Improving Care for Dual Eligibles through Innovations in Financing

Health Policy Center, the Urban Institute, Washington, DC, USA.
New England Journal of Medicine (Impact Factor: 55.87). 08/2011; 365(11):e21. DOI: 10.1056/NEJMp1108571
Source: PubMed


Elderly people and younger people with disabilities who are eligible for health coverage through both Medicare and Medicaid ("dual eligibles") are among the sickest and poorest people in the United States. Dual eligibles' extensive needs for medical and long-term care are often complicated by a perplexing and inefficient system of overlapping benefits, skewed incentives for health care providers, and financing fragmented between the federal and state governments. Medicare is the primary payer for dual eligibles and covers services including hospitals, physicians, and prescription drugs; Medicaid covers long-term care and is a secondary payer for Medicare-covered services. About 9.2 million Americans . . .

1 Read
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Roughly half of Medicare beneficiaries under age sixty-five are also eligible for Medicaid. These "dual eligibles" have been the subject of much research because of their low income and poor health status. Previous studies suggest that some states seek to shift costly health care services for this group out of state-run Medicaid programs and into the federally funded Medicare program--for example, replacing nursing home care with hospital care. Using state-level data on dual eligibles under age sixty-five, we found support for this hypothesis. In states with below-average per capita Medicaid spending, corresponding Medicare spending was above average. These state-level estimates also revealed a nearly threefold difference in total--Medicare plus Medicaid-price--adjusted spending per person, ranging from $16,309 in Georgia to $43,587 in New York. Such large variations among people with serious diseases suggest inefficiency. Some states may be spending too little for Medicaid, meaning that some patients' needs are not being met, or some states may be spending too much, meaning that more services are being provided than needed. Such inefficiency exposes patients to unnecessary risk, drives costs up unnecessarily, and highlights the large potential gains arising from improved care coordination for dual eligibles.
    Preview · Article · May 2012 · Health Affairs
  • [Show abstract] [Hide abstract]
    ABSTRACT: The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adults who receive long-term services and supports. The Affordable Care Act attempts to address some of these challenges. We analyzed three provisions of the act: the Hospital Readmissions Reduction Program; the National Pilot Program on Payment Bundling; and the Community-Based Care Transitions Program. These three provisions were designed to enhance care transitions for the broader population of adults coping with chronic illness. We found that these provisions inadequately address the unique needs of vulnerable subgroup members who require long-term services and supports and, in some instances, could produce unintended consequences that would contribute to avoidable poor outcomes. We recommend that policy makers anticipate such unintended consequences and advance payment policies that integrate care. They should also prepare the delivery system to keep up with new requirements under the Affordable Care Act, by supporting providers in implementing evidence-based transitional care practices, recrafting strategic and operational plans, developing educational and other resources for frail older adults and their family caregivers, and integrating measurement and reporting requirements into performance systems.
    No preview · Article · Jun 2012 · Health Affairs
  • [Show abstract] [Hide abstract]
    ABSTRACT: Using linked administrative records, we examined expenditure patterns under cash benefit and health insurance programs for 68,794 individuals first eligible for Social Security Disability Insurance (DI) and/or Supplemental Security Income (SSI) in 2000. Expenditures were tracked until death, age 65, or December 31, 2006. Cumulative per capita expenditures averaged US$111,160 in 2006 constant dollars, with 54% incurred under DI, 5% under SSI, and about 20% each under Medicare and Medicaid. SSI and Medicaid expenditures were somewhat higher early on. We concluded that SSI is a relatively low-expenditure program, but it has a major impact on total expenditures by providing access to Medicaid. An important role of SSI and Medicaid is to provide a temporary safety net supporting DI beneficiaries during their DI and Medicare waiting periods. The linkage of expenditure data under these four programs may be useful for evaluating the potential savings of initiatives to encourage individuals with disabilities to remain in the workforce.
    No preview · Article · Dec 2012 · Journal of Disability Policy Studies
Show more