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Dual Eligibles and Chronic Conditions

Explore the impact of dual eligibles on Medicare and Medicaid programs, the prevalence of chronic conditions, and the need for coordinated care for this vulnerable population.

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Dual Eligibles and Chronic Conditions

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  1. Dual Eligibles and Chronic Conditions DataBrief Series● September 2010● No. 2 28% of Medicare beneficiaries with 5 or more chronic conditions are dually eligible for Medicare and Medicaid?

  2. Dual Eligibles and Chronic Conditions • “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 more likely to have more chronic conditions, have a mental illness, and have functional impairments than Medicare-only beneficiaries.1 • 79 percent of Medicare spending is on beneficiaries with five or more chronic conditions.2 • Dual eligibles also consume a large portion of Medicaid dollars. • Dual eligibles are 18 percent of the Medicaid population but account for 46 percent of Medicaid spending.3 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. Anderson G. “Making the Case for Ongoing Care.” Robert Wood Johnson Foundation. February 2010. Center for Health Care Strategies, Inc. citation of Urban Institute analysis, 2008. DataBrief (2010) ● No. 2

  3. Dual eligibles comprise only 17% of the Medicare population but represent 28% of Medicare beneficiaries with 5 or more chronic conditions. Percent of Total Medicare Population (N=45 million) Percent of Medicare Population with 5 or More Chronic Conditions (N=585,740) DataBrief (2010) ● No. 2

  4. A substantial percent of dual eligibles have multiple chronic conditions, and they are more likely than Medicare-only beneficiaries to have multiple chronic conditions. With high care needs, it is important that Medicare and Medicaid programs work together better to coordinate care and ensure that care providers are accountable for good care outcomes for this vulnerable population.The recently passed health reform law addresses a lack of coordinated management of dual eligibles’ care needs through a newly created Federal Coordinated Health Care Office. • This analysis uses the 2008 Medicare claims data to determine the number of dual eligibles and Medicare-only beneficiaries who have chronic conditions. Dual eligibles were defined as being eligible for a state buy-in program sometime in 2008. Physician claims were used to identify a diagnosis of a common chronic condition; the list of 21 common chronic conditions came from the Medicare Chronic Condition Working file. This analysis is limited to individuals enrolled in the fee-for service, or traditional, Medicare program. DataBrief (2010) ● No. 2

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