumstances by MLTSS, as defined by living in a county with MLTSS program presence.

RESULTS

Among approximately 1 million (weighted sample) older dual-enrollees with significant LTSS needs, 56.2% (weighted percentage) lived in counties with MLTSS and 43.7% lived in counties with mandatory MLTSS enrollment in 2015. Those living in areas with MLTSS were much more likely to be of Hispanic or other race and ethnicity (50.5% vs 15.1%, P < .001) yet less likely to live in a rural location (8.7% vs 31.4%, P < .05) or in a residential care facility or nursing home (18.4% vs 34.7%, P < .05). The majority (78.5%) received assistance from 2 or more helpers and received more than 70 hours of care per week.

CONCLUSIONS AND IMPLICATIONS

Our findings reinforce the growing reach of MLTSS programs and importance of filling evidence gaps about who these programs are serving.

Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries

BACKGROUND

Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.

OBJECTIVE

To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.

RESEARCH DESIGN

We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.

PARTICIPANTS

North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.

MEASURES

We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).

RESULTS

Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.

CONCLUSIONS

Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

IMPORTANCE

The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.

OBJECTIVE

To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.

MAIN OUTCOME MEASURES

Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.

RESULTS

The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.

CONCLUSIONS

The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Home-Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature

BACKGROUND/OBJECTIVES

To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries.

DESIGN

A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles.

SETTING

HBMC including home-based primary care and palliative care programs.

PARTICIPANTS

Studies describing Medicaid beneficiaries receiving HBMC.

MEASUREMENTS

Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC.

RESULTS

The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits.

CONCLUSION

This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.

Reducing Emergency Department Visits Among Dual Eligible Patients via a Comprehensive Wellness Assessment

The objective was to assess whether a Comprehensive Wellness Assessment (CWA) is associated with reduced emergency department (ED) visits for Special Needs Program (SNP) enrollees with diabetes. This retrospective panel study used a Medicare Advantage plan's administrative claims data for 2010-2017 and pooled member-month observations. Multivariate regression and individual fixed-effects regression models were estimated. The outcome was ED visits measured as binary and continuous outcomes. Data were derived from claims data that included at least 1 ICD-9 or 10 code between January 2010 and December 2017. Regression results indicated that SNP enrollees completing a CWA was associated with a lower probability of any monthly ED use (β = -0.005, t-stat = -2.98) and fewer monthly visits (β = -0.008, t-stat = -2.95). Individual fixed-effects models also demonstrated a significant decline in SNP ED use after a CWA, though the strongest effects were confined to the first 4 months after a CWA. Care models with components such as CWAs may contribute an additional benefit in the form of a reduction in ED utilization. Completing a CWA appears to be effective in reducing ED utilization among SNP members with diabetes.

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers

BACKGROUND

Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.

OBJECTIVE

We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.

DESIGN

Cross-sectional, propensity score-weighted, multivariable regression analysis.

PARTICIPANTS

A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.

MAIN MEASURES

PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.

KEY RESULTS

Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]).

CONCLUSIONS

Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

Hospital Inpatient Admissions With Dehydration and/or Malnutrition in Medicare Beneficiaries Receiving Enteral Nutrition: A Cohort Study

BACKGROUND

Enteral nutrition (EN) supports many older and disabled Americans. This study describes the frequency and cost of acute care hospitalization with dehydration and/or malnutrition of Medicare beneficiaries receiving EN, focusing on those receiving home EN.

METHODS

Medicare 5% Standard Analytic Files were used to determine Medicare spending for EN supplies and the proportion and cost of beneficiaries receiving EN, specifically home EN, admitted to the hospital with dehydration and/or malnutrition.

RESULTS

In 2013, Medicare paid $370,549,760 to provide EN supplies for 125,440 beneficiaries, 55% of whom were also eligible for Medicaid. Acute care hospitalization with dehydration and/or malnutrition occurred in 43,180 beneficiaries receiving EN. The most common principal diagnoses were septicemia (21%), aspiration pneumonitis (9%), and pneumonia (5%). In beneficiaries receiving EN at home, >one-third (37%) were admitted with dehydration and/or malnutrition during a mean observation interval of 231 ± 187 days. Admitted patients were usually hospitalized more than once with dehydration and/or malnutrition (1.73 ± 1.30 admissions) costing $23,579 ± 24,966 per admitted patient, totaling >$129,685,622 during a mean observation interval of 276 ± 187 days. Mortality in the year following enterostomy tube placement was significantly higher for admitted compared with nonadmitted patients (40% vs 33%; P = .05).

CONCLUSION

Acute care hospitalizations with dehydration and/or malnutrition in Medicare beneficiaries receiving EN were common and expensive. Additional strategies to reduce these, with particular focus on vulnerable populations such as Medicaid-eligible patients, are needed.

The High Cost-related Medication Non-adherence Rate Among Medicare-Medicaid Dual-Eligible Diabetes Patients

CONTEXT

Access barriers to effective medication treatment have been a persistent issue for millions of older Americans despite the establishment of Medicare Part D.

OBJECTIVE

We aimed to assess the prevalence rate of cost-related medication non-adherence (CRN) and the patterns of CRN behaviors in Medicare-Medicaid dual eligibles with diabetes.

DESIGN SETTING PATIENTS INTERVENTIONS AND MAIN OUTCOME MEASURES

We used data from the 2011 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. Multivariate logistic regression analysis was performed to assess CRN rate, controlling for demographics and types of Medicare Part D plans.

RESULTS

The CRN rate in dual-eligible diabetes patients was 21%, compared to 16% in non-dual-eligible diabetes patients (p<0.01). In 2011, the standardized prevalence rate of CRN in dual-eligible diabetes patients was 21%, of those with CRN 29% reported three or more types of CRN behaviors.

CONCLUSION

Contrary to the common belief that dual eligibles have better insurance coverage for medication due to the assistance from Medicaid to pay some of the out-of-pocket payments, the CRN rate among dual eligibles is high and patients often report multiple types of CRN behaviors. This demonstrates that cost is a significant access barrier for dual-eligible diabetes patients. More research is needed to improve the insurance benefit design and expand insurance coverage for this high-need, high-cost subpopulation.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists

BACKGROUND

Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care.

PURPOSE

To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists.

METHODS

During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications.

RESULTS

Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications.

CONCLUSIONS

A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients.

Risk screening in a medicare/medicaid population administrative data versus self report

OBJECTIVE

To compare the abilities of two validated indices, one survey-based and the other database-derived, to prospectively identify high-cost, dual-eligible Medicare/Medicaid members.

DESIGN

A longitudinal cohort study.

SETTING

A Medicaid health maintenance organization in Philadelphia, Pa.

PARTICIPANTS

HMO enrollees (N = 558) 65 years and older eligible for both Medicare and Medicaid.

MEASUREMENTS AND MAIN RESULTS

Two hundred ninety six patients responded to a survey containing the Probability of Repeat Admission Questionnaire (Pra) between October and November 1998. Using readily available administrative data, we created an administrative proxy for the Pra. Choosing a cut point of 0.40 for both indices maximized sensitivity at 55% for the administrative proxy and 50% for the survey Pra. This classification yielded 103 high-risk patients by administrative proxy and 73 by survey Pra. High-cost patients averaged at least 2.3 times the resource utilization during the 6-month follow-up. Correlation between the two scores was 0.53, and the scales disagreed on high-cost risk in 78 patients (54 high-cost by administrative proxy only, and 24 high-cost by survey Pra only). These two discordant groups utilized intermediate levels of resources, $2,171 and $2,794, that were not statistically significantly different between the two groups (probability > chi2 =.66). Receiver operating characteristic curve areas (0.68 for survey Pra and administrative proxy for respondents, and 0.67 by administrative proxy for nonrespondents) revealed similar overall discriminative abilities for the two instruments for costs.

CONCLUSIONS

The Medicaid/Medicare dual-eligible population responded to the survey Pra at a rate of 53%, limiting its practical utility as a screening instrument. Using a cut point of 0.40, the administrative proxy performed as well as the survey Pra in this population and was equally applicable to nonrespondents. The time lag inherent in database screening limits its applicability for new patients, but combining database-driven and survey-based approaches holds promise for targeting patients who might benefit from case management intervention.