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Higher Hospital Readmissions, Worse Outcomes for Dual Eligibles

By Jennifer Bresnick

- Patients who are eligible for both Medicare and Medicaid experience more hospital readmissions, less positive outcomes, and significantly lower Medicare Advantage Star Ratings, according to a new study from Inovalon.  The large-scale study, which examined claimed data from more than two million dual eligible patients, found that nearly 80 percent of disparities in patient risk and outcomes were rooted in socioeconomic and demographic factors such as access to community resources and ability to remain in contact with the healthcare system.  The Star Rating system does not accurately reflect the reality of the additional burdens low-income and dual-eligible patients are facing, the research asserts, and should be updated to provide more accurate metrics of patient care.

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“The study provides compelling evidence that quality measures in the Five-Star Rating System do not fully capture the complexity of the circumstances in which Medicare’s dual eligible population lives or the complexities involved in their health care,” said Richard Bringewatt, president and chair, Special Needs Plan (SNP) Alliance. “Performance measures must take this evidence into account for health plans to have an accurate quality rating system. Plans and providers that serve disadvantaged populations, such as MA Special Needs Plans, should also take this evidence into account as it sheds light on a range of sociodemographic factors that, if properly addressed, could help us develop and target more ways to improve health outcomes for our members.”

Dual eligible patients are consistently more complex to effectively manage, the study found, but the fault doesn’t lie entirely with health plans.  Dual beneficiaries exhibited worse outcomes and more hospital readmissions than non-dual eligible members enrolled in the same plans, regardless of the proportions of dual eligible to non-dual eligible patients participating in the package.  Instead, the increased prevalence of poor outcomes is due to generally more serious underlying risk factors which impact lower income patient populations more severely.

The idea that patients of lower socioeconomic status experience poorer health, more chronic diseases, more restricted access to resources, and lower levels of health literacy is not a new one.  Health disparities based on social factors, from where a patient lives to how well he speaks English to how often he can buy fresh food at the grocery store are well documented, with everything from surgical outcomes to diabetic amputation rates predicated on income, ethnicity, age, and education.

“We’ve suspected all along that the poorer health outcomes of dual eligible members are not caused by the quality of plans, but are due to other factors,” said Dr. Paige Reichert, medical senior director of quality, Cigna HealthSpring. “If the disparity of outcomes between dual eligible and non-dual eligible members were due to the quality of care provided by the plan, the results would have been similar between both groups. However, because the study controlled for similar member characteristics, we see that it’s sociodemographic factors that are affecting health outcomes. Clearly the issues that are affecting the health outcomes of disadvantaged beneficiaries need to be addressed to eliminate health disparities, and should also be taken into account when measuring the quality of Medicare managed care plans.”

READ MORE: Big Data Analytics Link Economic Wellness to Population Health

The study found that socioeconomic factors account for at least 70 percent of observed differences in outcomes between dual eligible and non-dual eligible patients.  For hospital readmissions, living in a poor neighborhood was the single most important factor that predicted the risk of returning to the inpatient setting.  Community affluence accounts for 18.1 percent of the hospital readmissions disparity.  Forty-one percent of dual eligible patients live in challenging economic areas compared to just fifteen percent of other members.  Renal disease and dementia were among the most common chronic diseases that lead to hospital readmissions.


Living in a designated physician shortage area also significantly contributed to all-cause hospital readmissions, contributing to 11 percent of the gap between dual eligible and non-dual eligible patients.  Other chronic diseases, such as COPD, congestive heart failure, schizophrenia, and liver disease, were also pinned to increased readmissions.  Dual eligible patients who were readmitted to the hospital were likely to suffer from one or more chronic disease, with COPD, congestive heart failure, renal disease, and cerebrovascular disease occurring with notably higher frequency in Medicare and Medicaid patients than in those only eligible for one program.

“If dual eligible and non-dual eligible members had similar characteristics, of if the measure was statistically adjusted to account for these factors, eighty-two percent of the observed disparity could be mitigated,” the study says. Medicare Advantage Star Ratings have been used as a basis to calculate quality-based bonuses for high performing health plans since 2012.  Hospital readmissions are given three times the weight of other factors in the calculation.

More than half of the gap between these patient groups could be closed by better chronic disease management for a handful of common conditions strongly associated with hospital readmissions, and by adjusting the Medicare Star Measures to reflect the stark differences in where patients begin their journey through the healthcare system and how hard providers must work to overcome the background challenges of treating dual-eligible patients.

Establishing different weighting for the metrics would provide a more accurate picture of quality and outcomes for some of the most difficult patients, the research concludes, while better evaluating the performance of health plans for low-income and at-risk groups.


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