people are covered under both the Medicare and ... Not all dual eligibles are high spenders and most (74%) were not admi
K A I S E R FA M I LY F O U N DAT I O N
Medicare Policy Medicare’s Role for Dual Eligible Beneficiaries by Gretchen Jacobson, Tricia Neuman, and Anthony Damico
Introduction
Medicare’s Role for Dual Eligible Beneficiaries Medicare’s Role for Dual Eligible Beneficiaries
ISSUE BRIEF APRIL 2012
by Gretchen Jacobson, Tricia Neuman, and Anthony Damico by Gretchen Jacobson, Tricia Neuman, and Anthony Damico APRIL 2012 Nine million low-‐income elderly and disabled EXHIBIT 1 APRIL 2012 people are covered under both the Medicare and Dually eligible beneficiaries comprise 20% of the Medicare Introduction population and 15% of the Medicaid population Introduction Medicaid programs (Exhibit 1). These Nine m illion l ow-‐income e lderly a nd d isabled EXHIBIT 1 beneficiaries (often called “dual eligibles”) are Nine m illion l ow-‐income e lderly a nd d isabled EXHIBIT 1 people a re c overed u nder b oth t he M edicare a nd Dually e ligible b eneficiaries comprise 20% of the Medicare more likely than other Medicare beneficiaries to people a re c overed u nder b oth t he M edicare a nd Dually e ligible b eneficiaries c omprise 20% poopulation f the Medicare population a nd 1 5% o f t he M edicaid Medicaid programs (Exhibit 1). These be frail, live with multiple chronic conditions, and population a nd 1 5% o f t he M edicaid p opulation Medicaid programs 1). Tehese beneficiaries (often alled “dual ligibles”) a re have functional and (ccExhibit ognitive impairments. beneficiaries ( often c alled “ dual e more l ikely t han o ther M edicare b eneficiaries Medicare is their primary source oligibles”) f health are to more l ikely t han o ther M edicare b eneficiaries o Medicare Dual Eligibles Medicaid be frail, live with multiple chronic insurance coverage, as it is for the cnonditions, early 50 atnd 9 million be frail, ive with ultiple chronic conditions, 37 million 51 million have functional am nd cnder-‐65 ognitive mpairments. and million ellderly and u diisabled have f unctional a nd c ognitive i mpairments. Medicare is their primary source soupplements f health beneficiaries in 2012. Medicaid Medicare Dual Eligibles Medicaid Medicare their pfor rimary source ocf novered hearly ealth 5b0 y insurance ics ass ervices it is for ntot he Medicare, poverage, aying 9 mEillion ligibles Medicare Medicaid 37 million Dual 51 million insurance csoverage, as it ics are for he n early 50 care million elderly nder-‐65 disabled Medicare, uch aand s duental atnd long-‐term 9 million Total Medicaid 37 m illion 51 bm illion 2008: Total M edicare b eneficiaries, 2 008: eneficiaries, million under-‐65 beneficiaries n a2nd 012. M edicaid supplements services ealderly nd siupports, and by dhisabled elping to cover 46 million 60 million beneficiaries in 2012. edicaid supplements Medicare, for s ervices not covered by Medicare’s ppaying remiums aMnd cost-‐sharing Medicare, p aying f or s ervices n ot clovered by care Medicare, s uch a s d ental c are a nd ong-‐term requirements. Together, these two programs Total Medicare beneficiaries, 2008: Total Medicaid beneficiaries, 2008: Medicare, s uch a s d ental c are a nd l ong-‐term care services nd supports, and by hM elping to cbover 46 million unaffordable out-‐of-‐pocket 60 million medical and help to sahield very low-‐income edicare eneficiaries from pMotentially Total edicare beneficiaries, 2008: Total Medicaid beneficiaries, 2008: services a nd s upports, a nd b y h elping t o c over 46 million 60 million Medicare’s p remiums a nd c ost-‐sharing long-‐term care costs. Medicare’s premiums and these cost-‐sharing requirements. Together, two programs requirements. T ogether, t hese tswo programs Policymakers a t t he f ederal a nd tate level are increasingly in udnaffordable eveloping initiatives for dual eligibles help to shield very low-‐income M edicare beneficiaries from interested potentially out-‐of-‐pocket medical and help t o s hield v ery l ow-‐income M edicare b eneficiaries f rom p otentially u naffordable o ut-‐of-‐pocket m edical both to improve the coordination of their care, and to reduce spending for both Medicare and Medicaid. To and long-‐term care costs. long-‐term care costs. policy discussions, this policy brief describes the roles played by Medicare and Medicaid in help inform ongoing Policymakers a t the federal and state level are increasingly in odn eveloping initiatives for dual eligibles providing care for duals, illustrates how dual eligibles differ ifnterested rom others Medicare, and examines the Policymakers a t t he f ederal a nd s tate l evel a re i ncreasingly i nterested i n d eveloping i nitiatives f or d ual eligibles both t o i mprove t he c oordination o f t heir c are, a nd t o r educe s pending f or b oth M edicare a nd M edicaid. To variations in medical needs and Medicare spending among dual eligibles. both t o i mprove t he c oordination o f t heir c are, a nd t o r educe s pending f or b oth M edicare a nd M edicaid. To in help inform ongoing policy discussions, this policy brief describes the roles played by Medicare and Medicaid help i nform o ngoing p olicy d iscussions, t his p olicy b rief d escribes t he r oles p layed b y M edicare a nd M edicaid in Key findings include: illustrates how dual eligibles differ from others on Medicare, and examines the providing care for duals, providing cin are for duals, illustrates how dual eligibles differ dfrom thers on and examines the variations medical and Medicare pending eoligibles. Medicare, • In 2008, dual neeeds ligibles comprised 2s0 percent aomong f the Mual edicare population but 31 percent of Medicare variations i n m edical n eeds a nd M edicare s pending a mong d ual e ligibles. spending, and 15 percent of the Medicaid population but 39 percent of Medicaid spending. Key findings include: A larger share Key •findings include: of dual eligibles than others on Medicare were in fair/poor health (49% versus 22%), had • cognitive/mental In 2008, dual eligibles comprised 20 pversus ercent 2o f the Medicare impairments population b(ut 31 vpersus ercent of Maedicare impairments (58% 5%), functional 44% 26%) nd lived in • facilities In 2008, d(13% ual c omprised 2 0 p ercent o f t he M edicare p opulation b ut 3 1 p ercent of Medicare spending, and ev1ligibles 5 p ercent o f t he M edicaid p opulation b ut 3 9 p ercent o f M edicaid s pending. ersus 1%); a larger share of dual eligibles than others died in 2008 (7% versus 3%). spending, and 15 percent of the Medicaid population but 39 percent of Medicaid spending. •• Dual A larger s hare o f d ual e ligibles t han o thers o n M edicare w ere i n f air/poor h ealth ( 49% v ersus 2%), eligibles had higher hospitalization rates than others on Medicare (26% versus 18%), and 2w ere had • more A larger s hare o f d ual e ligibles t han o thers o n M edicare w ere i n f air/poor h ealth ( 49% v ersus 2 2%), had cognitive/mental i mpairments ( 58% v ersus 2 5%), f unctional i mpairments ( 44% v ersus 2 6%) a nd l ived in likely to have two or more hospitalizations (11% versus 6%). cognitive/mental impairments (58% versus 5%), functional impairments versus 6%) and lived facilities (13% versus 1%); a larger share of d2ual eligibles than others died (i44% n 2008 (7% 2versus 3%). in • Average edicare spending or dual eligibles was 1.8 times higher for ual than others on facilities M (13% versus 1%); a lfarger share of dual eligibles than others dd ied in e2ligibles 008 (7% versus 3%). • Medicare Dual eligibles had higher hospitalization than others on M versus 18%), and were ($14,169 versus $7,933), and 8rates % incurred $40,000 or edicare more in (26% Medicare expenditures in 2008; • total Dual eM higher ospitalization rates than thers on M edicare (26% versus 18%), and were more lligibles ikely to hhad two ofhr or mdore (11% 6%). edicare save pending ual heospitalizations ligibles in 2008 woas $versus 132 billion. more likely to have two or more hospitalizations (11% versus 6%). Average Msedicare for dual eligibles was 1.8 times higher for dlual eligibles than others oual n •• Medicare pending sfpending or under-‐65, disabled dual eligibles is substantially ower than spending for d • eligibles Average aMge edicare s pending f or d ual e ligibles w as 1 .8 t imes h igher f or d ual e ligibles t han o thers o n 2008; Medicare ($14,169 v ersus $ 7,933), a nd 8 % i ncurred $ 40,000 o r m ore i n M edicare e xpenditures i n 65 or older ($13,661 per capita versus $16,445 per capita, on average). Medicare ($14,169 versus $7,933), and 8% $40,000 or more in Medicare expenditures in 2008; total Medicare spending for dual eligibles in incurred 2008 was $132 billion. • Not ll dedicare ual eligibles are hfor igh dsual penders and ere bnillion. ot admitted to a hospital in 2008; 16% of total aM spending eligibles in m2ost 008 (74%) was $w 132 • dual Medicare spending or under-‐65, disabled dual eligibles is substantially lower than spending for dual eligibles had Mfedicare spending below $2,500 in 2008. • eligibles Medicare spending or u(nder-‐65, dual eligibles is substantially than spending for dual age 65 or oflder $13,661 dpisabled er capita versus $16,445 per capita, olower n average). A more ieligibles n-‐depth adge iscussion f these and opther findings follows, with paer description data sources and 65 or oolder ($13,661 er capita versus $16,445 capita, on oaf verage). • Not all dual eligibles are high spenders and most (74%) were not admitted to a hospital in 2008; 16% of estimation sed in tahis rief sipenders n the Appendix. (74%) • dual Not maeethods ll ligibles dual euligibles re hbigh and m$ost ere not admitted to a hospital in 2008; 16% of had Medicare spending below 2,500 in 2w 008. dual eligibles had Medicare spending below $2,500 in 2008. A more in-‐depth discussion of these and other findings follows, with a description of data sources and A more in-‐depth discussion these and ther findings follows, with a description of data estimation methods used in otf his brief in tohe Appendix. sources and estimation methods used in this brief in the Appendix. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-‐64.
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-‐64. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-‐64.
K A I S E R FA M I LY F O U N DAT I O N
Medicare Policy
Issue brief
Medicare and Medicaid Play Important but Different Roles for People who are Dually Eligible Dual eligibles, like all other Medicare EXHIBIT 2 Dual eligible beneficiaries account for a disproportionate beneficiaries, are eligible for Medicare if they are share of Medicare and Medicaid spending age 65 or older or are under age 65 with a Dual Eligibles as a Share of the Dual Eligibles as a Share of the Medicare Population and Medicare Medicaid Population and Medicaid permanent disability receiving SSDI, or have end-‐ Spending, 2008: Spending, 2008: stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).1 While dual eligibles account for 20 percent of all Medicare 61% 69% beneficiaries nationwide, they are a larger share 80% 85% of the Medicare population in some states than others, ranging from 36 percent of the Medicare population in Maine to 12 percent of the 39% 31% Medicare population in Colorado, Montana, 20% 15% Nevada and Utah (Table 1). Medicare is the Total Medicare Total Medicare Total Medicaid Total Medicaid Population, 2008: Spending, 2008: Population, 2008: Spending, 2008: primary source of health insurance for dual 46 Million $424 Billion 60 Million $330 Billion eligibles, and covers most medical services, including inpatient and outpatient care, physician services, diagnostic and preventive care and, since 2006, outpatient prescription drugs under Part D plans. Medicare does not cover routine outpatient dental care or non-‐skilled long-‐term services and supports, such as in home care or extended home and personal care in the community. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-‐64.
Medicaid, a need-‐based program funded jointly by the federal and state governments, plays a key role in filling these gaps for low-‐income Medicare beneficiaries. Medicaid provides help with Medicare’s premiums and cost-‐ sharing requirements, and helps pay for the services that are not covered by Medicare. The majority of the dual eligibles (77%) receive full Medicaid benefits, ranging from more than 98 percent of dual eligibles in California and Alaska to less than 50 percent in Alabama and Delaware (Table 1). The remaining 23 percent of dual eligibles (sometimes called “partial dual eligibles”) qualify for more limited assistance with premiums and cost-‐ sharing under Medicare Savings Programs (Table 2), according to the Kaiser Commission on Medicaid and the Uninsured.2 Dual eligibles are disproportionately counted among Medicare and Medicaid’s high spenders Hospitalizations and long-‐term care are the largest components (Exhibit 2). In 2008, dual eligibles comprised 20 of Medicare and Medicaid spending for dual eligibles percent of the Medicare population but 31 Distribution of Medicare Spending Distribution of Medicaid Spending for Dual Eligibles, by Service for Dual Eligibles, by Service percent of Medicare spending, and 15 percent of the Medicaid population but 39 percent of Medicare Inpatient premiums Medicaid spending.3 In 2008, Medicare spent Hospital 9% 27% Hospice $132 billion on medical services for people who 3% Medicare 69% Advantage Home Medicare 5% are dual eligibles (Exhibit 3). More than one-‐ Health 18% acute care Long Term cost-‐sharing Care SNF quarter (27%) of Medicare spending for dual 16% 6% Providers eligibles was for inpatient hospital services, 18 Acute care 5% not 16% 10% covered Drug percent for Part A and Part B services provided to by M edicare Subsidies Outpatient 1% 15% Prescription Drugs dual eligibles through Medicare Advantage plans, 1% Total Medicare Spending: $132 Billion Total Medicaid Spending: $129 Billion 16 percent for physicians and other medical providers, and 15 percent for direct and low-‐ income subsidy (LIS) payments for Part D prescription drug premiums and cost-‐sharing. Medicaid spent $129 billion on care for the dual eligibles in 2008, the majority of which (69%) was for long-‐term care services and supports. EXHIBIT 3
NOTES: Home health and dental services comprise less than 1% of Medicaid spending. Payments to facilities comprise less than 1% of Medicare spending. Medicare premiums paid by Medicaid also includes cost-‐sharing for Qualified Medicare Beneficiaries only. Medicare Advantage payments are for Part A and B services only. Prescription drug subsidy payments include both the federal direct subsidy and the low income subsidy (LIS) payments. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-‐64.
Medicare’s Role For Dual Eligible Beneficiaries
2
K A I S E R FA M I LY F O U N DAT I O N
Medicare Policy
Issue brief
Dual Eligibles are Poorer and Have More Medical Needs Than Other Medicare Beneficiaries People who are dual eligibles differ from others on Medicare in their demographic composition, health care needs, service utilization, and Medicare spending. Due to eligibility criteria, dual eligibles have lower incomes, and 86 percent have incomes below 150 percent of the federal poverty level (Exhibit 4). Those with higher incomes are primarily individuals who “spend down” their assets and become eligible for Medicaid due to medical and long-‐term care expenses. Nearly four in 10 dual eligibles (39%) is under-‐65 and disabled – more than triple the rate among all other beneficiaries (11%). The share of dual eligibles who are under-‐65, disabled varies greatly across the states, from less than one-‐third (29%) in California to more than half (53%) in Utah (Table 1). Dual eligibles tend to have more chronic conditions, cognitive limitations and functional limitations than other Medicare beneficiaries (Exhibit 5). Half of all dual eligibles rate their health status as fair or poor, more than double the rate among non-‐dual eligibles. More than half (55%) of dual eligibles have three or more chronic conditions (versus 44% of non-‐dual eligibles), and more than half (58%) of all dual eligibles have a cognitive or mental impairment (versus 25% of non-‐dual eligibles). A larger share of dual eligibles need help with activities of daily living (ADLs), such as dressing or feeding, than non-‐dual eligibles (44% of dual eligibles versus 26% of non-‐dual eligibles).
EXHIBIT 4
A larger share of dual eligibles than other beneficiaries is low-‐income, female, under age-‐65 disabled and minorities Share of beneficiaries who are:
86%
Below 150% f Below 150% of othe Federal the Poverty FPL Level
22% 61%
Female Female
Under aUnder ge 65 Aage nd65 and Disabled disabled African American African American Hispanic Hispanic
53%
39%
Dual Eligibles
11%
20%
All other Medicare beneficiaries
7% 17% 6%
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
EXHIBIT 5
A larger share of dual eligibles than other Medicare beneficiaries has multiple chronic conditions, and functional or cognitive impairments Share of beneficiaries with:
58%
Cognitively or or Cognitively Mentally Impaired Mentally Impaired
25% 55%
3+ Chronic Conditions
3+ Chronic Conditions
44% 50%
In Fair or Poor Health
In Fair or Poor Health
22% 44%
Require Assistance Require Assistance 1+ ADLs with 1with + ADLs Long-‐term care Long-‐term Care Facility Resident 1% facility residents
26% 13%
Dual Eligibles
All other Medicare beneficiaries
NOTE: ADLs are activities of daily living, and include self-‐care tasks. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
With relatively high rates of cognitive and physical limitations, it is not surprising that a substantially larger share of dual eligibles than other Medicare beneficiaries live in a facility, such as a nursing home or mental health facility (13% of dual eligibles versus 1% of non-‐dual eligibles). In fact, almost three-‐quarters (73%) of all Medicare beneficiaries living in a long-‐term care facility are dual eligibles. As a consequence of their poorer health status, dual eligibles are more than twice as likely as other beneficiaries to die during the year (7% of dual eligibles versus 3% of other beneficiaries).
Medicare’s Role For Dual Eligible Beneficiaries
3
K A I S E R FA M I LY F O U N DAT I O N
Medicare Policy
Issue brief
As a result of having greater medical needs, dual EXHIBIT 6 eligibles a lso u se m ore M edicare s ervices, Hospital, ER, home health aEXHIBIT nd s6 killed nursing facility rates As a result of having greater medical needs, dual particularly acute care ervices, than other are higher for dual eligibles than for other beneficiaries eligibles also use m ore sM edicare services, Hospital, ER, home health and skilled nursing facility rates Medicare beneficiaries Exhibit 6than ). Among particularly acute care s(ervices, other dual are hoigher for dwith: ual eligibles than for other beneficiaries Share f dual eligibles eligibles in bfeneficiaries ee-‐for-‐service Medicare, more tdhan Medicare (Exhibit 6). Among ual Share of dual eligibles with: 26% one-‐quarter (26%) had at lM east one more than 1+ 1+ inpatient stay Inpatient Stay eligibles in fee-‐for-‐service edicare, 18% hospitalization i n 2 008 ( versus 1 8% o f o ther 26% one-‐quarter (26%) had at least one 1+ 1+ inpatient stay Inpatient Stay beneficiaries) a nd 1 1 p ercent h ad t wo o r m ore 18% 17% hospitalization in 2008 (versus 18% of other 1+ 1+ ER visit ER Visit hospitalizations (versus 6% of hoad ther 12% beneficiaries) and 11 percent two or more 17% beneficiaries). D(ual eligibles also more 1+ 1+ ER visit ER Visit hospitalizations versus 6% of woere ther 12% 11% 1+ Home health likely to use the mergency 7 percent 1+ Home Health Visit beneficiaries). Deual eligibles room; were a1lso more of visit 8% Dual eligibles dual had at least one emergency room 11% 1+ Home health likely etligibles o use the emergency room; 17 percent of 1+ Home Health Visit visit 8%9% visit 12% thers). Deual eligibles raoom lso Dual eligibles All other Medicare dual (eversus ligibles had oaf t oleast one mergency 1+ 1+ SNF stay SNF Stay beneficiaries used m ore p ost-‐acute c are t han o ther M edicare 4% visit (versus 12% of others). Dual eligibles also All other Medicare 9% 1+ 1+ SNF stay SNF Stay beneficiaries. Nine percent f dual eligibles had beneficiaries used more post-‐acute care tohan other Medicare 4% at l east o ne s tay i n a s killed n ursing f acility ( SNF) beneficiaries. Nine percent of dual eligibles had compared to stay 4 percent of others, and among those with a a SNF stay, dual eligibles spent more days in the SNF at least one in a skilled nursing facility (SNF) than o ther M edicare b eneficiaries ( on a verage, 44 dw ays versus 29 dsays for ther beneficiaries). compared to 4 percent of others, and among those ith for a ad Sual NF esligibles tay, dual eligibles pent moore days in the SNF Similarly, home health rates were h(on igher for dual other vbersus eneficiaries, sers, dually than other Medicare beneficiaries average, 44 edligibles ays for than dual for eligibles 29 days afnd or aomong ther bueneficiaries). eligible b eneficiaries h ad n early t wice a s m any v isits i n 2 008 t han o thers ( on a verage, 2 37 v isits f or d ual ed ligibles Similarly, home health rates were higher for dual eligibles than for other beneficiaries, and among users, ually versus 1 18 v isits a mong o ther M edicare b eneficiaries). eligible beneficiaries had nearly twice as many visits in 2008 than others (on average, 237 visits for dual eligibles NOTE: Excludes Medicare Advantage enrollees. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008. NOTE: Excludes Medicare Advantage enrollees. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
versus 118 visits among other Medicare beneficiaries). In 2008, Medicare spending for dual eligibles EXHIBIT 7 averaged $ 14,169 p er p erson – 1 .8 t imes h igher The distribution of Medicare spending by type of service is In 2008, Medicare spending for dual eligibles EXHIBIT 7 than spending for opther Medicare similar for dual eligibles and other beneficiaries averaged $14,169 er person – 1.8 bteneficiaries, imes higher The distribution of Medicare spending by type of service is which averaged $7,933 Exhibit 7). b eneficiaries, Inpatient than spending for other (M edicare similar for dual eligibles and oDistribution ther beneficiaries of Spending for Distribution of Spending for hospital comprised the l(argest component of which averaged $7,933 Exhibit 7). Inpatient Other Beneficiaries, by Service Dual Eligibles, by Service Medicare spending tfhe or blargest oth dual eligibles aond Distribution of Spending for Distribution of Spending for hospital comprised component f Other Beneficiaries, Inpatient by Service Dual Eligibles, by Service other b eneficiaries, a ccounting f or r oughly o ne Inpatient Hospice Hospital Medicare spending for both dual eligibles and Hospital Home 2% 28% quarter o f a verage p er b eneficiary s pending., 27% Hospice Inpatient Health other beneficiaries, accounting for roughly one Inpatient Medicare 3% Hospice4% Hospital Advantage Hospital Home SNF 4% 2% followed payments Medicare sApending., dvantage Home 5% 28% Medicare Health quarter obf y average per tbo eneficiary 18% 27% Hospice Health 4% Medicare Drug 3% Advantage 5% SNF plans f or P art A a nd P art B s ervices. P ayments t o Advantage Subsidies Home SNF followed by payments to Medicare Advantage 6% 4% 25% Medicare Health 5% Providers 18% LIS/ medical comprised a smaller share of to Drug 5% Advantage 9% SNF10% 16% plans for pProviders art A and Part B services. Payments Drug Outpatient Subsidies Providers 25% 6% Outpatient Subsidies Providers spending or dual ecligibles than or other 23% LIS/ medical pfroviders omprised a sfmaller share of 15% 9% 16% 10% Drug Outpatient Providers beneficiaries ( 16% v ersus 2 3%). O f n ote, f ederal Outpatient Subsidies spending for dual eligibles than for other 23% Average Spending Per Average Spending Per 15% subsidy p ayments ( general s ubsidies a nd l ow-‐ Dual Eligible: $14,169 Other Beneficiaries: $7,933 beneficiaries (16% versus 23%). Of note, federal Average Spending Per Average Spending Per income prescription drug subsidy spubsidies) ayments f(or general subsidies and low-‐ Dual Eligible: $14,169 Other Beneficiaries: $7,933 premiums comprised much larger share of income subsidies) for ap rescription drug spending f or d ual e ligibles t han f or o (15% versus 5%), as would be expected since dual premiums comprised a much larger sther hare boeneficiaries f eligibles r eceive l ow i ncome s ubsidy ( payments f or p remiums and c5ost-‐sharing in abddition to direct spending for dual eligibles than for other beneficiaries (15% versus %), as would e expected since sdubsidy ual payments. eligibles receive low income subsidy (payments for premiums and cost-‐sharing in addition to direct subsidy NOTE: Prescription drug subsidy payments include both the federal direct subsidy and the low income subsidy (LIS) payments. Payments to facilities comprise less than 1% of Medicare spending. Medicare Advantage payments are for Part A and B services only. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008. NOTE: Prescription drug subsidy payments include both the federal direct subsidy and the low income subsidy (LIS) payments. Payments to facilities comprise less than 1% of Medicare spending. Medicare Advantage payments are for Part A and B services only. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
payments.
Dual Eligibles: A Population with Diverse Needs, Patterns of Service Utilization and Costs Dual Eligibles: A Population with Diverse Needs, Patterns of Service Utilization and Costs The dual eligible population is far from homogeneous. People who are dual eligibles have a wide range of
conditions, circumstances, and health needs. Some, often wdho escribed as e“ligibles high need” ost”, ohf ave The dual eligible population is far from chare omogeneous. People are dual have oar “whigh ide rcange extensive n eed f or a cute, p ost-‐acute a nd l ong-‐term c are s ervices a nd s upports. O ther d ual e ligibles, while low conditions, circumstances, and health care needs. Some, often described as “high need” or “high cost”, have income and qualify or Medicaid in addition to Medicare, se relatively few services and and have lower than extensive need for afcute, post-‐acute and long-‐term care suervices and supports. Other dual eligibles, while low average M edicare c osts. A lmost t hree-‐quarters ( 74%) o f a ll d ual e ligibles n ever h ad a n i npatient h ospitalization income and qualify for Medicaid in addition to Medicare, use relatively few services and and have lower than average Medicare costs. Almost three-‐quarters (74%) of all dual eligibles never had an inpatient hospitalization
Medicare’s Role For Dual Eligible Beneficiaries
4
K A I S E R FA M I LY F O U N DAT I O N
Medicare Policy
Issue brief
and the vast majority (83%) never had an emergency room visit in 2008 – some of the most expensive health care services on a per capita basis. While a large share of dual eligibles are in fair or poor health, as previously noted, almost one in five (19%) dual eligibles rated their health as excellent or very good. Below, we examine variations within the dual eligible population in terms of health needs, service utilization, and Medicare spending.
More than one-‐third of dual eligibles incurred up to $5,000 in Medicare spending in 2008. While average Medicare spending for dual eligibles was $14,169 in 2008, Medicare spending was less than $7,036 for half of the dual eligibles (Exhibit 8). For 16 percent of dual eligibles, Medicare spending was less than $2,500 in 2008 and for another 21 percent, Medicare spending was between $2,500 and $5,000. Conversely, Medicare spending for one-‐quarter (25%) of dual eligibles exceeded $15,000, and Medicare spending for 8 percent of dual eligibles exceeded $40,000 in 2008. Not surprisingly, dual eligibles with Medicare EXHIBIT 8 Medicare s pending w as m ore than $40,000 for 8% and spending below $2,500 (“low cost”) were slightly less t han $ 2,500 f or 1 6% o f the dual eligible population younger and healthier than dual eligibles with Distribution of Medicare spending Medicare spending above $40,000 (“high cost”) for Dual Eligibles, 2008: $40,000 in 2008 (on average, age 66 years old versus 72 or more Less than $2,500 $20,000-‐ 8% years old for high-‐cost dual eligibles). A much 16% $40,000 smaller share of low-‐cost than high-‐cost dual 11% $15,000-‐ $20,000 6% eligibles lived in a long-‐term care facility (10% $2,500-‐$5,000 versus 31%) reflecting the relatively high rates of $10,000-‐ 21% hospital and skilled nursing facility care among $15,000 13% Medicare beneficiaries living in nursing homes. $5,000-‐$10,000 As migh be expected, a smaller share of the low-‐ 26% cost dual eligibles rated their health status as fair Average Spending = $14,169 or poor health than the high-‐cost group (38% Median Spending = $7,036 versus 72%) and a smaller share reported having three or more chronic conditions (43% versus 73%). The low-‐cost dual eligibles were far less likely than the high-‐cost dual eligibles to have end-‐stage renal disease (less than 1% versus 11% of high-‐cost dual eligibles), diabetes (21% low-‐cost versus 50% high–cost), or a heart valve problem or other heart condition (29% low-‐cost versus 60% high–cost). SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
EXHIBIT 9
Use of acute and post-‐acute services is much higher for high-‐cost than low-‐cost dual eligibles Share of dual eligibles with: Inpatient Stay 1+ 1+ inpatient stay
87%
1%
1+ Outpatient visit
1+ Outpatient Visit
1+ 1+ Physician visit Physician Visit
1+ Home health visit
1+ Home Health Visit SNF Stay 1+ 1+ SNF stay
1+ 1+ ER visit ER Visit
86%
45% 53%
82%
47%
