Background NC Medicaid is amid a transformation to value-based care models. The transformation requires the consideration of models that may best serve the 1 in 5 NC Medicaid beneficiaries who are dually enrolled in Medicare. The lack of integration of Medicare and Medicaid administration, financing, and care may contribute to suboptimal health outcomes and care experiences. Integrating Medicare and Medicaid to improve care for dually enrolled individuals requires knowledge of the demographic, eligibility, and enrollment trends, as well as the medical needs of these individuals throughout North Carolina. Methods We performed a cross-sectional analysis of 2019 NC Medicaid administrative enrollment data and 2015–2020 Medicare and Medicaid public use files. Results Nearly half of North Carolina’s full-benefit dual-eligible (FBDE) population was eligible for Medicare due to disability. About one-third of the FBDE population lost full Medicaid benefits at some point during 2019; of these, 65% were under age 65. Most FBDE beneficiaries were enrolled in Medicaid fee-for-service, with 3.5% enrolled in Community Alternatives Program (CAP) waivers, 2% in Medicaid waivers for beneficiaries with behavioral health or intellectual and developmental disabilities (BH/IDD) or traumatic brain injury (TBI), and 1% in the Program of All-Inclusive Care for the Elderly (PACE). Enrollment in Medicare Duals Special Needs Plans (D-SNPs) increased from 7.3% of the FBDE population in 2015 to 32.5% in 2021. Limitations This descriptive, cross-sectional evaluation of North Carolina duals may not be generalizable to other time periods and contexts. Conclusion Medicare-Medicaid integration presents an opportunity to improve the value of care for dual-eligible beneficiaries and aligns with the goals of NC Medicaid transformation. Integration strategies that leverage the current infrastructure may minimize disruption of services for beneficiaries and mitigate the impacts of unstable enrollment, particularly among working-age adults and disabled beneficiaries. The diversity within the dual-eligible populations requires a strategy designed to improve health equity across race, disability, eligibility, geography, and health care needs.
When comparing risk-adjustment approaches based on Medicaid status of Medicare beneficiaries, this analysis found that predicted spending levels varied depending on states’ Medicaid eligibility criteria.
Cost containment for dual-eligible beneficiaries (those enrolled in Medicare and Medicaid) is a key policy goal, but few studies have examined spending trends for this population. We contrasted growth in Medicare fee-for-service per beneficiary spending for those with and without Medicaid in the period 2007–15. Relative to Medicare-only enrollees, dual-eligible beneficiaries consistently had higher overall Medicare spending levels; however, they experienced steeper declines in spending growth over the study period. These trends varied across populations of interest. For instance, dual-eligible beneficiaries ages sixty-five and older went from having annual spending growth rates that were 1.8 percentage points higher than Medicare-only beneficiaries in 2008 to rates that were 1.1 percentage points lower in 2015. Across population groups, long-term users of nursing home care had some of the highest spending growth rates, averaging 1.7–4.1 percent annually depending on age group and Medicaid participation. These findings have implications for value-based payment and other Medicare policies aimed at controlling spending for dual-eligible beneficiaries.
Over the past decade, traditional Medicare’s per-beneficiary spending grew at historically low levels. To understand this phenomenon, it is important to examine trends in postacute care, which experienced exceptionally high spending growth in prior decades.Describe per-beneficiary spending trends between 2007 and 2015 for postacute care services among traditional Medicare beneficiaries age 65 and older.Trend analysis of individual-level Medicare administrative data to generate per-beneficiary spending and utilization estimates for postacute care, including skilled nursing facilities, home health, and inpatient rehabilitation facilities.Per-beneficiary postacute care spending increased from $1,248 to $1,424 from 2007 to 2015. This modest increase reflects dramatic changes in annual spending and utilization growth rates, including a reversal from positive to negative spending growth rates for the skilled nursing facility and home health sectors. For example, the average annual spending growth rate for skilled nursing facility services declined from 7.4 percent over the 2008–11 period to –2.8 percent over the 2012–15 period. Among beneficiaries with inpatient use, growth rates for postacute care spending and utilization slowed, but more moderately than observed among all beneficiaries. Reductions in hospital use, as well as reduced payment rates, contributed to declines in postacute spending.
Importance Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina’s full benefit, dual-eligible population. Design, Setting, and Participants This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures Medicare and Medicaid utilization and spending per person-year (PPY). Results The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users’ combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Conclusions and relevance Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
This cross-sectional study evaluates how policy changes for Medicare Advantage plans affected supplemental benefit availability across geographic social vulnerability, membership diversity, and rebates from 2019 to 2022.
