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National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care
Disability and Health Journal 6 (2013) 87e94 www.disabilityandhealthjnl.com
Research Paper
National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care Jenna Libersky, M.P.H.*, Allison Hedley Dodd, Ph.D., M.A., and Shinu Verghese, M.S. Mathematica Policy Research, USA
Abstract Background: To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. Objective: This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. Methods: We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21e64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. Results: Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%e46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. Conclusions: From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care. Ó 2013 Elsevier Inc. All rights reserved. Keywords: Medicaid; Dual eligibles; Managed care; Disability
In an effort to relieve budget pressures and improve access to and quality of care, states are increasingly enrolling individuals with disabilities in Medicaid managed care, including those who are dually eligible for Medicaid and Medicare. As of October 2010, 25 states reported enrolling duals in managed care arrangements (excluding Programs of All-Inclusive Care for the Elderly, or PACE)1 with the highest Medicaid managed care penetration rates for duals in Delaware (89%), Arizona (65%), Oregon (47%), and Minnesota (34%).2 However, most current national estimates of managed care enrollment and spending do not differentiate between duals under and over age 65, despite their very different care needs.3 As states introduce new or expand existing managed care programs for duals,
Funding and Disclosure: This work was funded by the Centers for Medicare & Medicaid services under CMS Contract No. HHSM-500-2005-00025I. Its findings were presented to the Disability Research Interest Group in conjunction with Academy Health conference on June 23, 2012. The authors have no conflicts of interest to report. * Corresponding author. 1100 1st Street Northeast, Suite 1200, Washington, DC 20024, USA. Tel.: þ1 202 250 3589. E-mail address: [email protected] (J. Libersky). 1936-6574/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.11.004
it will be important to understand the distinct enrollment and cost trends for duals under age 65 across the range of managed care arrangements in which they participate. This study quantifies changes in enrollment by managed care arrangement for duals under age 65 between 2005 and 2008. It also compares differences in Medicaid managed care enrollment and spending between dual eligibles and Medicaid-only beneficiaries who receive Supplemental Security Income (SSI) for disability, which allows for inferences about Medicare service use and costs not included in this study. Methods We used 2005 and 2008 Medicaid Analytic eXtract (MAX) dataa to gain insight into Medicaid enrollment and spending among full-benefit dual and non-dual disabled adults between the ages of 21 and 64. At the time
a MAX is a set of annual, person-level data files that contain Medicaid eligibility, service utilization, and payments derived from state reporting of Medicaid eligibility and claims data into the Medicaid Statistical Information System (MSIS).
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of our analysis, 2008 was the most recent year with MAX data available for each state. We chose 2005 as a comparison year to (1) capture recent changes in managed care enrollment and (2) use data that were created in a structure similar to the 2008 files. We analyzed the experience of 2 groups of disabled adults: ‘‘duals’’ and ‘‘Medicaid-only.’’ The 2 study populations are similar in that they must meet essentially the same medical and functional requirements that determine disability, and in order to receive Medicaid benefits, they must have the limited income and resources needed to qualify for SSI. They differ in that duals also qualify for Medicare because they have sufficient work history and have had the disability at least 2 yearsb before receiving Medicare benefits. For 2008, duals were defined as having Medicare Eligibility Database (EDB)-confirmed full-benefit dual status during each of the months enrolled in Medicaid. In the 2005 data, duals were defined as disabled adults eligible for full dual benefits in each of the quarters they were enrolled in Medicaid and confirmed by the EDB as a full dual in one or more quarters.c Full-benefit disabled adults who were never eligible for dual benefits during the year were classified as Medicaid-only enrollees in both years. There are 3 models of managed care programs in Medicaid, and individuals can be enrolled in more than 1 type simultaneously. First, comprehensive managed care (CMC) programs, such as Health Maintenance Organizations (HMO) and Health Insuring Organizations (HIO), provide a broad range of health care services to enrollees, although some specialized services can be carved out of the plan. Second, prepaid health plans (PHPs) usually provide a limited or specialized set of services, such as behavioral health, dental care, long-term care, or other services, like prenatal care and transportation. In a third type, Primary Care Case Management (PCCM), enrollees receive regular care from a primary care provider who is designated to manage that person’s care and must obtain a referral for specialty services. In the first two arrangements, states make monthly capitated payments for each enrollee, regardless of the level of service use. However, for enrollees in PCCMs, services are paid on a fee-forservice (FFS) basis and a monthly case management fee is paid on capitation. We used a hierarchical approach to classify the study population into 4 managed care service types: (1) CMC; (2) PHP only (no CMC); (3) PCCM only and (4) FFS only (no managed care). Because behavioral health PHPs were the most prevalent among the disabled population, we grouped those enrollees together, regardless of other PHP participation. Given recent interest in expanding this type
b Shorter waiting periods apply for individuals with end-stage renal disease, terminal illness, or amyotrophic lateral sclerosis (ALS). c In 2005, dual status was reported quarterly, not monthly, in both MAX and MSIS.
of managed care arrangement, individuals with long-term care PHP enrollment but no behavioral health PHP enrollment were grouped together, regardless of their enrollment in other non-behavioral health PHPs. This resulted in 9 mutually-exclusive arrangements: (1) CMC only (no PHP enrollment); (2) behavioral health PHP with CMC (with or without other PHPs); (3) long-term care PHP with CMC (with or without other PHPs); (4) other PHP with CMC; (5) behavioral health PHP without CMC (with or without other PHPs); (6) long-term care PHP without CMC (with or without other PHPs); (7) other PHP without CMC; (8) PCCM only; and (9) FFS only. We used these categories to quantify enrollment and calculate total and average Medicaid expenditures by year. Analyses were conducted using SAS 9.1. Because the major focus of the study was to examine managed care arrangements for adult duals, we compare 2008 adult duals to: (1) 2005 adult duals, to capture changes in managed care arrangements and (2) 2008 Medicaid-only disabled adults, to capture differences between dual and non-dual disabled adults. Although we adjusted spending for member months of enrollment, we chose to present the annual averages only because the trends were similar between the two estimates. Results Demographics While adult duals, as defined by this study, are only 4% of all Medicaid beneficiaries nationwide, their population is sizeabled2,468,266 in 2008, up from 2,439,026 enrollees in 2005 (Table 1). Most adult duals are between the ages of 45 and 64 (63.1% in 2008) and are White (61.0%) or African American (21.4%). The Medicaid-only disabled adult group is similar, though slightly younger (58.1% are aged 45e64). Females and minorities make up a larger share of the Medicaid-only disabled adult population than that of adult duals. Though there is some variation, similar trends are seen across states (not shown). Enrollment Nationwide, the proportion of adult duals in some type of managed care arrangement (i.e., not in FFS only) increased from 37.3% in 2005 to 51.4% in 2008 (Table 2), resulting in more than 360,000 more duals in managed care compared to 2005. While there was little change in enrollment in CMC only or PCCM only, the use of PHPs to provide services increased greatly between 2005 and 2008. In 2008, nearly half of adult duals (46.6%) were enrolled in a PHP, either with or without CMC, compared to 31.0% PHP enrollment in 2005. The increase in the use of behavioral health PHPs is particularly notable with nearly one quarter (22.4%) of 2008 adult duals enrolled in a behavioral health PHP (with or without CMC) by 2008.
J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94 Table 1 Demographics of adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008 2005 2008 Nationwide Age (%) 21e44 45e64 Sex (%) Male Female Race or ethnicity (%) White Black or African American American Indian or Alaskan Native Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander More than 1 race Missing race
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2008
Percentage of adult duals (N 5 2,439,026)
Percentage of adult duals (N 5 2,468,266)
Percentage of Medicaid-only disabled adults (N 5 2,924,290)
39.2 60.8
36.9 63.1
41.9 58.1
49.4 50.6
48.6 51.4
43.9 56.1
62.0 21.0 0.8 0.8 6.1 0.5 1.3 7.5
61.0 21.4 0.9 0.9 6.4 0.6 1.8 6.9
49.1 27.6 1.2 1.5 8.1 1.4 2.5 8.7
In 2008, managed care programs were used more often to provide services to the Medicaid-only disabled adults than to adult duals (Table 2). Less than 20% of Medicaid-only disabled adults were enrolled in FFS only (17.0%) compared to nearly 49% of dual adults. Both CMC programs (35.1% versus 11.7%) and PCCM Only (10.5% versus 1.6%) were more common among Medicaid-only disabled adults than among adult duals. Enrollment among the Medicaid-only disabled adults in behavioral health PHPs (both with and without CMC) was similar to that of adult duals, although the Medicaid-only disabled adults were more likely to be enrolled in a CMC as well. Between 2005 and 2008, the number of states that offered managed care increased in 4 of the 8 managed care
arrangement types (Fig. 1). The number of states with more than 10% of adult duals enrolled in a managed care arrangement increased over this period in 3 arrangements: behavioral health, long-term care, and other PHP, all without simultaneous enrollment in a CMC. Fig. 1 shows that the increase in the number of enrollees in behavioral health PHPs was due to greater enrollment of duals within each state in such plans, as well as an increase in the number of states offering these programs. For example, not only did the number of states with more than 1% of enrollees in a behavioral health PHP without CMC increase from 14 in 2005 to 15 in 2008, the number of states with more than 50% of adult duals enrolled in such plans also increased. Also of note is the increased enrollment in long-term care PHPs
Table 2 Total expenditures and enrollment by type of managed care service arrangement for adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008 2005 2008 2008 Nationwide
Adult duals (N 5 2,439,026)
Adult duals (N 5 2,468,266)
Medicaid-only disabled adults (N 5 2,924,290)
Total expenditures ($) CMC only or with PHP CMC only (%) Behavioral health PHP with CMC (with or without other PHP) (%) Long-term care PHP with CMC (with or without other PHP) (%) Other PHP with CMC (%) PHP with no CMC Behavioral health PHP without CMC (with or without other PHP) (%) Long-term care PHP without CMC (with or without other PHP) (%) Other PHP without CMC (%) PCCM only (%) FFS only (%)
38,410,417,165 10.6 3.3 4.7 O0.0 2.6 23.7 9.2 0.4 14.1 3.0 62.7
34,280,359,182 11.7 3.2 5.4 O0.0 3.1 38.1 17.0 0.8 20.3 1.6 48.6
47,277,918,647 35.1 17.5 12.9 O0.0 4.7 37.6 12.3 0.3 24.9 10.5 17.0
Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5 Primary Care Case Management; PHP 5 prepaid health plan, including behavioral or long-term care plans; other PHP includes managed dental, managed prenatal, and other managed care plans as identified in MSIS. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures.
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Fig. 1. Number of states with O1% of all-year full duals age 21e64 enrolled in each managed care arrangement type in 2005 and 2008.
without CMC, with 3 states enrolling 10e49% of duals in 2008 compared to 1 state offering the arrangement to 10e49% of duals in 2005. At the same time, the prevalence of some managed care arrangements decreased from 2005 to 2008, with 6 fewer states having more than 1% of adult duals enrolled in PCCM only and 3 fewer having more than 1% of adult duals enrolled in CMC only in 2008. Expenditures Medicaid expenditures for adult duals were significant, totaling about $34 billion nationwide in 2008 (Table 2), and accounting for 12% of total Medicaid spending for all full-benefit enrollees (not shown). Total Medicaid expenditures are comprised of capitation and FFS payments for all types of services, including inpatient care, long-term care, behavioral health, prescription drugs, acute care, and other services. The average annual amount paid per dual varied by managed care arrangement, with long-term care PHPs with CMC and without CMC having the highest average costs ($29,660 and $24,215, respectively; Table 3). Most of the costs in both arrangements were paid through capitation (85.4% for long-term care with CMC, and 86.7% for long-term care without CMC), though a very small number of adult duals (!0.03% in 4 states) were enrolled in these arrangements (data not shown).
Behavioral health PHPs with CMC and CMC only had the lowest average costs paid among the adult duals ($6664 and $7529, respectively). Here, capitation payments accounted for 43.7 and 48.0% of total average costs, respectively. Across CMC arrangements (only or with PHP), an average of 56.2% of total expenditures were paid through capitation (not shown). Average Medicaid expenditures for adult duals were generally lower than those of the Medicaid-only disabled adults, although a few managed care categories had markedly higher average expenditures for Medicaid-only disabled adults (CMC only, behavioral health PHP with CMC, and long-term care PHP without CMC) with average expenditures for duals less than half of those for the Medicaid-only disabled adults. The percentage of average total expenditures paid through capitation was similar between the 2 populations for most managed care arrangements, with the exception of behavioral health PHP and long-term care PHPs with CMC. For behavioral health PHP with CMC, the portion of total average expenditures from capitation payments was lower for adult duals (43.7%) than for Medicaid-only disabled adults (71.6%), while for long-term care PHP with CMC, the portion from capitation payments was higher (85.4% versus 49.3%). The difference in costs between adult duals and the Medicaid-only disabled was likely due to services that
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Table 3 Average Medicaid expenditures by managed care service arrangement type for adult duals age 21e64 and Medicaid-only disabled adults in 2008 Average annual Medicaid expenditures
CMC only Behavioral health PHP with CMC (with or without other PHPs) Long-term care PHP with CMC (with or without other PHPs) Other PHP with CMC Behavioral health PHP without CMC (with or without other PHPs) Long-term care PHP without CMC (with or without other PHPs) Other PHP without CMC PCCM only FFS only
Number of states with O0% enrollment in service type
Adult duals Total ($)
Capitation (%)
FFS (%)
Total ($)
Capitation (%)
FFS (%)
31 14
7529 6664
48.0 43.7
52.0 56.3
15,107 13,619
52.1 71.6
47.9 28.4
4
29,660
85.4
14.6
47,597
49.3
50.7
12 18
12,032 8051
47.7 18.4
52.3 81.6
11,893 14,053
46.3 10.0
53.7 90.0
5
24,215
86.7
13.3
51,227
75.8
24.2
20 22 47
9870 8097 19,373
1.1 0.8 0.1
98.9 99.2 99.9
13,894 12,506 27,441
2.5 0.5 0.2
97.5 99.5 99.8
Medicaid-only disabled adults
Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5 Primary Care Case Management; PHP 5 prepaid health plan, including behavioral or long-term care plans; other PHP includes managed dental, managed prenatal, and other managed care plans as identified in MSIS. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
Medicare covered for the dual enrollees, namely inpatient, outpatient, post-acute (e.g., skilled nursing facilities), and prescription drug claims. Although capitation payments to PHP and CMC plans would likely reflect this difference in benefits covered by Medicaid and Medicare, we did not have verifying information. Therefore, we compared the average 2008 FFS expenditures for PCCM only and FFS only, which are comprised almost entirely of FFS payments, by claim type, to identify which services accounted for differences in total expenditures (Table 4). For PCCM only and FFS only, the average expenditures Table 4 Average fee-for-service (FFS) Medicaid expenditures in 2008 for adult duals and Medicaid-only disabled adults for PCCM only or FFS only enrollees Average Medicaid expenditures ($)
Nationwide Total FFS e all types of service Inpatient hospital Institutional long-term care Prescribed drugs All other services
PCCM only
FFS only
Adult duals
Medicaid-only disabled adults
Adult duals
Medicaid-only disabled adults
8033
12,449
19,355
27,374
2182 22,117
13,423 13,654
2198 68,919
21,286 82,476
661 7672
4049 6868
224 13,010
5593 14,385
Note: Institutional long-term care includes mental hospital services for the aged, inpatient psychiatric facility services for individuals under the age of 21, intermediate care facility services for the mentally retarded, and all other nursing facility services. All other services includes those not counted in other categories, like durable medical equipment, home- and community-based services, personal care, transportation, and home health care. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
for both inpatient hospital and prescription drug costs among adult duals are only a fraction of those for Medicaid-only disabled adults (for example, $2198 versus $21,286 for FFS only 2008 inpatient hospital average expenditures). For institutional long-term care, the average FFS cost for adult duals is higher than those for the Medicaid-only group in PCCM only ($22,117 compared to $13,654), but lower in the FFS only group ($68,919 compared to $82,476). Average FFS costs for all other types of services were roughly similar for adult duals and Medicaid-only disabled adults in both the PCCM only and FFS only arrangements. While the national averages give us insight into differences in costs between adult duals and Medicaid-only disabled adults, there is a great deal of variation in average Medicaid expenditures across states within each type of managed care arrangement. Table 5 illustrates the states with the highest and lowest costs for each type of managed care arrangement among states that had more than 1% of adult duals enrolled in a given managed care arrangement. The greatest range in the 2008 average expenditure was for PHPs without CMC. Behavioral health PHP without CMC had the largest range, from $38,191 in Georgia to $3375 in Hawaii. In contrast, PHPs with CMC had more narrow ranges in cost, with the lowest range for behavioral health PHP with CMC (from $10,258 in Colorado to $3672 in Texas). There was also a great deal of variation in CMC only arrangements due largely to differences in the types of services covered. For example, Minnesota’s CMC only program, Disability Health Options, had the highest average Medicaid expenditures ($24,282) because it covered Medicaid-funded acute and long-term care services, including extensive home- and community-based waiver services and nursing facility care for up to 180 days through a Medicare Advantage Special Needs Plan. In
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Table 5 Top 3 and bottom 3 average Medicaid expenditures for states with O1% enrollment of adult duals in 2008 by managed care service arrangement type No. of states United with O1% Service arrangement States enrolled Top 3 Bottom 3 CMC only
State Avg ($) Behavioral health PHP with CMC State (with or without other PHPs) Avg ($) Long-term care PHP with CMC State (with or without other PHPs) Avg ($) Other PHP with CMC State Avg ($) Behavioral health PHP without CMC State (with or without other PHPs) Avg ($) Long-term care PHP without CMC State (with or without other PHPs) Avg ($) Other PHP without CMC State Avg ($) PCCM only State Avg ($) FFS only State Avg ($)
e 7529 e 6664 e 29,659 e 12,041 e 8051 e 24,215 e 9870 e 8097 e 19,373
e 13 e 7 e 0 e 3 e 15 e 3 e 16 e 8 e 41
Minnesota 24,282 Colorado 10,258 e e California 13,067 Georgia 38,191 Arizona 37,458 DC 31,329 Idaho 13,198 DC 113,616
Maryland 14,457 Oregon 9526 e e Delaware 3723 Arizona 37,713 Wisconsin 22,402 Delaware 26,176 Indiana 10,731 Iowa 113,027
New Jersey 13,754 Tennessee 8183 e e Kentucky 3094 Colorado 17,196 New Mexico 5,614 Utah 25,983 Vermont 7622 Pennsylvania 67,811
Indiana 3688 Pennsylvania 6498 e e e e Nebraska 4558 e e Alabama 4432 Louisiana 6280 Alabama 7860
Rhode Island 3260 Arizona 3727 e e e e Pennsylvania 4497 e e Florida 3167 Illinois 5353 Wisconsin 6770
Florida 2863 Texas 3672 e e e e Hawaii 3375 e e Wisconsin 2847 Texas 2726 Nevada 3300
Note: MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
contrast, the next highest spending state in that category (Maryland) covered many Medicaid-covered services but did not cover specialty mental health, personal care, and long-term care after 30 days in its CMC only program (HealthChoice). Discussion The proportion of Medicaid-only disabled adults enrolled in comprehensive managed care programs in 2008 (35.1%) was more than three times greater than that among dual enrollees (11.7%). This trend was driven, at least in part, by research indicating that risk-based managed care can improve care and control costs for adults with disabilities. If programs are structured, financed, and implemented well,4 managed care can reduce preventable hospitalizations,5 increase access to services,6 and improve quality of care and patient satisfaction.7,8 Enrollment in Medicaid managed care for adult duals grew from 2005 to 2008, but most of the growth occurred in PHPs without CMC. This is unlikely to lead to better care, more coordinated care, or cost control because PHP plans divide covered benefits into separate Medicaid managed care contracts or carve out many services paid on a FFS basis. Because the services covered by each PHP differ, there was also significant variation in annual costs per enrollee across states. Since 2008, states have begun to contract with managed care plans for an expanded array of services for duals enrollees. Only 3 states operated long-term care PHPs in 2008, but by October 2010, 11 states had started managed
long-term care programs, with aggregate enrollment exceeding 400,000. Moreover, several states that had previously carved out pharmacy benefits, behavioral health, or other Medicaid services had begun to carve the benefits back into their managed care contracts.1 To ensure better coordination of care and lower total costs for duals, however, managed care plans must coordinate benefits across Medicare and Medicaid. By receiving capitated payments for the full set of Medicare and Medicaid services, managed care plans have no need to shift costs from one payer to another as often occurs in FFS care9 and have more incentive to reduce duplicate or unnecessary services and deliver care in the least costly setting. The 2010 Affordable Care Act (ACA) included a number of provisions designed to promote integration of Medicare and Medicaid benefits and services for duals through improved care quality, service coordination, and increased access to home- and community-based long-term services and supports. For example, the Financial Alignment Initiatives, also known as ‘‘dual demonstrations,’’ will allow states to test two delivery system models that integrate Medicare and Medicaid financing and operations; up to 2 million duals are expected to participate in these demonstrations. As of September 2012, 26 states have submitted proposals, a handful of which are scheduled to enroll beneficiaries as early as 2013. To support the demonstrations, CMS is also making Medicare Parts A, B, and D data for duals available to states for use in coordinating care.10 While the impact of the demonstrations is not yet known, they hold promise for more integrated systems of care for adult duals.
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Limitations This analysis was unable to examine total spending for duals due to the lack of linked Medicare data; consequently, we could not assess whether total Medicare and Medicaid costs are affected by different Medicaid managed care arrangements for duals across states.d Second, we cannot explain all of the reasons for cross-state variation in managed care program costs using Medicaid claims alone. Differences in total state costs may reflect different benefits included in managed care plans of the same type, variation in how capitation rates are set for the same types of services, differences in the amount of services provided within a plan, or differences in the quality and completeness of claims data submitted for managed care enrollees.e Understanding the reasons for differences in state costs will require in-depth analysis of state managed care programs to examine the amount or type of services covered under capitation payments, analysis of the quality of capitation data, and analysis of encounter data on the services that are actually provided.11 In addition, costs by managed care arrangement type may also differ due to the way state states classify plans in the data. For example, some behavioral health PHPs may look more like CMC plans in the range of services covered but the state classifies the plan as a PHP because it contains a behavioral health component. The variety in the types of PHPs classified as ‘‘other’’ also makes it difficult to compare data across states.12
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states. However, this trend did not result in expanded use of CMC among adult duals. With over one-third of Medicaid-only disabled adults enrolled in CMC programs (CMC only or with PHP), states are clearly interested in using managed care to contain costs and improve service delivery for adults with disabilities. However, until recently federal Medicare rules have given states little incentive, and in some cases prohibited them, from enrolling adult duals into comprehensive managed care plans. To encourage greater integration of care for duals, new federal initiatives aim to reduce barriers that have made it difficult for states to enroll duals into comprehensive managed care. As more dual enrollees are enrolled in managed care plans, it will be important to monitor the types of managed care programs in which adult duals are enrolled and evaluate the degree to which they can integrate care and reduce costs. Acknowledgments The authors would like to thank Cara Petroski of the Centers for Medicare & Medicaid Services (CMS) for her support. At Mathematica, we also thank Julie Sykes for her guidance and encouragement. In addition, we thank Debra Lipson, Jim Verdier, and Catherine Desroches for providing helpful comments on drafts. References
Conclusion From 2005 to 2008, the number of states with managed care programs for adult duals increased, as did the percentage of duals enrolled in these programs within
d Using a linked dataset that became available more recently, Bubolz, et al. 2012, found that for dual beneficiaries under age 65, Medicare expenditures appeared to substitute for Medicaid expenditures. ‘‘States with lower rates of Medicaid spending experienced higher rates of Medicare expenditures, and vice versa.’’ While the study did not examine all the reasons for this finding, they cited a lack of evidence ‘‘that variations in the proportion of patients enrolled in managed care programs across states was systematically associated with per capita state-level Medicare or Medicaid expenditures.’’ Thomas B,, Emerson C, and Skinner J, Shifting From Medicaid To Medicare: State Spending On Dual Eligibles Under Age 65 Shows Variations, Evidence Of Cost, Health Aff (Millwood). 2012; 31(5):939e947. e As required by the Balanced Budget Act of 1997, states submit quarterly eligibility and claims program data to CMS through the Medicaid Statistical Information System (MSIS), which is used to construct MAX. States are more likely to submit capitated payment data for CMC enrollees than PHP enrollees. In 2008, 86.0% of states with CMC enrollees submitted capitation data for more than 90 percent of their CMC enrollees, while 11.6% of states submitted no capitation data. Among states with PHP enrollees, 64.7% of states submitted capitation data for more than 90 percent of their PHP enrollees, while 17.6% of states submitted no capitation data. Borck R, Dodd A, Zlatinov A, Verghese S, Malsberger R, Petroski C. The Medicaid Analytic eXtract 2008 Chartbook. Baltimore, MD: Centers for Medicare & Medicaid Services; 2012. 14.
1. Gifford K, Smith V, Snipes D, Paradise J. A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2011 Sep. 2. Verdier J. Including Medicare-Medicaid dual eligibles in managed care: current status and future prospects. In: Paper presented at World Congress 6th Annual Leadership Summit on Medicare, 2010 Jul 20, Washington, DC. 3. Kasper J, Watts M, Lyons B. Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications and Patterns of Medicaid and Medicare Service Use and Spending. Washington, DC: Kaiser Family Foundation; 2010 Jul. 4. Highsmith N, Somers S. Adults with Disabilities in Medi-Cal Managed Care: Lessons from Other States. Oakland, CA: Medi-Cal Policy Institute; 2003 Sep. 5. Bindman A, Chattopadhyay A, Osmond D, Huen W, Bacchetti P. Preventing Unnecessary Hospitalizations in Medi-Cal: Comparing Feefor-Service with Managed Care. San Francisco, CA: California Healthcare Foundation; 2004 Feb. 6. Coughlin TA, Long SK, Graves JA. Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study. Inquiry. 2008e2009 Winter;45(4):395e407. 7. Palsbo SE, Ho PS. Consumer evaluation of a disability care coordination organization. J Health Care Poor Underserved. 2007 Nov;18(4): 887e901. 8. Hill SC, Wooldridge J. Informed participation in TennCare by people with disabilities. J Health Care Poor Underserved. 2006 Nov;17(4): 851e875. 9. Grabowski C. Medicare and Medicaid: conflicting incentives for longterm care. Milbank Q. 2007;85(4):579e610. 10. CMS Medicare-Medicaid Coordination Office. Access to Medicare Data to Coordinate Care for Dual Eligible Beneficiaries. Baltimore,
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MD: Center for Medicaid, CHIP and Survey & Certification Informational Bulletin; 2011 May 11. 11. Dodd A, Nysenbaum J, Zlatinov A. Assessing the Usability of the MAX 2007 Inpatient and Prescription Encounter Data for Enrollees in Comprehensive Managed Care. CMS Medicaid Policy Brief 5. Washington, DC: Mathematica Policy Research; 2012 Apr. Service use for CMC and PHPs is captured in encounter data, which are claims records that contain utilization but no Medicaid expenditure
information. While states have not submitted encounter data as consistently as FFS data, an initial review of this data showed that for many states it appears to be usable. 12. Refer to the MAX anomaly tables for a description of other PHPs in each state. The tables are available from the CMS Medicaid Analytic eXtract (MAX) General Information site at https://www.cms.gov/ Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/MAXGeneralInformation.html.
Research Paper
National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care Jenna Libersky, M.P.H.*, Allison Hedley Dodd, Ph.D., M.A., and Shinu Verghese, M.S. Mathematica Policy Research, USA
Abstract Background: To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. Objective: This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. Methods: We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21e64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. Results: Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%e46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. Conclusions: From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care. Ó 2013 Elsevier Inc. All rights reserved. Keywords: Medicaid; Dual eligibles; Managed care; Disability
In an effort to relieve budget pressures and improve access to and quality of care, states are increasingly enrolling individuals with disabilities in Medicaid managed care, including those who are dually eligible for Medicaid and Medicare. As of October 2010, 25 states reported enrolling duals in managed care arrangements (excluding Programs of All-Inclusive Care for the Elderly, or PACE)1 with the highest Medicaid managed care penetration rates for duals in Delaware (89%), Arizona (65%), Oregon (47%), and Minnesota (34%).2 However, most current national estimates of managed care enrollment and spending do not differentiate between duals under and over age 65, despite their very different care needs.3 As states introduce new or expand existing managed care programs for duals,
Funding and Disclosure: This work was funded by the Centers for Medicare & Medicaid services under CMS Contract No. HHSM-500-2005-00025I. Its findings were presented to the Disability Research Interest Group in conjunction with Academy Health conference on June 23, 2012. The authors have no conflicts of interest to report. * Corresponding author. 1100 1st Street Northeast, Suite 1200, Washington, DC 20024, USA. Tel.: þ1 202 250 3589. E-mail address: [email protected] (J. Libersky). 1936-6574/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.11.004
it will be important to understand the distinct enrollment and cost trends for duals under age 65 across the range of managed care arrangements in which they participate. This study quantifies changes in enrollment by managed care arrangement for duals under age 65 between 2005 and 2008. It also compares differences in Medicaid managed care enrollment and spending between dual eligibles and Medicaid-only beneficiaries who receive Supplemental Security Income (SSI) for disability, which allows for inferences about Medicare service use and costs not included in this study. Methods We used 2005 and 2008 Medicaid Analytic eXtract (MAX) dataa to gain insight into Medicaid enrollment and spending among full-benefit dual and non-dual disabled adults between the ages of 21 and 64. At the time
a MAX is a set of annual, person-level data files that contain Medicaid eligibility, service utilization, and payments derived from state reporting of Medicaid eligibility and claims data into the Medicaid Statistical Information System (MSIS).
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of our analysis, 2008 was the most recent year with MAX data available for each state. We chose 2005 as a comparison year to (1) capture recent changes in managed care enrollment and (2) use data that were created in a structure similar to the 2008 files. We analyzed the experience of 2 groups of disabled adults: ‘‘duals’’ and ‘‘Medicaid-only.’’ The 2 study populations are similar in that they must meet essentially the same medical and functional requirements that determine disability, and in order to receive Medicaid benefits, they must have the limited income and resources needed to qualify for SSI. They differ in that duals also qualify for Medicare because they have sufficient work history and have had the disability at least 2 yearsb before receiving Medicare benefits. For 2008, duals were defined as having Medicare Eligibility Database (EDB)-confirmed full-benefit dual status during each of the months enrolled in Medicaid. In the 2005 data, duals were defined as disabled adults eligible for full dual benefits in each of the quarters they were enrolled in Medicaid and confirmed by the EDB as a full dual in one or more quarters.c Full-benefit disabled adults who were never eligible for dual benefits during the year were classified as Medicaid-only enrollees in both years. There are 3 models of managed care programs in Medicaid, and individuals can be enrolled in more than 1 type simultaneously. First, comprehensive managed care (CMC) programs, such as Health Maintenance Organizations (HMO) and Health Insuring Organizations (HIO), provide a broad range of health care services to enrollees, although some specialized services can be carved out of the plan. Second, prepaid health plans (PHPs) usually provide a limited or specialized set of services, such as behavioral health, dental care, long-term care, or other services, like prenatal care and transportation. In a third type, Primary Care Case Management (PCCM), enrollees receive regular care from a primary care provider who is designated to manage that person’s care and must obtain a referral for specialty services. In the first two arrangements, states make monthly capitated payments for each enrollee, regardless of the level of service use. However, for enrollees in PCCMs, services are paid on a fee-forservice (FFS) basis and a monthly case management fee is paid on capitation. We used a hierarchical approach to classify the study population into 4 managed care service types: (1) CMC; (2) PHP only (no CMC); (3) PCCM only and (4) FFS only (no managed care). Because behavioral health PHPs were the most prevalent among the disabled population, we grouped those enrollees together, regardless of other PHP participation. Given recent interest in expanding this type
b Shorter waiting periods apply for individuals with end-stage renal disease, terminal illness, or amyotrophic lateral sclerosis (ALS). c In 2005, dual status was reported quarterly, not monthly, in both MAX and MSIS.
of managed care arrangement, individuals with long-term care PHP enrollment but no behavioral health PHP enrollment were grouped together, regardless of their enrollment in other non-behavioral health PHPs. This resulted in 9 mutually-exclusive arrangements: (1) CMC only (no PHP enrollment); (2) behavioral health PHP with CMC (with or without other PHPs); (3) long-term care PHP with CMC (with or without other PHPs); (4) other PHP with CMC; (5) behavioral health PHP without CMC (with or without other PHPs); (6) long-term care PHP without CMC (with or without other PHPs); (7) other PHP without CMC; (8) PCCM only; and (9) FFS only. We used these categories to quantify enrollment and calculate total and average Medicaid expenditures by year. Analyses were conducted using SAS 9.1. Because the major focus of the study was to examine managed care arrangements for adult duals, we compare 2008 adult duals to: (1) 2005 adult duals, to capture changes in managed care arrangements and (2) 2008 Medicaid-only disabled adults, to capture differences between dual and non-dual disabled adults. Although we adjusted spending for member months of enrollment, we chose to present the annual averages only because the trends were similar between the two estimates. Results Demographics While adult duals, as defined by this study, are only 4% of all Medicaid beneficiaries nationwide, their population is sizeabled2,468,266 in 2008, up from 2,439,026 enrollees in 2005 (Table 1). Most adult duals are between the ages of 45 and 64 (63.1% in 2008) and are White (61.0%) or African American (21.4%). The Medicaid-only disabled adult group is similar, though slightly younger (58.1% are aged 45e64). Females and minorities make up a larger share of the Medicaid-only disabled adult population than that of adult duals. Though there is some variation, similar trends are seen across states (not shown). Enrollment Nationwide, the proportion of adult duals in some type of managed care arrangement (i.e., not in FFS only) increased from 37.3% in 2005 to 51.4% in 2008 (Table 2), resulting in more than 360,000 more duals in managed care compared to 2005. While there was little change in enrollment in CMC only or PCCM only, the use of PHPs to provide services increased greatly between 2005 and 2008. In 2008, nearly half of adult duals (46.6%) were enrolled in a PHP, either with or without CMC, compared to 31.0% PHP enrollment in 2005. The increase in the use of behavioral health PHPs is particularly notable with nearly one quarter (22.4%) of 2008 adult duals enrolled in a behavioral health PHP (with or without CMC) by 2008.
J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94 Table 1 Demographics of adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008 2005 2008 Nationwide Age (%) 21e44 45e64 Sex (%) Male Female Race or ethnicity (%) White Black or African American American Indian or Alaskan Native Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander More than 1 race Missing race
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2008
Percentage of adult duals (N 5 2,439,026)
Percentage of adult duals (N 5 2,468,266)
Percentage of Medicaid-only disabled adults (N 5 2,924,290)
39.2 60.8
36.9 63.1
41.9 58.1
49.4 50.6
48.6 51.4
43.9 56.1
62.0 21.0 0.8 0.8 6.1 0.5 1.3 7.5
61.0 21.4 0.9 0.9 6.4 0.6 1.8 6.9
49.1 27.6 1.2 1.5 8.1 1.4 2.5 8.7
In 2008, managed care programs were used more often to provide services to the Medicaid-only disabled adults than to adult duals (Table 2). Less than 20% of Medicaid-only disabled adults were enrolled in FFS only (17.0%) compared to nearly 49% of dual adults. Both CMC programs (35.1% versus 11.7%) and PCCM Only (10.5% versus 1.6%) were more common among Medicaid-only disabled adults than among adult duals. Enrollment among the Medicaid-only disabled adults in behavioral health PHPs (both with and without CMC) was similar to that of adult duals, although the Medicaid-only disabled adults were more likely to be enrolled in a CMC as well. Between 2005 and 2008, the number of states that offered managed care increased in 4 of the 8 managed care
arrangement types (Fig. 1). The number of states with more than 10% of adult duals enrolled in a managed care arrangement increased over this period in 3 arrangements: behavioral health, long-term care, and other PHP, all without simultaneous enrollment in a CMC. Fig. 1 shows that the increase in the number of enrollees in behavioral health PHPs was due to greater enrollment of duals within each state in such plans, as well as an increase in the number of states offering these programs. For example, not only did the number of states with more than 1% of enrollees in a behavioral health PHP without CMC increase from 14 in 2005 to 15 in 2008, the number of states with more than 50% of adult duals enrolled in such plans also increased. Also of note is the increased enrollment in long-term care PHPs
Table 2 Total expenditures and enrollment by type of managed care service arrangement for adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008 2005 2008 2008 Nationwide
Adult duals (N 5 2,439,026)
Adult duals (N 5 2,468,266)
Medicaid-only disabled adults (N 5 2,924,290)
Total expenditures ($) CMC only or with PHP CMC only (%) Behavioral health PHP with CMC (with or without other PHP) (%) Long-term care PHP with CMC (with or without other PHP) (%) Other PHP with CMC (%) PHP with no CMC Behavioral health PHP without CMC (with or without other PHP) (%) Long-term care PHP without CMC (with or without other PHP) (%) Other PHP without CMC (%) PCCM only (%) FFS only (%)
38,410,417,165 10.6 3.3 4.7 O0.0 2.6 23.7 9.2 0.4 14.1 3.0 62.7
34,280,359,182 11.7 3.2 5.4 O0.0 3.1 38.1 17.0 0.8 20.3 1.6 48.6
47,277,918,647 35.1 17.5 12.9 O0.0 4.7 37.6 12.3 0.3 24.9 10.5 17.0
Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5 Primary Care Case Management; PHP 5 prepaid health plan, including behavioral or long-term care plans; other PHP includes managed dental, managed prenatal, and other managed care plans as identified in MSIS. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures.
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Fig. 1. Number of states with O1% of all-year full duals age 21e64 enrolled in each managed care arrangement type in 2005 and 2008.
without CMC, with 3 states enrolling 10e49% of duals in 2008 compared to 1 state offering the arrangement to 10e49% of duals in 2005. At the same time, the prevalence of some managed care arrangements decreased from 2005 to 2008, with 6 fewer states having more than 1% of adult duals enrolled in PCCM only and 3 fewer having more than 1% of adult duals enrolled in CMC only in 2008. Expenditures Medicaid expenditures for adult duals were significant, totaling about $34 billion nationwide in 2008 (Table 2), and accounting for 12% of total Medicaid spending for all full-benefit enrollees (not shown). Total Medicaid expenditures are comprised of capitation and FFS payments for all types of services, including inpatient care, long-term care, behavioral health, prescription drugs, acute care, and other services. The average annual amount paid per dual varied by managed care arrangement, with long-term care PHPs with CMC and without CMC having the highest average costs ($29,660 and $24,215, respectively; Table 3). Most of the costs in both arrangements were paid through capitation (85.4% for long-term care with CMC, and 86.7% for long-term care without CMC), though a very small number of adult duals (!0.03% in 4 states) were enrolled in these arrangements (data not shown).
Behavioral health PHPs with CMC and CMC only had the lowest average costs paid among the adult duals ($6664 and $7529, respectively). Here, capitation payments accounted for 43.7 and 48.0% of total average costs, respectively. Across CMC arrangements (only or with PHP), an average of 56.2% of total expenditures were paid through capitation (not shown). Average Medicaid expenditures for adult duals were generally lower than those of the Medicaid-only disabled adults, although a few managed care categories had markedly higher average expenditures for Medicaid-only disabled adults (CMC only, behavioral health PHP with CMC, and long-term care PHP without CMC) with average expenditures for duals less than half of those for the Medicaid-only disabled adults. The percentage of average total expenditures paid through capitation was similar between the 2 populations for most managed care arrangements, with the exception of behavioral health PHP and long-term care PHPs with CMC. For behavioral health PHP with CMC, the portion of total average expenditures from capitation payments was lower for adult duals (43.7%) than for Medicaid-only disabled adults (71.6%), while for long-term care PHP with CMC, the portion from capitation payments was higher (85.4% versus 49.3%). The difference in costs between adult duals and the Medicaid-only disabled was likely due to services that
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Table 3 Average Medicaid expenditures by managed care service arrangement type for adult duals age 21e64 and Medicaid-only disabled adults in 2008 Average annual Medicaid expenditures
CMC only Behavioral health PHP with CMC (with or without other PHPs) Long-term care PHP with CMC (with or without other PHPs) Other PHP with CMC Behavioral health PHP without CMC (with or without other PHPs) Long-term care PHP without CMC (with or without other PHPs) Other PHP without CMC PCCM only FFS only
Number of states with O0% enrollment in service type
Adult duals Total ($)
Capitation (%)
FFS (%)
Total ($)
Capitation (%)
FFS (%)
31 14
7529 6664
48.0 43.7
52.0 56.3
15,107 13,619
52.1 71.6
47.9 28.4
4
29,660
85.4
14.6
47,597
49.3
50.7
12 18
12,032 8051
47.7 18.4
52.3 81.6
11,893 14,053
46.3 10.0
53.7 90.0
5
24,215
86.7
13.3
51,227
75.8
24.2
20 22 47
9870 8097 19,373
1.1 0.8 0.1
98.9 99.2 99.9
13,894 12,506 27,441
2.5 0.5 0.2
97.5 99.5 99.8
Medicaid-only disabled adults
Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5 Primary Care Case Management; PHP 5 prepaid health plan, including behavioral or long-term care plans; other PHP includes managed dental, managed prenatal, and other managed care plans as identified in MSIS. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
Medicare covered for the dual enrollees, namely inpatient, outpatient, post-acute (e.g., skilled nursing facilities), and prescription drug claims. Although capitation payments to PHP and CMC plans would likely reflect this difference in benefits covered by Medicaid and Medicare, we did not have verifying information. Therefore, we compared the average 2008 FFS expenditures for PCCM only and FFS only, which are comprised almost entirely of FFS payments, by claim type, to identify which services accounted for differences in total expenditures (Table 4). For PCCM only and FFS only, the average expenditures Table 4 Average fee-for-service (FFS) Medicaid expenditures in 2008 for adult duals and Medicaid-only disabled adults for PCCM only or FFS only enrollees Average Medicaid expenditures ($)
Nationwide Total FFS e all types of service Inpatient hospital Institutional long-term care Prescribed drugs All other services
PCCM only
FFS only
Adult duals
Medicaid-only disabled adults
Adult duals
Medicaid-only disabled adults
8033
12,449
19,355
27,374
2182 22,117
13,423 13,654
2198 68,919
21,286 82,476
661 7672
4049 6868
224 13,010
5593 14,385
Note: Institutional long-term care includes mental hospital services for the aged, inpatient psychiatric facility services for individuals under the age of 21, intermediate care facility services for the mentally retarded, and all other nursing facility services. All other services includes those not counted in other categories, like durable medical equipment, home- and community-based services, personal care, transportation, and home health care. MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
for both inpatient hospital and prescription drug costs among adult duals are only a fraction of those for Medicaid-only disabled adults (for example, $2198 versus $21,286 for FFS only 2008 inpatient hospital average expenditures). For institutional long-term care, the average FFS cost for adult duals is higher than those for the Medicaid-only group in PCCM only ($22,117 compared to $13,654), but lower in the FFS only group ($68,919 compared to $82,476). Average FFS costs for all other types of services were roughly similar for adult duals and Medicaid-only disabled adults in both the PCCM only and FFS only arrangements. While the national averages give us insight into differences in costs between adult duals and Medicaid-only disabled adults, there is a great deal of variation in average Medicaid expenditures across states within each type of managed care arrangement. Table 5 illustrates the states with the highest and lowest costs for each type of managed care arrangement among states that had more than 1% of adult duals enrolled in a given managed care arrangement. The greatest range in the 2008 average expenditure was for PHPs without CMC. Behavioral health PHP without CMC had the largest range, from $38,191 in Georgia to $3375 in Hawaii. In contrast, PHPs with CMC had more narrow ranges in cost, with the lowest range for behavioral health PHP with CMC (from $10,258 in Colorado to $3672 in Texas). There was also a great deal of variation in CMC only arrangements due largely to differences in the types of services covered. For example, Minnesota’s CMC only program, Disability Health Options, had the highest average Medicaid expenditures ($24,282) because it covered Medicaid-funded acute and long-term care services, including extensive home- and community-based waiver services and nursing facility care for up to 180 days through a Medicare Advantage Special Needs Plan. In
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Table 5 Top 3 and bottom 3 average Medicaid expenditures for states with O1% enrollment of adult duals in 2008 by managed care service arrangement type No. of states United with O1% Service arrangement States enrolled Top 3 Bottom 3 CMC only
State Avg ($) Behavioral health PHP with CMC State (with or without other PHPs) Avg ($) Long-term care PHP with CMC State (with or without other PHPs) Avg ($) Other PHP with CMC State Avg ($) Behavioral health PHP without CMC State (with or without other PHPs) Avg ($) Long-term care PHP without CMC State (with or without other PHPs) Avg ($) Other PHP without CMC State Avg ($) PCCM only State Avg ($) FFS only State Avg ($)
e 7529 e 6664 e 29,659 e 12,041 e 8051 e 24,215 e 9870 e 8097 e 19,373
e 13 e 7 e 0 e 3 e 15 e 3 e 16 e 8 e 41
Minnesota 24,282 Colorado 10,258 e e California 13,067 Georgia 38,191 Arizona 37,458 DC 31,329 Idaho 13,198 DC 113,616
Maryland 14,457 Oregon 9526 e e Delaware 3723 Arizona 37,713 Wisconsin 22,402 Delaware 26,176 Indiana 10,731 Iowa 113,027
New Jersey 13,754 Tennessee 8183 e e Kentucky 3094 Colorado 17,196 New Mexico 5,614 Utah 25,983 Vermont 7622 Pennsylvania 67,811
Indiana 3688 Pennsylvania 6498 e e e e Nebraska 4558 e e Alabama 4432 Louisiana 6280 Alabama 7860
Rhode Island 3260 Arizona 3727 e e e e Pennsylvania 4497 e e Florida 3167 Illinois 5353 Wisconsin 6770
Florida 2863 Texas 3672 e e e e Hawaii 3375 e e Wisconsin 2847 Texas 2726 Nevada 3300
Note: MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures. Source: MAX 2008.
contrast, the next highest spending state in that category (Maryland) covered many Medicaid-covered services but did not cover specialty mental health, personal care, and long-term care after 30 days in its CMC only program (HealthChoice). Discussion The proportion of Medicaid-only disabled adults enrolled in comprehensive managed care programs in 2008 (35.1%) was more than three times greater than that among dual enrollees (11.7%). This trend was driven, at least in part, by research indicating that risk-based managed care can improve care and control costs for adults with disabilities. If programs are structured, financed, and implemented well,4 managed care can reduce preventable hospitalizations,5 increase access to services,6 and improve quality of care and patient satisfaction.7,8 Enrollment in Medicaid managed care for adult duals grew from 2005 to 2008, but most of the growth occurred in PHPs without CMC. This is unlikely to lead to better care, more coordinated care, or cost control because PHP plans divide covered benefits into separate Medicaid managed care contracts or carve out many services paid on a FFS basis. Because the services covered by each PHP differ, there was also significant variation in annual costs per enrollee across states. Since 2008, states have begun to contract with managed care plans for an expanded array of services for duals enrollees. Only 3 states operated long-term care PHPs in 2008, but by October 2010, 11 states had started managed
long-term care programs, with aggregate enrollment exceeding 400,000. Moreover, several states that had previously carved out pharmacy benefits, behavioral health, or other Medicaid services had begun to carve the benefits back into their managed care contracts.1 To ensure better coordination of care and lower total costs for duals, however, managed care plans must coordinate benefits across Medicare and Medicaid. By receiving capitated payments for the full set of Medicare and Medicaid services, managed care plans have no need to shift costs from one payer to another as often occurs in FFS care9 and have more incentive to reduce duplicate or unnecessary services and deliver care in the least costly setting. The 2010 Affordable Care Act (ACA) included a number of provisions designed to promote integration of Medicare and Medicaid benefits and services for duals through improved care quality, service coordination, and increased access to home- and community-based long-term services and supports. For example, the Financial Alignment Initiatives, also known as ‘‘dual demonstrations,’’ will allow states to test two delivery system models that integrate Medicare and Medicaid financing and operations; up to 2 million duals are expected to participate in these demonstrations. As of September 2012, 26 states have submitted proposals, a handful of which are scheduled to enroll beneficiaries as early as 2013. To support the demonstrations, CMS is also making Medicare Parts A, B, and D data for duals available to states for use in coordinating care.10 While the impact of the demonstrations is not yet known, they hold promise for more integrated systems of care for adult duals.
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Limitations This analysis was unable to examine total spending for duals due to the lack of linked Medicare data; consequently, we could not assess whether total Medicare and Medicaid costs are affected by different Medicaid managed care arrangements for duals across states.d Second, we cannot explain all of the reasons for cross-state variation in managed care program costs using Medicaid claims alone. Differences in total state costs may reflect different benefits included in managed care plans of the same type, variation in how capitation rates are set for the same types of services, differences in the amount of services provided within a plan, or differences in the quality and completeness of claims data submitted for managed care enrollees.e Understanding the reasons for differences in state costs will require in-depth analysis of state managed care programs to examine the amount or type of services covered under capitation payments, analysis of the quality of capitation data, and analysis of encounter data on the services that are actually provided.11 In addition, costs by managed care arrangement type may also differ due to the way state states classify plans in the data. For example, some behavioral health PHPs may look more like CMC plans in the range of services covered but the state classifies the plan as a PHP because it contains a behavioral health component. The variety in the types of PHPs classified as ‘‘other’’ also makes it difficult to compare data across states.12
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states. However, this trend did not result in expanded use of CMC among adult duals. With over one-third of Medicaid-only disabled adults enrolled in CMC programs (CMC only or with PHP), states are clearly interested in using managed care to contain costs and improve service delivery for adults with disabilities. However, until recently federal Medicare rules have given states little incentive, and in some cases prohibited them, from enrolling adult duals into comprehensive managed care plans. To encourage greater integration of care for duals, new federal initiatives aim to reduce barriers that have made it difficult for states to enroll duals into comprehensive managed care. As more dual enrollees are enrolled in managed care plans, it will be important to monitor the types of managed care programs in which adult duals are enrolled and evaluate the degree to which they can integrate care and reduce costs. Acknowledgments The authors would like to thank Cara Petroski of the Centers for Medicare & Medicaid Services (CMS) for her support. At Mathematica, we also thank Julie Sykes for her guidance and encouragement. In addition, we thank Debra Lipson, Jim Verdier, and Catherine Desroches for providing helpful comments on drafts. References
Conclusion From 2005 to 2008, the number of states with managed care programs for adult duals increased, as did the percentage of duals enrolled in these programs within
d Using a linked dataset that became available more recently, Bubolz, et al. 2012, found that for dual beneficiaries under age 65, Medicare expenditures appeared to substitute for Medicaid expenditures. ‘‘States with lower rates of Medicaid spending experienced higher rates of Medicare expenditures, and vice versa.’’ While the study did not examine all the reasons for this finding, they cited a lack of evidence ‘‘that variations in the proportion of patients enrolled in managed care programs across states was systematically associated with per capita state-level Medicare or Medicaid expenditures.’’ Thomas B,, Emerson C, and Skinner J, Shifting From Medicaid To Medicare: State Spending On Dual Eligibles Under Age 65 Shows Variations, Evidence Of Cost, Health Aff (Millwood). 2012; 31(5):939e947. e As required by the Balanced Budget Act of 1997, states submit quarterly eligibility and claims program data to CMS through the Medicaid Statistical Information System (MSIS), which is used to construct MAX. States are more likely to submit capitated payment data for CMC enrollees than PHP enrollees. In 2008, 86.0% of states with CMC enrollees submitted capitation data for more than 90 percent of their CMC enrollees, while 11.6% of states submitted no capitation data. Among states with PHP enrollees, 64.7% of states submitted capitation data for more than 90 percent of their PHP enrollees, while 17.6% of states submitted no capitation data. Borck R, Dodd A, Zlatinov A, Verghese S, Malsberger R, Petroski C. The Medicaid Analytic eXtract 2008 Chartbook. Baltimore, MD: Centers for Medicare & Medicaid Services; 2012. 14.
1. Gifford K, Smith V, Snipes D, Paradise J. A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2011 Sep. 2. Verdier J. Including Medicare-Medicaid dual eligibles in managed care: current status and future prospects. In: Paper presented at World Congress 6th Annual Leadership Summit on Medicare, 2010 Jul 20, Washington, DC. 3. Kasper J, Watts M, Lyons B. Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications and Patterns of Medicaid and Medicare Service Use and Spending. Washington, DC: Kaiser Family Foundation; 2010 Jul. 4. Highsmith N, Somers S. Adults with Disabilities in Medi-Cal Managed Care: Lessons from Other States. Oakland, CA: Medi-Cal Policy Institute; 2003 Sep. 5. Bindman A, Chattopadhyay A, Osmond D, Huen W, Bacchetti P. Preventing Unnecessary Hospitalizations in Medi-Cal: Comparing Feefor-Service with Managed Care. San Francisco, CA: California Healthcare Foundation; 2004 Feb. 6. Coughlin TA, Long SK, Graves JA. Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study. Inquiry. 2008e2009 Winter;45(4):395e407. 7. Palsbo SE, Ho PS. Consumer evaluation of a disability care coordination organization. J Health Care Poor Underserved. 2007 Nov;18(4): 887e901. 8. Hill SC, Wooldridge J. Informed participation in TennCare by people with disabilities. J Health Care Poor Underserved. 2006 Nov;17(4): 851e875. 9. Grabowski C. Medicare and Medicaid: conflicting incentives for longterm care. Milbank Q. 2007;85(4):579e610. 10. CMS Medicare-Medicaid Coordination Office. Access to Medicare Data to Coordinate Care for Dual Eligible Beneficiaries. Baltimore,
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MD: Center for Medicaid, CHIP and Survey & Certification Informational Bulletin; 2011 May 11. 11. Dodd A, Nysenbaum J, Zlatinov A. Assessing the Usability of the MAX 2007 Inpatient and Prescription Encounter Data for Enrollees in Comprehensive Managed Care. CMS Medicaid Policy Brief 5. Washington, DC: Mathematica Policy Research; 2012 Apr. Service use for CMC and PHPs is captured in encounter data, which are claims records that contain utilization but no Medicaid expenditure
information. While states have not submitted encounter data as consistently as FFS data, an initial review of this data showed that for many states it appears to be usable. 12. Refer to the MAX anomaly tables for a description of other PHPs in each state. The tables are available from the CMS Medicaid Analytic eXtract (MAX) General Information site at https://www.cms.gov/ Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/MAXGeneralInformation.html.