Integrating Medicare and Medicaid coverage in managed care: effects on quality, utilization, and disparities

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PROJECT SUMMARY / ABSTRACT Policymakers are pursuing strategies to integrate coverage for dual-eligibles—individuals with Medicare and Medicaid—to better coordinate care across these programs. Dual-Eligible Special Needs Plans (D-SNPs)— Medicare Advantage plans that exclusively serve duals—have emerged as the largest category of plans intended to serve as a platform for integration. However, D-SNPs vary in their level of integration with Medicaid. While many D-SNPs meet only a minimum level of integration (primarily related to care coordination), a growing number of plans have attained greater integration by covering Medicare and Medicaid spending for the same patients. CMS continues to refine integration standards for D-SNPs and policymakers have called for designing these standards to improve the quality, efficiency, and equity of care for duals—a priority given this population’s medical and social vulnerability. Yet little evidence exists about the extent to which differences among D-SNPs, including plan attributes and state policies affecting integration, are linked to quality, care patterns that drive spending, or disparities. Further, there is no evidence about how policy levers to expand enrollment in integrated D-SNPs affect care. One such lever is default enrollment—a mechanism that allows certain Medicaid managed care plans to automatically enroll Medicaid beneficiaries into integrated D-SNPs when they become dual eligibles (e.g., at age 65). Although only some D-SNPs are permitted to use default enrollment, there is interest in expanding this mechanism. To inform policy, this project will provide new evidence about variations in the performance of D-SNPs, including by factors affecting these plans’ level of Medicaid integration (Aim 1); assess plan performance and disparities in vulnerable subgroups of duals, including Black and Hispanic duals, duals with a disability, and those with behavioral health conditions (Aim 2); and investigate the effects of using default enrollment to integrate coverage, leveraging variation between plans permitted to use this mechanism and a quasi-experimental difference-in-differences design (Aim 3). To measure key aspects of plan performance relevant to integration, we will use Medicaid T-MSIS data, Medicare Advantage encounter data, and nursing facility assessment data linked at the beneficiary level (Aims 1-3) and CAHPS patient experience surveys (Aims 1-2). Continuous updating of these data allows us to monitor changes in performance as CMS phases in new D-SNP integration standards, enabling us to evaluate and inform evolving policy. This project is directly related to AHRQ priorities and priority populations through its focus on how the design of D-SNPs—an emerging managed care model for complex patients—affects quality, efficiency, and equity of care. To maximize this project’s impact, we will work with a Policy Advisory Committee of experts in integration policy from the government, research, and insurance sectors, building on the team’s track record of translating health services research to inform policy.