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Integrated Medicare and Medicaid Managed Care and Rehospitalization of Dual Eligibles
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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.
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

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:

1. Jacobson G, Neuman T, Damico A. Medicare’s role for dual eligible beneficiaries.  Kaiser Family Foundation website. Published April 2012. Accessed March, 2014.

2. Report to the congress; new approaches in Medicare. Medicare Payment Advisory Commission website. Published June 2004. Accessed August 2014.

3. Young K, Garfield R, Musumeci M, Clemans-Cope L, Lawton E. Medicaid’s role for dual eligible beneficiaries. Kaiser Family Foundation website. Published August 2013. Accessed July 2014.

4. Grabowski D. Medicare and Medicaid: conflicting incentives for long-term care. Milbank Q. 2007;85(4):579-610.

5. Merrell K, Colby D, Hogan C. Medicare beneficiaries covered by Medicaid buy-in agreements. Health Aff (Millwood). 1997;16(1):175-184.

6. Walsh EG, Clark WD. Managed care and dually eligible beneficiaries: challenges in coordination. Health Care Financ Rev. 2002;24(1):63-82.

7. Komisar HL, Feder J, Kasper JD. Unmet long-term care needs: an analysis of Medicare-Medicaid dual eligibles. Inquiry. 2005;42(2):171-182.

8. Unruh MA, Grabowski DC, Trivedi AN, Mor V. Medicaid bed-hold policies and hospitalization of long-stay nursing home residents. Health Serv Res. 2013;48(5):1617-1633.

9. Grabowski DC, Feng Z, Intrator O, Mor V. Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations. Health Serv Res. 2010;45(6, pt 2):1963-1980.

10. Financial alignment initiative. CMS website. Updated September 14, 2015. Accessed February, 2014.

11. Musumeci M. Financial and administrative alignment demonstrations for dual eligible beneficiaries compared: states with memoranda of understanding approved by CMS. Kaiser Family Foundation website. Published July 2014. Accessed August 2014.

12. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): An innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45(2):223-232.

13. Kane RL. Setting the PACE in chronic care. Contemp Gerontol. 1999;6(2):47-50.

14. Chatterji P, Burstein NR, Kidder D, White A. Evaluation of the program of all-inclusive care for the elderly (PACE) demonstration: the impact of PACE on participant outcomes. CMS website. Published July 1998. Accessed August 2014.

15. Kane RL, Homyak P, Rudolph N. Multi state evaluation of dual eligibles demonstration: final report. CMS website. Published July 2004. Accessed July 2014

16. Kane RL, Homyak P, Bershadsky B, Flood S. The effects of a variant of the program for all inclusive care of the elderly on hospital utilization and outcomes. J Am Geriatr Soc. 2006;54(2):276-283.

17. Kane RL, Homyak P, Bershadsky B, Lum T, Flood S, Zhang H. The quality of care under a managed-care program for dual eligibles. Gerontologist. 2005;45(4):496-504.

18. Beauchamp J, Cheh V, Schmitz R, Kemper P, Hall J. The effect of the Program of All-Inclusive Care for the Elderly (PACE) on quality. CMS website. Published February 12, 2008. Accessed December 2013.

19. Kane R, Homyak P. Multi state evaluation of dual eligibles demonstration: Minnesota senior health options evaluation focusing on utilization, cost, and quality of care. CMS website. Published 2002. Revised August 2003. Accessed July 2014.

20. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

21. Segal M. Dual eligible beneficiaries and potentially avoidable hospitalizations. CMS website. Published September 2011. Accessed July 2014.

22. Senior Care Options overview. Mass Resources website. Accessed September, 2015.

23. Morgan RO, Virnig BA, DeVito CA, Persily NA. The Medicare-HMO revolving door—the healthy go in and the sick go out. N Engl J Med. 1997;337(3):169-175.

24. Unruh MA, Trivedi AN, Grabowski DC, Mor V. Does reducing length of stay increase rehospitalization of Medicare fee-for-service beneficiaries discharged to skilled nursing facilities? J Am Geriatr Soc. 2013;61(9):1443-1448.

25. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383.

26. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613-619.

27. Ashton CM, Wray NP. A conceptual framework for the study of early readmission as an indicator of quality of care. Soc Sci Med. 1996;43(11):1533-1541.

28. Ashton CM, Kuykendall DH, Johnson ML, Wray NP, Wu L. The association between the quality of inpatient care and early readmission. Ann Intern Med. 1995;122(6):415-421.

29. Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care. 1997;35(10):1044-1059.

30. Report to Congress: promoting greater efficiency in Medicare. Medicare Payment Advisory Committee website. Published 2007. Accessed July 2014.

31. Kane R, Homyak P, Bershadsky B, Flood S, Zhang H. Patterns of utilization for the Minnesota senior health options program. J Am Geriatr Soc. 2004;52(12):2039-2044.

32. Hellinger FJ, Wong HS. Selection bias in HMOs: a review of the evidence. Med Care Res Rev. 2000;57(4):405-439.

33. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11):1817-1825
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