Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid

Katherine Hayes
G. William Hoagland
Nancy Lopez
Marisa Workman
Peter Fise
Katherine Taylor
Rachel Meltzer
Soobin Seong
September 2016

This resource examines reimbursement structures that serve beneficiaries who are dually eligible for Medicare and Medicaid. It also includes an analysis comparing care patterns for dual-eligible beneficiaries with those of Medicare-only patients. The findings and recommendations include:

  • On average, dual-eligible beneficiaries have risk scores that are 50 percent higher than the average risk score for all other Medicare beneficiaries.
  • One-tenth of the dual-eligible population accounted for 38.5 percent of total combined Medicare and Medicaid spending on all dual-eligible beneficiaries in 2011.
  • Average annual Medicare spending for dual-eligible beneficiaries is more than twice as high as average annual Medicare spending for all other Medicare beneficiaries.
  • Dual-eligible beneficiaries have higher rates of hospitalizations and re-hospitalizations for medical conditions such as hypertension, congestive heart failure, and chronic obstructive pulmonary disease. Comprehensive care can often prevent the need for a hospital inpatient admission for treatment of these conditions.
  • Bipartisan Policy Center recommendations include changes to existing reimbursement structures, consolidating regulatory authority for dual-eligible programs within the Medicare-Medicaid Coordination Office at the Centers for Medicare and Medicaid Services, and building on lessons learned from existing programs to develop a consolidated framework for program design.
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