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State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment.

ABSTRACT: OBJECTIVE:To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE:2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN:Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS:Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS:Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

SUBMITTER: Roberts ET

PROVIDER: S-EPMC6863237 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment.

Roberts Eric T ET Mellor Jennifer M JM McInerney Melissa M Sabik Lindsay M LM

Health services research 20191001 6

<h4>Objective</h4>To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment.<h4>Data source</h4>2010-2013 Medicare Current Beneficiary Survey.<h4>Study design</h4>Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We u ...[more]

PMID: 31576563

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Project description:ImportanceLittle is known about small-area variations in health care spending and utilization across the 3 major funders of health care in the US: Medicare, Medicaid, and private insurers.ObjectiveTo measure regional health spending and utilization across Medicare, Medicaid, and the privately insured; to observe whether there are regions that are simultaneously low spending for all 3 payers; and to determine what factors are correlated with regional spending and utilization by payer.Design, setting, and participantsObservational cross-sectional analysis of the US health system in 2016 and 2017 for 241 of 306 hospital referral regions (HRRs) and 2 states. Participants include individuals with employer-sponsored coverage from Aetna, Humana, or UnitedHealth; individuals with Medicaid fee-for-service coverage in 2016 and 2017; and individuals with Medicare coverage. The analysis was carried out from January 2020 to May 2022.Main outcomes and measuresSpending per beneficiary and inpatient days per beneficiary by payer and overall.ResultsThe data include 25 381 167 individuals with employer-sponsored coverage, 69 891 299 with Medicaid coverage in 2016 and 2017, and 26 711 426 individuals with Medicare fee-for-service coverage. The percentage of enrollees who identified as female was 54.1% in the Medicaid program, 56.2% in the Medicare program, and 50.4% in private insurance. The mean (SD) age was 26.9 (21.8) years for Medicaid and 75.0 (7.9) years for Medicare enrollees; for private insurance enrollees, just age brackets were reported: 18 to 24 years (15.9%), 25 to 34 years (24.2%), 35 to 44 years (21.3%), 45 to 54 years (20.8%), and 55 to 64 years (17.8%). In 2017, the mean (SD) HRR-level spending per beneficiary was $4441 ($710) for private insurance, $10 281 ($1294) for Medicare, and $6127 ($1428) for Medicaid. Across HRRs, the correlation coefficients and 95% CIs were 0.020 (-0.106 to 0.146; P = .76) for private insurance and Medicare spending, 0.213 (0.090 to 0.330; P < .001) for private insurance and Medicaid, and 0.162 (0.037 to 0.282; P < .01) for Medicare and Medicaid. Just 3 HRRs (Boulder, Colorado; Bloomington, Illinois; and Olympia, Washington) were in the lowest spending quintile for all 3 insurance programs; 4 HRRs were in the highest (The Bronx, New York; Manhattan, New York; White Plains, New York; and Dallas, Texas). By contrast, the correlation coefficients and 95% CIs for utilization, measured in hospital days, were 0.465 (0.361 to 0.559; P < .001) for private insurance and Medicare, 0.527 (0.429 to 0.612; P < .001) for private insurance and Medicaid, and 0.278 (0.157 to 0.390; P < .001) for Medicare and Medicaid.Conclusions and relevanceThese findings suggest that payer-specific factors are correlated with health spending variation among Medicare beneficiaries, Medicaid beneficiaries, and the commercially insured and that payer-specific policies will be necessary to improve efficiency in the US health sector.

Project description:INTRODUCTION:Recent U.S. trends demonstrate sharp rises in adverse opioid-related health outcomes, including opioid use disorder (OUD), overdose, and death. Yet few affected people receive treatment for OUD and a minority of those who receive treatment are effectively retained in care. The purpose of this study was to examine duration of buprenorphine treatment for OUD following treatment initiation to identify risk factors for early discontinuation. METHODS:We analyzed insurance claims from the 2013-2015 MarketScan multi-state Medicaid database. The sample included adults 18-64?years old with an OUD diagnosis in the 6 months before initiating buprenorphine treatment, defined as 6 months without a buprenorphine claim prior to the index buprenorphine claim (N?=?17,329 individuals). We used Cox proportional hazards regression to estimate risk of discontinuing treatment (>30 days without buprenorphine supply), and logistic regression to estimate the odds of persistent treatment for a minimum of 180 days. RESULTS:Over one-quarter of the sample discontinued buprenorphine in the first month of treatment (N?=?4928; 28.4%) and most discontinued before 180 days (N?=?11,189; 64.6%). In the proportional hazards model, risk factors for discontinuation included a lower initial buprenorphine dose (?4?mg; Hazard Ratio [HR]?=?1.72, p?<?.001), male sex (HR?=?1.19, p?<?.001), younger age (HR?=?1.34, p?<?.001), minority race/ethnicity (black HR?=?1.31, p?<?.001; Hispanic HR?=?1.24, p?=?.01; other HR?=?1.09, p?<?.001), capitated insurance (HR?=?1.21, p?<?.001), comorbid substance use disorders (alcohol HR?=?1.07, p?=?.04; non-opioid drugs HR?=?1.14, p?<?.001), hepatitis C (HR?=?1.06, p?=?.01), opioid overdose history (HR?=?1.20, p?=?.001), or any inpatient care (HR?=?1.22, p?<?.001) in the 6-month baseline period. In logistic models, these risk factors were similarly associated with significantly lower odds of treatment retention for at least 180 days. CONCLUSION:For Medicaid beneficiaries with OUD treated with buprenorphine, there is a need to implement treatment models that more effectively address barriers to treatment retention. These barriers are particularly challenging for minorities, younger individuals, and those with additional substance use disorders.

Project description:ImportanceMedicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care.ObjectiveTo compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards.Design, setting, and participantsWe used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20 163 nonelderly adult Medicaid managed care (MMC) enrollees and 54 465 commercially insured enrollees in 5 states adopting access standards, and 37 290 MMC enrollees in 5 matched states that previously adopted access standards.Main outcomes and measuresReported access to specialty care in the previous 6 months.ResultsSeven thousand six hundred ninety-eight (69%) Medicaid enrollees and 28 423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline) compared with 11 889 (67%) of Medicaid enrollees in states that had previously implemented access standards. Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, -1.2 percentage points; 95% CI, -2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, -4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities.Conclusions and relevanceSpecialty access standards did not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.

Dataset Information

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment.

Publications

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment.

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