Objective. To gain a better understanding of the factors associated with Medicaid enrollment among Medicare beneficiaries as well as the factors associated with nursing home entry, a significant predictor of dual eligibility for Medicare and Medicaid coverage.
Key Outcomes. We estimate the probability of transitioning to dual eligibility for Medicare and Medicaid coverage among Medicare-only beneficiaries, as well as the probability of entry to nursing home care not financed by the Medicare skilled nursing facility (SNF) benefit.
Data. We used the 2009 Medicare Master Beneficiary Summary File (MBSF) to identify all fee-for-service Medicare-Medicaid enrollees (MMEs) age 22 and older. For comparison purposes, we also used the Medicare 5 percent sample to develop a group of Medicare-only beneficiaries who did not transition to MME status during 2009. Data on prior service utilization and chronic conditions were obtained by linking these data to 2008 and 2009 Medicare inpatient, outpatient, and hospice claims files, 2008 and 2009 Chronic Conditions Warehouse Timeline files, the 2009 MBSF Chronic Conditions segment, and the 2008 MBSF Cost and Utilization segment.
Methodology. Factors predicting transition to MME status and non-SNF nursing home entry--a frequent precursor of MME entry--were identified by estimating separate multivariate logistic regression models, by age group--beneficiaries under age 65 and those 65 and older.
Results. Emergency room (ER) visits, inpatient stays, and nursing home utilization are all positively predictive of transition to MME status. Residence in a nursing home increases the likelihood of transition to MME status in the next month by 2-14 times, depending on the age group and whether the care is covered by the Medicare SNF benefit. Among beneficiaries admitted to inpatient care from the ER who also had both SNF and non-SNF nursing home care during the prior six months, approximately 27 per thousand beneficiaries under age 65 are expected to transition to MME in the next month; the corresponding figure for beneficiaries age 65 and older is 11 per thousand. Residence in a SNF increased the likelihood someone would enter non-SNF nursing home care by 10-30 times depending on the age group. Beneficiaries with a dementia-related condition were also more likely to enter non-SNF nursing home care relative to those without this type of chronic condition.
Conclusions/Implications. Because ER visits leading to inpatient stays and nursing home stays are significant factors for the transition from Medicare-only to MME status, care coordination programs and other similar initiatives that avoid or interrupt this chain of events would likely reduce MME entry transitions. Beneficiaries with dementia-related conditions are particularly vulnerable to entering long-term institutional care, so initiatives that avoid or interrupt this chain of events for such individuals might have an especially large effect on MME transitions.