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Integrated Medicare and Medicaid Managed Care and Rehospitalization of Dual Eligibles
Hye-Young Jung, PhD; Amal N. Trivedi, MD, MPH; David C. Grabowski, PhD; and Vincent Mor, PhD
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Integrated Medicare and Medicaid Managed Care and Rehospitalization of Dual Eligibles

Hye-Young Jung, PhD; Amal N. Trivedi, MD, MPH; David C. Grabowski, PhD; and Vincent Mor, PhD
Integrated Medicare and Medicaid managed care may not sufficiently address the problems of inefficiency and fragmentation in care for hospitalized dual eligible enrollees.
Limitations
Our study has limitations to consider. First, we did not have data covering time periods prior to the initial implementation of SCO. Second, because the program was voluntary, unobserved differences between SCO enrollees and FFS beneficiaries may have led to residual confounding. For example, we did not have detailed measures of cognitive and functional status, nor did we have information on social support or use of long-term care facilities. Third, our study was limited to 1 state and the results may not generalize broadly to demonstrations in other regions that cover different dual populations. Lastly, since our evaluation was relatively early in the implementation of SCO and before the current policy emphasis on reducing rehospitalizations, it may be that SCO did not have targeting mechanisms in place that are increasingly common as providers seek to control costs associated with  readmissions.33

CONCLUSIONS
Given the complex healthcare needs of duals and the disproportionate share of Medicare and Medicaid spending directed toward this population, policy makers have sought new strategies to better allocate services for individuals participating in both programs. Although there is a lack of compelling evidence to support integrated managed care as a potential solution to providing more efficient care of better quality to duals, CMS and state administrators continue to move ahead with new programs based on this approach. Currently, 26 states are actively working with CMS to develop dual demonstration programs; 13 MOUs have been finalized. The majority of these programs use capitated risk-based managed care models, similar to SCO.10,11 The rationale for states’ demonstration projects was to provide better care to the dual population by improving the coordination of medical services with close management. However, our study raises questions as to whether coordinating the financing and delivery of services through an integrated managed program adequately addresses inefficiency and fragmentation in care for duals. Programs seeking to improve care for duals may need to consider not only the structure of benefits, but also the specific interventions used by plans and the characteristics of duals who are likely to enroll so that participation can be appropriately gauged and services tailored accordingly.  


Author Affiliations: Department of Healthcare Policy and Research, Weill Cornell Medical College (HYJ), New York, NY; the Department of Health Services, Policy and Practice, Brown University School of Public Health (VM, ANT), Providence, RI; Research Enhancement Award Program, Providence VA Medical Center (ANT), Providence, RI; the Department of Health Care Policy, Harvard Medical School (DCG), Boston, MA.

Source of Funding: This study was supported by the Agency for Healthcare Research and Quality (1R36HS020756-01, Health Services Research Dissertation Grant Award to Dr Jung), and the National Institute on Aging (1P01AG027296, Shaping Long-Term Care, P.I. to Dr Mor).

Author Disclosures: Dr Mor is the chair of the Quality Committe of HCR ManorCare Company, the chair of the scientific advisory committee for Navihealth, and is employed by the Veterans Administration as a health research scientist. He also has a grant to his institution pending from the Commonwealth Fund, and has received lecture fees from PointRight Inc for speaking at annual conferences. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (HYJ, ANT, VM); acquisition of data (HYJ, VM); analysis and interpretation of data (HYJ, ANT, DCG, VM); drafting of the manuscript (HYJ); critical revision of the manuscript for important intellectual content (HYJ, ANT, DCG, VM); statistical analysis (HYJ, DCG); obtaining funding (HYJ); and supervision (HYJ, DCG, VM).

Address correspondence to: Hye-Young Jung, PhD, Department of Healthcare Policy and Research, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065. E-mail: arj2005@med.cornell.edu.
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