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Comparative Study
. 2020 Mar 10;323(10):961-969.
doi: 10.1001/jama.2020.1021.

Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017

Rishi K Wadhera  1 , Yun Wang  1   2 , Jose F Figueroa  3   4 , Francesca Dominici  2 , Robert W Yeh  1 , Karen E Joynt Maddox  5
Affiliations
Comparative Study

Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017

Rishi K Wadhera et al. JAMA. .

Abstract

Importance: Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries).

Objective: To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries.

Design, setting, and participants: Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018.

Exposures: Dual vs nondual enrollment status.

Main outcomes and measures: Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates.

Results: There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period.

Conclusions and relevance: Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Wadhera reported receiving support from the National Heart, Lung, and Blood Institute and has served as a consultant to Regeneron. Dr Figueroa reported receiving support from the Commonwealth Fund and the Harvard Center for AIDS Research. Dr Dominici reported receiving support from the National Institute of Environmental Health Sciences, the Health Effects Institute, the National Institutes of Health, and the Environmental Protection Agency; and reported receiving personal fees from Colgate and Johnson & Johnson. Dr Yeh reported receiving support from the National Heart, Lung, and Blood Institute and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; and receiving grants and personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic. Dr Joynt Maddox reported receiving support from the National Heart, Lung, and Blood Institute, the National Institute on Aging, the Commonwealth Fund, and the US Department of Health and Human Services. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. County-Level Variation in the Proportion of Beneficiaries Aged 65 Years or Older Dually Enrolled in Medicare and Medicaid
The decline in dual enrollment in the southeastern United States may reflect the implementation of stricter requirements to obtain Medicaid benefits in some states.
Figure 2.
Figure 2.. Annual All-Cause Mortality Rates Among Dually and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older
Mortality rates were adjusted for age, sex, and race. Lines were smoothed using the Loess method. The shaded areas around the curves indicate 95% CIs. Beneficiaries were dually enrolled in Medicare and Medicaid or nondually enrolled in Medicare only.
Figure 3.
Figure 3.. County-Level Variation in All-Cause Mortality Among Beneficiaries Aged 65 Years or Older Dually Enrolled in Medicare and Medicaid
The panels show county-level variation in annual age-, sex-, and race-standardized all-cause mortality.
Figure 4.
Figure 4.. All-Cause Hospitalization Rates Among Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older
The all-cause hospitalization rates were adjusted for age, sex, and race. All hospitalizations per beneficiary within each calendar year were included. Lines were smoothed using the Loess method. The shaded areas around the curves indicate 95% CIs. Beneficiaries were dually enrolled in Medicare and Medicaid or nondually enrolled in Medicare only.
Figure 5.
Figure 5.. Risk-Adjusted Hospitalization-Related Mortality Among Dually and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older
Hospitalization-related mortality was adjusted for patient demographic characteristics (age, sex, and race) and clinical comorbidities. For beneficiaries with multiple hospitalizations within a calendar year, 1 hospitalization was randomly selected. Lines were smoothed using the Loess method. The shaded areas around the curves indicate 95% CIs. Beneficiaries were dually enrolled in Medicare and Medicaid or nondually enrolled in Medicare only.
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