Health outcomes of dually eligible beneficiaries under different Medicare payment arrangements

Dually eligible beneficiaries (hereafter, Duals) qualify for Medicare and Medicaid due to low income and/or disability. Duals comprise 19% of Medicare beneficiaries but consume 35% of Medicare spending. Identifying high-quality, efficient care arrangements may improve outcomes and reduce costs for Duals. This study evaluated the effect of different payment arrangements on Duals' quality and efficiency outcomes.

Retrospective, cross-sectional analysis using CMS data and health plan contract information from 17 participating physician groups (n = 15,488 primary care physicians).

We identified Duals within the same physician groups treated under at-risk Medicare Advantage (MA), traditional Medicare (TM), and fee-for-service (FSS) MA payment arrangements. We then compared the 3 cohorts across 20 health outcome metrics for the 2016-2019 period.

The sample comprised 1,980,691 person-years (at-risk MA, 15.4%; TM, 48.3%; and FFS MA, 36.4%). Duals in at-risk MA had better outcomes in 17 of 20 measures compared with TM, with avoidable hospital and emergency department (ED) measures showing 9.0% to 32.7% higher quality and efficiency. Compared with FFS MA, at-risk MA had better outcomes in 18 of 20 measures, with avoidable hospital and ED measures showing 7.7% to 15.3% higher quality and efficiency. FFS MA had better outcomes than TM for 17 of 20 measures; 1 measure favored TM.

At-risk MA was associated with higher quality and lower health resource utilization for Duals compared with TM and FFS MA. The CMS goal of accountable care arrangements should include at-risk MA for Duals due to these beneficiaries' increasing health care utilization and costs.