DataBrief:

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DataBrief Series ● September 2010 ● No. 1

Characteristics of Dual Eligibles

33% of dual eligibles suffer from diabetes, stroke, dementia, and/or COPD – conditions that often require the use of personal care and supportive services?

• “Dual eligibles” are low-income individuals who qualify for both the Medicare program and the Medicaid program.

• Dual eligibles receive their health care services through the Medicare program while the Medicaid program pays for services and supports not covered by Medicare including long-term nursing home stays and physician and hospital co-pays.

• Dual eligibles are “over-represented” in the Medicare population with chronic conditions, meaning they are more likely than their Medicare-only counterparts to have a chronic condition.1

• Even when compared to Medicare beneficiaries with the same number of chronic conditions, dual eligibles spend more Medicare dollars per capita across various health care settings.

• A large portion of Medicaid dollars are also spent on dual eligibles.– Though representing only 18 percent of the Medicaid population, duals account for

46 percent of Medicaid spending.2

Characteristics of Dual Eligibles; Health Status

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1 Coughlin, Waidman, O’Malley Watts. “Where Does the Burden Lie? Medicaid and Medicare Spending for Dual Eligible Beneficiaries.” Kaiser Commission on Medicaid and the Uninsured. April 2009

2 Center for Health Care Strategies, Inc. citation of Urban Institute analysis, 2008

Disabling conditions more prevalent among dual eligibles than Medicare-only beneficiaries.

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About the data:

Analytics powered by Avalere Health LLC

A Clear Policy ConnectionDual eligibles are more likely to suffer from diabetes, stroke, dementia, and/or COPD than Medicare-only beneficiaries. These conditions often require intensive medical services and supports.

The high prevalence of these conditions among dual eligibles necessitates careful coordination between providers to ensure the delivery of high quality health care services. It demonstrates the importance of addressing the conflicting financial incentives between Medicare and Medicaid and the separate administrative rules of the two programs.

As a result of health reform, the Centers for Medicare and Medicaid Services (CMS) now possesses new authority to test creative approaches to program integration. CMS’ newly established Federal Coordinating Health Care Office and Center for Medicare and Medicaid Innovation have unprecedented opportunity to break down payment and care silos between the states and the federal government. The goal is to move toward providing dual eligibles with seamless access to benefits and care coordination under both the Medicare and Medicaid programs.

This analysis uses 2008 Medicare claims data to identify individuals with four specific diseases: Diabetes, Chronic Obstructive Pulmonary Disease, Dementia and related diseases, and Stroke/Transient Ischemic Attack. Dual eligibles were defined as being eligible for a state buy-in program sometime in 2008. Hospital and physician claims were analyzed for disease information. This analysis is limited to individuals enrolled in the fee-for service, or traditional, Medicare program.

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