Medicare-Medicaid Dual-Eligible Patients and Potentially Preventable Hospital Stays

For the 8 million Medicare beneficiaries who were also enrolled in their states’ Medicaid program in 2008, Medicaid pays for the Medicare premiums and other out-of-pocket expenses, including deductibles and coinsurance, as well as for Medicaid-only services such as long-term care. These dual eligibles, among the most sick and poor citizens in the United States, have complex healthcare needs, according to a brief from the Agency for Healthcare Research and Quality (AHRQ). Studies have shown that compared with other Medicare beneficiaries, dual eligibles are more likely to be in poor health, have multiple chronic physical conditions, and have >1 mental/cognitive condition. Eligibles, on average, incur nearly twice the level of total health expenditures compared with other Medicare beneficiaries, and account for almost half of all Medicaid spending and more than a quarter of Medicare spending. AHRQ’s Healthcare Cost and Utilization Project recently issued Statistical Brief #96, Potentially Preventable Hospitalizations among Medicare-Medicaid Dual Eligibles, 2008, to identify conditions that are commonly associated with potentially preventable hospitalizations to help guide development of strategies to improve care and patient outcomes while lowering costs. In 2008, dual eligibles accounted for approximately one third of all Medicare stays with a principal diagnosis of pressure ulcers (36.0%), asthma (31.9%), and diabetes (31.6%). Dual eligibles also accounted for 25.9% of hospitalizations with a principal diagnosis of urinary tract infection (UTI), 24.2% of those for chronic obstructive pulmonary disease (COPD), 24.0% for bacterial pneumonia, 20.1% for dehydration, 19.8% for congestive heart failure (CHF), and 13.3% for injurious falls. The stays by dual eligibles contributed 14% to 37% of total hospital costs for all Medicare stays for those conditions: 36.6% for pressure ulcers, 32.5% for asthma, 31.2% for diabetes, 27.6% for UTIs, 25.2% for bacterial pneumonia, 23.9% for COPD, 20.9% for dehydration, 20.8% for CHF, and 13.9% for injurious falls. The data in the brief were drawn from 27 states that collect multiple payer variables to allow identification of dual coverage by Medicare and Medicaid. Extrapolated to the national level, the total number of hospitalizations for all 9 conditions would be 727,906 for dual eligibles (9 hospital stays per 100 dual-eligible beneficiaries); the total hospital costs would be $6.37 billion. The highest rate of hospitalization among dual eligibles was with a diagnosis of bacterial pneumonia (2041 stays per 100,000 enrollees). CHF followed, with 1829 stays per 100,000 enrollees, and COPD at 1179 stays per 100,000 enrollees. For other Medicare beneficiaries, the highest rate was 1707 stays per 100,000 enrollees with a diagnosis of CHF, followed by bacterial pneumonia (1484 stays per 100,000 enrollees) and injurious falls (1109 stays per 100,000 enrollees). Of the 9 conditions, the highest average hospital cost per stay was for pressure ulcers, regardless of dual eligibility (~$15,000), followed by stays for injurious falls ($11,680 for dual eligibles and $11,300 for non–dual-eligibles). With the exception of stays for diabetes and stays for COPD, the average hospital cost per dual-eligible stay was higher compared with the average hospital cost per non–dual-eligible stay: CHF, $8670 versus $8140; COPD, $7490 versus $7620; diabetes, $9800 versus $10,000; asthma, $7210 versus $7000; bacterial pneumonia, $9720 versus $9150; UTI, $6740 versus $6180; injurious falls, $11,680 versus $11,130; dehydration, $5860 versus $5500; and pressure ulcers, $15,200 versus $14,790, respectively. Overall, 62.6% of dual-eligible patients were female, 59.6% were white, 24.1% were black, 10.3% were Hispanic, and 6.0% were other race/ethnicity. More than half (52.1%) of the stays for dual eligibles for diabetes were among patients 18 to 64 years of age, whereas 7.3% of stays among dual-eligible patients ≥85 years of age were for diabetes. Dual-eligible patients ≥85 years of age accounted for 33.3% of stays for injurious falls, 29.5% of stays for UTI, 25.7% of stays for bacterial pneumonia, and 25.0% of stays for dehydration.