Transcript Dual Eligibles and Medicare Spending

DataBrief:
Characteristics
of Dual Eligibles
Did you know…
33% of dual eligibles suffer from
diabetes, stroke, dementia, and/or
COPD – conditions that often require
the use of personal care and
supportive services?
DataBrief Series ● September 2010 ● No. 1
Characteristics of Dual Eligibles; Health Status
• “Dual eligibles” are low-income individuals who qualify for both the Medicare program
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and the Medicaid program.
Dual eligibles receive their health care services through the Medicare program while
the Medicaid program pays for services and supports not covered by Medicare
including long-term nursing home stays and physician and hospital co-pays.
Dual eligibles are “over-represented” in the Medicare population with chronic
conditions, meaning they are more likely than their Medicare-only counterparts to
have a chronic condition.1
Even when compared to Medicare beneficiaries with the same number of chronic
conditions, dual eligibles spend more Medicare dollars per capita across various health
care settings.
A large portion of Medicaid dollars are also spent on dual eligibles.
– Though representing only 18 percent of the Medicaid population, duals account for
46 percent of Medicaid spending.2
1
Coughlin, Waidman, O’Malley Watts. “Where Does the Burden Lie? Medicaid and Medicare Spending for Dual
Eligible Beneficiaries.” Kaiser Commission on Medicaid and the Uninsured. April 2009
2
Center for Health Care Strategies, Inc. citation of Urban Institute analysis, 2008
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Disabling conditions more prevalent among dual
eligibles than Medicare-only beneficiaries.
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About the data:
This analysis uses 2008 Medicare
claims data to identify individuals
with four specific diseases:
Diabetes, Chronic Obstructive
Pulmonary Disease, Dementia
and related diseases, and
Stroke/Transient Ischemic Attack.
Dual eligibles were defined as
being eligible for a state buy-in
program sometime in 2008.
Hospital and physician claims
were analyzed for disease
information. This analysis is
limited to individuals enrolled in
the fee-for service, or traditional,
Medicare program.
A Clear Policy Connection
Dual eligibles are more likely to suffer from diabetes, stroke,
dementia, and/or COPD than Medicare-only beneficiaries. These
conditions often require intensive medical services and supports.
The high prevalence of these conditions among dual eligibles
necessitates careful coordination between providers to ensure
the delivery of high quality health care services. It demonstrates
the importance of addressing the conflicting financial incentives
between Medicare and Medicaid and the separate administrative
rules of the two programs.
As a result of health reform, the Centers for Medicare and
Medicaid Services (CMS) now possesses new authority to test
creative approaches to program integration. CMS’ newly
established Federal Coordinating Health Care Office and Center
for Medicare and Medicaid Innovation have unprecedented
opportunity to break down payment and care silos between the
states and the federal government. The goal is to move toward
providing dual eligibles with seamless access to benefits and care
coordination under both the Medicare and Medicaid programs.
Analytics powered by Avalere Health LLC
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