High-Cost Dual Eligibles' Service Use Demonstrates The Need For Supportive And Palliative Models Of Care

Abstract

Health care spending is generally highest among people who need both complex medical care and long-term services and supports, such as adults dually eligible for Medicare and Medicaid. Understanding how different types of complex patients use services over time can inform policies that target this population. High combined Medicare and Medicaid spending are found in two distinct groups of high-cost dual eligibles: older beneficiaries who are nearing the end of life, and younger beneficiaries with sustained need for functional supports. However, both groups have high hospitalization costs. Among high-cost dual eligibles living in the community, those who are older spend less on home and community-based services than those who are younger. Greater use of such services might provide stable support in the last year or two of life, when illness and functional decline accelerate. Tailored approaches to each population's distinct needs could yield care of increased value to patients and their families, with the potential to lower costs if patients' needs can be met with fewer stays in short-term inpatient facilities.

Keywords: Chronic Care; Health Spending; Long-Term Care; Medicaid; Medicare.

Exhibit 2

Percentages of patients dually eligible for Medicare and Medicaid and high cost in 2010, by age-residence groups in 2010 and cost status in 2011 Source/Note: SOURCE Authors’ analysis of linked Medicare and Medicaid data for 2010–11. NOTES The test for independence across the four age-residence groups is significant (p < 0.001). High-cost patients are those in the top decile of spending in their state.

Exhibit 3

Predicted probabilities of dying or remaining high cost in 2011 among surviving sample members, by age range Source/Notes: SOURCE Authors’ analysis of linked Medicare and Medicaid data for 2010–11. NOTES Predicted probabilities were estimated from a multinomial logistic model that adjusted for sex, race, community versus nursing home residence, whether or not the patient had three or more of sixeen chronic conditions, a flag for each chronic condition, and indicators for state of residence. The error bars indicate 95% confidence intervals. Full regression results are available in online Appendix Table 2 (see Note 35 in text). High-cost patients are those in the top decile of spending in their state.