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Roberts ET, Duggan C, Stein R, Jonnadula S, Johnston KJ, Figueroa JF. Quality, Spending, Utilization, and Outcomes Among Dual-Eligible Medicare-Medicaid Beneficiaries in Integrated Care Programs: A Systematic Review. JAMA HEALTH FORUM 2024; 5:e242187. [PMID: 39028653 PMCID: PMC11259897 DOI: 10.1001/jamahealthforum.2024.2187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/03/2024] [Indexed: 07/21/2024] Open
Abstract
Importance Most dual-eligible Medicare-Medicaid beneficiaries are enrolled in bifurcated insurance programs that pay for different components of care. Therefore, policymakers are prioritizing expansion of integrated care plans (ICPs) that manage both Medicare and Medicaid benefits and spending. Objective To review evidence of the association between ICPs and health care spending, quality, utilization, and patient outcomes among dual-eligible beneficiaries. Evidence Review A search was conducted of PubMed/MEDLINE (January 1, 2010, through November 1, 2023) and Google Scholar (January 1, 2010, through October 1, 2023) and augmented with reports from US federal and state government websites. Three categories of ICPs were evaluated: Programs of All-Inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) and related models aligning Medicare and Medicaid coverage. The review included studies that evaluated beneficiaries dually eligible for and enrolled in full Medicaid; compared an ICP to a nonintegrated arrangement; and evaluated utilization, spending, care coordination, patient experience, or health for 100 or more beneficiaries. Findings In all, 26 ICP evaluations met the inclusion criteria and were included in the analysis: 5 of PACE, 13 of MMPs, and 8 of FIDE-SNPs and other aligned models. Evidence generally showed associated reductions in long-term nursing home stays in PACE (3 of 4 studies) and FIDE-SNPs and related aligned models (3 of 5 studies) but was mixed in evaluations of MMPs. Four of 9 studies of MMPs and 2 of 3 studies of FIDE-SNPs found higher outpatient use, although other studies showed no difference. Evidence on Medicaid spending was limited, whereas 8 of 10 studies of MMPs showed an association between these plans and higher Medicare spending. Evidence was mixed or inconclusive regarding care coordination and hospitalizations, and it was insufficient to evaluate patient satisfaction, health, and outcomes in beneficiary subgroups (eg, those with serious mental illness). Furthermore, studies had limited ability to control for bias from unmeasured differences between enrollees of ICPs compared with nonintegrated models. Conclusions and Relevance This systematic review found variability and gaps in evidence regarding ICPs and spending, quality, utilization, and outcomes. Studies found some ICPs were associated with reductions in long-term nursing home admissions, and several identified increases in outpatient care. However, MMPs were primarily associated with higher Medicare spending. Evidence for other outcomes was limited or inconclusive. Research addressing these evidence gaps is needed to guide ongoing efforts to integrate coverage and care for dual-eligible beneficiaries.
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Affiliation(s)
- Eric T. Roberts
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- University of Pennsylvania Leonard Davis Institute of Health Economics, Philadelphia
| | - Ciara Duggan
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rebekah Stein
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - José F. Figueroa
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
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Garrido MM, Biko D, Dorneo A, Shafer PR, Frakt AB. Access to insurance navigation support through the State Health Insurance Assistance Program (SHIP). HEALTH AFFAIRS SCHOLAR 2024; 2:qxae072. [PMID: 38911681 PMCID: PMC11192052 DOI: 10.1093/haschl/qxae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 06/25/2024]
Abstract
Medicare enrollment is complex, particularly for low-income individuals who are dually eligible for Medicare and Medicaid, and the wrong plan choice can adversely impact beneficiaries' out-of-pocket costs and access to providers and medications. The State Health Insurance Assistance Program (SHIP) is a federal program that provides counseling on Medicare coverage, but the degree to which SHIP services are accessible to low-income beneficiaries is unknown. We interviewed SHIP counselors and coordinators to characterize factors affecting access to and quality of SHIP services for low-income beneficiaries. Availability of volunteers was cited as the primary barrier to SHIP services. Topics related to dual eligibility for Medicare and Medicaid were frequently covered in counseling sessions, and staff expressed a desire for more training related to Medicaid and integrated-care programs. Our results suggest that additional counselors and increased training on topics relevant to dually eligible individuals may improve SHIP's ability to provide health insurance-related information to low-income Medicare beneficiaries.
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Affiliation(s)
- Melissa M Garrido
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, MA 02130, United States
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, United States
| | - David Biko
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, MA 02130, United States
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, United States
| | - Allison Dorneo
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, MA 02130, United States
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, United States
| | - Paul R Shafer
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, MA 02130, United States
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, United States
| | - Austin B Frakt
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, MA 02130, United States
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, United States
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA 02115, United States
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Wexler MG, Watman D, Perez S, Ankuda C, Reckrey JM. "It shouldn't be like this": Family caregivers navigating insurance for family members with dementia. J Am Geriatr Soc 2024; 72:1453-1459. [PMID: 38280225 PMCID: PMC11090749 DOI: 10.1111/jgs.18779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/08/2023] [Accepted: 12/17/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Almost 11.3 million family caregivers of people with dementia must navigate the health insurance landscape to meet the complex medical and long-term care needs of their family members. This study explores factors that influence family caregivers' decisions about insurance and how these choices affect the care and support people with dementia receive. METHODS Semi-structured interviews were conducted from June 2022 to January 2023 with 15 family caregivers of people with dementia dual eligible for Medicaid and Medicare and enrolled in home-based primary care in New York City. A set of open-ended questions were asked exploring caregivers' perspectives on navigating insurance plans. Interviews were recorded, transcribed, and analyzed using thematic analysis with both deductive and inductive coding. RESULTS Analysis revealed three major themes: (1) challenges of Medicaid enrollment, (2) making do with existing insurance, and (3) mistrust of the insurance system. Initial enrollment in Medicaid compounded the stress of adjusting to caregiving. The enrollment process was impacted by clinical factors, financial factors, and input from providers and social workers; however, caregivers could not identify a centralized system for obtaining insurance information and support. Once Medicaid was in place, participants described advocating on behalf of their family member within the constraints of their current insurance plans (Medicare and Medicaid) and ensuring they had the necessary knowledge to understand their family member's coverage. Participants voiced a need for ongoing vigilance to ensure their family members received needed care and support. CONCLUSION The challenges family caregivers experience when navigating insurance for their family members with dementia contribute to caregiver burden. Robust and centralized professional support for family members both immediately after a family member's dementia diagnosis and as the disease progresses could increase caregivers' capacity to make insurance decisions that best support their family members with dementia.
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Affiliation(s)
| | - Deborah Watman
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sasha Perez
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claire Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Orimaye SO, Schmidtke KA. Combining artificial neural networks and a marginal structural model to predict the progression from depression to Alzheimer's disease. FRONTIERS IN DEMENTIA 2024; 3:1362230. [PMID: 39081615 PMCID: PMC11285640 DOI: 10.3389/frdem.2024.1362230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/21/2024] [Indexed: 08/02/2024]
Abstract
Introduction Decades of research in population health have established depression as a likely precursor to Alzheimer's disease. A combination of causal estimates and machine learning methods in artificial intelligence could identify internal and external mediating mechanisms that contribute to the likelihood of progression from depression to Alzheimer's disease. Methods We developed an integrated predictive model, combining the marginal structural model and an artificial intelligence predictive model, distinguishing between patients likely to progress from depressive states to Alzheimer's disease better than each model alone. Results The integrated predictive model achieved substantial clinical relevance when using the area under the curve measure. It performed better than the traditional statistical method or a single artificial intelligence method alone. Discussion The integrated predictive model could form a part of a clinical screening tool that identifies patients who are likely to progress from depression to Alzheimer's disease for early behavioral health interventions. Given the high costs of treating Alzheimer's disease, our model could serve as a cost-effective intervention for the early detection of depression before it progresses to Alzheimer's disease.
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Affiliation(s)
- Sylvester O. Orimaye
- College of Global Population Health, University of Health Sciences and Pharmacy, St. Louis, MO, United States
| | - Kelly A. Schmidtke
- College of Arts and Sciences, University of Health Sciences and Pharmacy, St. Louis, MO, United States
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Ma Y, Roberts ET, Johnston KJ, Orav EJ, Figueroa JF. Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency. JAMA Netw Open 2024; 7:e245876. [PMID: 38602676 PMCID: PMC11009828 DOI: 10.1001/jamanetworkopen.2024.5876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024] Open
Abstract
Importance Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known. Objective To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid. Design, Setting, and Participants This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023. Exposure Onset of PHE. Main Outcomes and Measures Loss of Medicaid for at least 1 month within a year. Results Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020. Conclusions and Relevance During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE.
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Affiliation(s)
- Yanlei Ma
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - E. John Orav
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Roberts ET, Xue L, Lovelace J, Kypriotis C, Connor KL, Liang Q, Grabowski DC. Changes in Care Associated With Integrating Medicare and Medicaid for Dual-Eligible Individuals. JAMA HEALTH FORUM 2023; 4:e234583. [PMID: 38127588 PMCID: PMC10739174 DOI: 10.1001/jamahealthforum.2023.4583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/23/2023] [Indexed: 12/23/2023] Open
Abstract
Importance There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited. Objective To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania. Design, Setting, and Participants This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023. Main Outcomes and Measures Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays. Results The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration. Conclusions and Relevance In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.
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Affiliation(s)
- Eric T. Roberts
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lingshu Xue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - John Lovelace
- UPMC Insurance Services Division, Pittsburgh, Pennsylvania
| | - Chris Kypriotis
- Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Qingfeng Liang
- Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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