Does Integrating Medicare and Medicaid Improve Care for Dual Eligibles?

Integrating Medicare and Medicaid coverage for dual eligible beneficiaries was associated with higher use of home- and community-based services (HCBS) but did not reduce hospitalization or improve care coordination, a study published in JAMA Health Forum found.

Beneficiaries eligible for both Medicare and Medicaid tend to have complex care needs and face the added challenge of navigating two different insurance programs. While Medicare covers hospital and post-acute care, outpatient care, and prescription drugs, Medicaid covers long-term care, including nursing home care and HCBS.

In fully integrated dual eligible special needs plans (FIDE-SNPs), one managed care plan coordinates Medicare and Medicaid services and spending. These plans are a subset of dual eligible special needs plans (D-SNPs) offered by Medicare Advantage insurers.

Integrating this coverage creates an incentive to deliver care more efficiently, as one plan is responsible for all care costs.

Researchers assessed how UPMC for You’s FIDE-SNP in Pennsylvania impacted care delivery and health outcomes among dual eligible beneficiaries. They used UPMC Medicare enrollment and claims data from 2015 to 2020 and UPMC Medicaid data from 2018 to 2020. They also analyzed 2017 claims from the state’s prior fee-for-service Medicaid program and 2015 to 2020 Medicare enrollment and claims data for a comparison cohort of dual eligibles with traditional Medicare.

The study focused on four outcomes: HCBS use, care management and coordination measures, inpatient care and admissions, and days of long-term nursing home care covered by Medicaid.

The integration cohort included 7,967 beneficiaries, and the comparison cohort included 3,832 beneficiaries. At baseline, beneficiaries in the integration cohort received a mean of 2.83 days of HCBS per month. This figure increased differentially for the integration cohort versus the comparison cohort by 0.28 days after the first post-integration year, 0.49 days after two years, and 0.61 days after three years.

In 2017, beneficiaries in the integration cohort had a mean of 0.74 outpatient visits per month and filled a mean of 3.34 medications for chronic conditions per month. The mean proportion of patients who had a follow-up outpatient visit after a hospital stay was 0.47. These outcomes measured care management and coordination.

There were no differential changes in medication use or follow-up outpatient visits after hospitalization between the cohorts, and outpatient visits per month declined in the integration cohort after three years.

Similarly, hospital utilization and post-acute care in skilled nursing facilities did not change differentially across the cohorts. There was an increase in post-acute home healthcare use in the integration cohort that coincided with the COVID-19 pandemic, making it unclear if this was due to the integration or the shift to home-based care during the pandemic.

There was a differential increase in days of long-term nursing home care in the integration cohort, indicating a greater reduction in days in the comparison cohort. However, nursing home residents experienced high mortality, especially in the comparison cohort, researchers noted.

After excluding beneficiaries who died in 2018, HCBS use increases were similar, but the rise in nursing home days was non-existent.

“Altogether, these results demonstrate some benefits of integration, particularly in facilitating increased engagement with community-based services and supports, but they also highlight opportunities to improve how integrated programs manage care and a need to further evaluate their performance,” researchers wrote.

The findings of increased HCBS use are consistent with integrated plans’ incentives to manage long-term care in community settings rather than nursing homes. The results also suggest that integrated programs should prioritize improving care coordination and management of hospital utilization.