Setting eligibility criteria for a care-coordination benefit

Area of Science:

• Gerontology
• Health Services Research
• Public Health Policy

Background:

• Medicare beneficiaries aged 65 and older represent a significant population with complex health needs.
• Care coordination programs aim to improve health outcomes and manage chronic conditions in older adults.
• Defining eligibility for care coordination is crucial for program effectiveness and resource allocation.

Purpose of the Study:

• To compare different clinically relevant eligibility criteria sets for Medicare care coordination.
• To determine the variations in the number and characteristics of individuals served by different criteria sets.
• To inform policy decisions regarding Medicare care coordination benefits.

Main Methods:

• Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS).
• Inclusion of community-dwelling adults aged 65 and older (n=10,640), representing ~33.6 million Medicare beneficiaries.
• Examination of three distinct criteria sets based on medical conditions, cognitive impairment, and ADL/IADL dependency.

Main Results:

• Eligibility for care coordination ranged from 1.3% to 5.8% of Medicare beneficiaries, depending on the criteria set.
• A specific Congressional proposal (≥4 severe conditions + 1 ADL/IADL dependency) would apply to 427,000 older adults.
• Criteria focusing on cognitive impairment would disproportionately serve an older demographic.

Conclusions:

• Multiple eligibility criteria sets for Medicare care coordination are clinically sound.
• The choice of eligibility criteria significantly influences the number and demographic profile of beneficiaries served.
• Careful consideration of criteria is necessary to align Medicare benefits with specific population needs.