The Insurance Coverage Paradox- Characterizing Outcomes Among Dual-Eligible Hemorrhagic Stroke Patients

Background: Socioeconomic factors, such as insurance status, have been shown to affect outcomes following emergency injuries. Dual-eligible beneficiaries, receiving both Medicare and Medicaid, constitute a vulnerable population. There is a lack of data on the impact of dual-eligible status on hemorrhagic stroke outcomes. The aim of our study was to compare hemorrhagic stroke outcomes among dual-eligible patients compared to Medicare, Medicaid, privately insured, and no charge (free or charity) patients.Study Design: We conducted a 10-year span retrospective analysis of the National Inpatient Sample. Adult patients who were emergently hospitalized for intracranial hemorrhage were included. Multivariable logistic regression was used to adjust for confounders. Primary clinical outcomes of interest included mortality (in-hospital), complications (any), and favorable discharge (home/home with services).Results: A total of 410,621 patients met inclusion of which 6.8% were dual-eligible. Dual-eligibles had higher odds of in-hospital mortality compared to no-charge (adjusted odds ratio (aOR)=1.61, 95% CI= [1.04 – 2.49]) and increased odds of complications compared to Medicaid (aOR=1.23 [1.11 – 1.37]) and privately insured patients (aOR=1.19 [1.11 – 1.28]), both p<0.001. Dual-eligibles had lower odds of favorable discharge compared to all other groups (all p<0.001), and underwent shorter lengths of stay, an 18% decrease, compared to Medicaid patients (p<0.001). Inflation adjusted admission costs among dual-eligibles were 24% lower compared to Medicaid patients (p<0.001), amounting to a $3,684 decrease in cost.Conclusions: Dual-eligible beneficiaries experience unique health disparities from lower odds of favorable discharge to increased odds of complications and in-hospital mortality compared to other insured and uninsured groups. There is a need to uncover and address unknown sources of disparities to improve emergency treatment of hemorrhagic stroke among dual-eligibles.

Subjective Well-Being, Depression, and Delays in Care Among Older Adults: Dual-Eligible Versus Medicare-Only Beneficiaries

We aimed to (a) determine the role of subjective well-being and depression in care delays among Medicare beneficiaries and (b) examine whether subjective well-being and depression play a differential role among Medicare-only and dual-eligible beneficiaries. A nationally representative sample of 1,696 older adults participated in the study. Roughly, 22% of participants reported often or sometimes experiencing care delays, with more delays among dual eligibles. We found that higher levels of subjective well-being were significantly related to less frequent care delays. In contrast, higher levels of depression were significantly related to more frequent care delays. Moreover, as depression increased, the predicted probability of delays increased to a greater extent among dual eligibles than Medicare-only beneficiaries. These findings signify the importance of identifying and implementing strategies to enhance subjective well-being and reduce depression in older adults, particularly dual eligibles, to improve access to timely care.

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare–Medicaid Dual-Eligibles

Assisted living has become more widely used by dual-eligible Medicare beneficiaries as states try to rebalance their long-term services and supports away from institutional (nursing home) care. In an analysis of 2014 Medicare data for 506,193 adults who live in large (25+ beds) assisted living communities, we found wide variability among states in the share of assisted living residents who were dual-eligible, ranging from 6% in New Hampshire to over 40% in New York. This variation is strongly correlated with the Medicaid support for assisted living care: In states with a Medicaid state plan option covering services in assisted living or both a state plan and waiver, the percent of assisted living residents with dual-eligibility was more than 10 percentage points higher than in states with neither a state plan nor waiver. Findings provide a basis for understanding the role of Medicaid financing in access to assisted living for duals.

EFFECTS OF MEDICAID MANAGED CARE ENROLLMENT ON HOSPITALIZATION RISK AMONG DUAL-ELIGIBLES

Many state Medicaid agencies have recently expanded Medicaid managed care (MMC) to include low-income older adults that are Medicare-Medicaid dually enrolled (duals). While little evidence exists regarding the effects of these expansions on health outcomes, duals may be especially vulnerable to low-quality or low-intensity care delivered by MMC due to their high use of services and the fragmentation inherent in the two-payer system. Using difference-in-differences (DID) and instrumental variables estimation, this study provides the first national examination of the impact of MMC on hospitalization for duals using claims data. DID results indicate that managed long-term services and supports (LTSS) expansions among duals are associated with increased rates of hospitalization while comprehensive managed care results in no change in hospital use. Further analyses exploring heterogeneity shed light on how these managed care payment models affect older adults and individuals using LTSS.