DUAL ELIGIBLES IN MASSACHUSETTS:

1. DUAL ELIGIBLES IN MASSACHUSETTS: A PROFILE OF HEALTH CARE SERVICES AND SPENDING FOR NON-ELDERLY ADULTS ENROLLED IN BOTH MEDICARE AND MEDICAID ELLEN BRESLIN DAVIDSON AND TONY DREYFUS, BD GROUP

2. TODAY’S PRESENTATION • DUAL ELIGIBLE POPULATION IN MASSACHUSETTS IN 2008 • PRESENTATION FORMAT • EXPLAIN KEY POINTS ABOUT THE DATA • COVER MAJOR TAKEAWAYS • PRESENT SLIDES, WITH TIME FOR REVIEW & QUESTIONS

3. KEY POINTS ABOUT THE DATA • MEDICAID AND MEDICARE COMBINED DATA SET • EOHHS AND MMPI OBTAINED DATA VIA DATA USE AGREEMENT • JEN ASSOCIATES CONSTRUCTED THE DATA SET • MERCER PROVIDED DATA BASES • BD GROUP ANALYZED THE DATA • DATA SET INCLUDES • CALENDAR YEAR 2008, ONLY ONE YEAR OF DATA • DUALS AGES 21-64 YEARS OF AGE • CONTAINS ONLY DUALS WHO ARE NOT IN MANAGED CARE • EXCLUDES PACE AND MEDICARE ADVANTAGE ENROLLEES (n=10,000) • CONTAINS PAID FEE-FOR-SERVICE CLAIMS • EXCLUDES MEDICARE DEDUCTIBLES AND COPAYMENTS

4. EXECUTIVE SUMMARY • DIVERSE POPULATION • BEHAVIORAL HEALTH, PHYSICAL DIAGNOSES, AND DEVELOPMENTAL DISABILITIES • ONLY 3 PERCENT RESIDED IN INSTITUTIONS • 97 PERCENT OF DUALS LIVED IN THE COMMUNITY • 19 PERCENT USED HIGH LEVEL OF LONG-TERM SUPPORT SERVICES • HIGH INPATIENT USE • SMALL PROPORTION (6 PERCENT) HAD ANNUAL PER CAPITA COSTS OVER $100,000 • BEHAVIORAL HEALTH DIAGNOSES • 65 PERCENT HAD A BEHAVIORAL HEALTH DIAGNOSIS • HALF WITH DEPRESSION OR MODERATE MENTAL ILLNESS • SUBGROUPS WITH MORE COMPLEX BEHAVIORAL HEALTH NEEDS

5. TOGETHER MEDICAID AND MEDICARE SPENT $2.5 BILLION FOR DUALS IN 2008 COMBINED MEDICAID AND MEDICARE SPENDING FOR DUALS, 2008 $2.5 Billion / 105,000 Duals = $23,700 average annual per capita MEDICARE SPENDING $1.2 BILLION ($11,500 PER PERSON) 49% 51% MEDICAID SPENDING $1.3 BILLION ($12,200 PER PERSON)

6. MORE THAN THREE OUT OF FIVE DUALS WERE AGES 45–64 NUMBER AND PERCENT OF DUALS 21–64 BY AGE, 2008 33% 30% 22% 15% 21–34 35–44 45–54 55–64 AGE

7. A SMALL PROPORTION OF DUALS ACCOUNTED FOR A LARGE PROPORTION OF TOTAL SPENDING PROPORTIONS OF DUALS AGES 21–64 AND EXPENDITURES, 2008 $0 – $20K $20 – $50K $50 – $100K > $100K RANGE OF ANNUAL PER CAPITA SPENDING LEVELS SHARE OF ENROLLEES SHARE OF SPENDING

8. NEARLY NINE OUT OF TEN HEALTH CARE DOLLARS WERE SPENT ON DUALS LIVING IN THE COMMUNITY SHARE OF ENROLLEES AND EXPENDITURES FOR DUALS IN THE COMMUNITY AND IN INSTITUTIONS, 2008 DUALS RECEIVING NO OR LOW LEVEL OF SUPPORT SERVICES IN THE COMMUNITY DUALS RECEIVING HIGH LEVEL OF SUPPORT SERVICES IN THE COMMUNITY ALL DUALS RESIDING IN THE COMMUNITY DUALS RESIDING IN INSTITUTIONS SHARE OF ENROLLEES SHARE OF SPENDING

9. PER CAPITA SPENDING FOR DUALS RESIDING IN INSTITUTIONS WAS ALMOST DOUBLE THAT FOR DUALS RECEIVING A HIGH LEVEL OF SUPPORT SERVICES IN THE COMMUNITY AVERAGE ANNUAL PER CAPITA COMBINED MEDICAID AND MEDICARE SPENDING FOR DUALS IN THE COMMUNITY AND IN INSTITUTIONS, 2008 DUALS RECEIVING NO OR LOW LEVEL OF SUPPORT SERVICES IN THE COMMUNITY DUALS RECEIVING HIGH LEVEL OF SUPPORT SERVICES IN THE COMMUNITY ALL DUALS IN THE COMMUNITY ALL DUALS DUALS RESIDING IN INSTITUTIONS AVERAGE ANNUAL PER CAPITA SPENDING NUMBER OF ENROLLEES

10. NEARLY FOUR OUT OF FIVE DUALS HAD A PHYSICAL ILLNESS OR DISABILITY AND TWO OUT OF THREE HAD A BEHAVIORAL DIAGNOSIS PERCENTAGES OF DUAL ELIGIBLES WITH DIAGNOSES IN THREE MAJOR DIAGNOSTIC CATEGORIES, 2008 PHYSICAL ILLNESSOR DISABILITY (n=82,400) BEHAVIORAL DIAGNOSIS (n=67,600) DEVELOPMENTAL DISABILITY (n=14,300)

11. WHAT HAVE WE LEARNED SO FAR • POPULATION • 60 PERCENT 45-64 YEARS OF AGE • ONLY 3 PERCENT RESIDED IN INSTITUTIONS • 19 PERCENT USED HIGH LEVEL OF LONG-TERM SUPPORT SERVICES • 65 PERCENT HAD A BH DIAGNOSIS • SPENDING • $2.5 BILLION IN COMBINED MEDICAID AND MEDICARE SPENDING • SMALL PROPORTION (6 PERCENT) HAD ANNUAL PER CAPITA COSTS OVER $100,000 • 90 PERCENT OF SPENDING WAS FOR DUALS LIVING IN THE COMMUNITY

12. DUALS WITH DIAGNOSES IN TWO OR MORE MAJOR DIAGNOSTIC AREAS ACCOUNTED FOR MORE THAN 80 PERCENT OF SPENDING PROPORTIONS OF DUAL ELIGIBLES WHO HAD DIAGNOSES RECORDED IN ZERO, ONE, TWO, OR THREE MAJOR DIAGNOSTIC CATEGORIES AND THEIR SPENDING, 2008 ZERO ONE TWO THREE SHARE OF ENROLLEES SHARE OF SPENDING

13. DEPRESSION WAS THE MOST COMMON BEHAVIORAL DIAGNOSIS; HIGHEST PER CAPITA SPENDING WAS FOR THOSE WITH SERIOUS MENTAL ILLNESS NUMBER OF DUALS AND AVERAGE ANNUAL EXPENDITURES FOR THOSE WITH SELECTED BEHAVIORAL DIAGNOSES, 2008 DEPRESSION SCHIZOPHRENIA ALCOHOL OR SUBSTANCE ABUSE OTHER SERIOUS MENTAL ILLNESS NUMBER OF DUALS AVERAGE ANNUAL PER CAPITA SPENDING

14. DUALS WITH DEVELOPMENTAL DISABILITY ANDDIAGNOSES FROM OTHER MAJOR CATEGORIESHAD HIGH AVERAGE HEALTH CARE EXPENDITURES AVERAGE ANNUAL PER CAPITA SPENDING FOR DUALS WITH DEVELOPMENTAL DISABILITY AND DIAGNOSES FROM OTHER MAJOR DIAGNOSTIC CATEGORIES, 2008 DEVELOPMENTAL ONLY (n=1,550) DEVELOPMENTAL AND BEHAVIORAL (n=1,340) DEVELOPMENTAL AND PHYSICAL (n=4,200) DEVELOPMENTAL, BEHAVIORAL AND PHYSICAL (n=7,200) NOTE: 14 PERCENT OF DUALS HAVE A DEVELOPMENTAL DISABILITY

15. ANNUAL HEALTH CARE SPENDING FOR DUALS WITH COMMON DIAGNOSES AVERAGE ANNUAL PER CAPITA SPENDING FOR DUALS WITH COMMON DIAGNOSES, 2008 CATEGORIES CANNOT BE SUMMED. THESE ARE NOT MUTUALLY EXCLUSIVE CATEGORIES. DIABETES (n=23,200) CHRONIC OBSTRUCTIVE PULMONARY DISEASE (n=24,700) CORONARY HEART DISEASE (n=15,000)

16. WHAT HAVE WE LEARNED SO FAR • DUALS WITH MULTIPLE DIAGNOSES ACCOUNTED FOR 80 PERCENT OF THE SPENDING • PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS, WITH DEPRESSION BEING THE MOST COMMON • DUALS WITH A DEVELOPMENTAL DISABILITY AND OTHER CONDITIONS HAD HIGH COSTS • SOME OF THE MOST COMMON DIAGNOSES INCLUDE DIABETES, COPD, CHD

17. 35 PERCENT OF COMBINED HEALTH CARE SPENDINGWAS FOR LONG-TERM SUPPORT SERVICES AND 22 PERCENT FOR INPATIENT SERVICES DISTRIBUTION OF COMBINED MEDICAID AND MEDICARE SPENDING FOR DUAL ELIGIBLES BY SERVICE CATEGORIES, 2008 Pharmacy All Other, including lab, radiology, DME Outpatient 13% 8% 8% Physicians/Practitioners 14% 35% Long-term Support Services 22% Inpatient

18. DISTRIBUTION OF LONG-TERM SUPPORT SERVICES (LTSS) SPENDING ON DUALS TOTAL COMBINED MEDICAID AND MEDICARE SPENDING ON LTSS FOR DUALS, 2008 Institutional Services $280M HCBS Waiver Services$390M 33% 45% 22% Non-Institutional (Non-Waiver) Services $190M

19. EIGHTEEN PERCENT OF DUALS SPENT AT LEAST ONE NIGHT IN THE HOSPITAL; FOUR PERCENT WERE HOSPITALIZED FOR MORE THAN FIFTEEN DAYS PROPORTION OF DUALS AND THEIR USE OF INPATIENT CARE, 2008 0 1–15 16–30 >30 HOSPITAL DAYS

20. THIRTY-EIGHT PERCENT OF DUALS RECEIVED MORE THAN FIVE PRESCRIPTIONS PER MONTH PROPORTIONS OF DUAL ELIGIBLES WITH AVERAGE NUMBER OF PRESCRIPTIONS PER MONTH, 2008 None <1 1–2 >2–5 >5–10 >10–15 >15 AVERAGE NUMBER OF PRESCRIPTIONS PER MONTH

21. WHAT HAVE WE LEARNED • DIVERSE POPULATION • BEHAVIORAL HEALTH, PHYSICAL DIAGNOSES, DEVELOPMENTAL DISABILITIES • ONLY 3 PERCENT RESIDED IN INSTITUTIONS • HIGH LONG-TERM SUPPORT SERVICES USE, HIGH INPATIENT USE • 19 PERCENT USED A HIGH LEVEL OF LONG-TERM SUPPORT SERVICES • HIGH COSTS • SMALL PROPORTION (6 PERCENT) HAD ANNUAL PER CAPITA COSTS OVER $100,000 • MOST COMPLEX GROUP HAD 3 TIMES THE AVERAGE PER CAPITA COST • BEHAVIORAL HEALTH DIAGNOSES • 65 PERCENT HAD A BEHAVIORAL HEALTH DIAGNOSIS • HALF WITH DEPRESSION OR MODERATE MENTAL ILLNESS • SUBGROUPS WITH MORE COMPLEX BEHAVIORAL HEALTH NEEDS