This analysis identified nursing home use (SNF or other nursing home) as an important predictor of MME status, particularly among younger Medicare beneficiaries. Additionally, having both a Medicare-financed SNF stay and a non-SNF stay is an even stronger predictor of MME status. Chronic conditions, particularly related to Alzheimer's or dementia, were also strong predictors. SNF stays, Alzheimer's or dementia, and depression were strongly predictive of entry into nursing home care not covered by the Medicare SNF benefit, the type of care that predicts the transition to dual enrollment in Medicare and Medicaid.
Some limitations of this study should be noted in considering our results. First, our analysis was restricted to those not in managed care, and understanding how transition rates differ for those in managed care may be informative and policy relevant. Second, our results are informative of factors that predict MME status and nursing home entry, but do not necessarily cause these transitions. Third, while we analyze general service utilization, we do not look at specific diagnoses or procedures that may be informative of more targeted policy prescriptions.
We also did not address state characteristics in this paper. When estimating models where we included variables for specific state characteristics instead of state fixed effects, we found mixed and contradictory results. One possibility is that the indicators we included may reflect other characteristics that are not captured in the models, but with which they are correlated. Without variation over time, it is difficult to disentangle these effects. Thus, future work is needed to fully understand how characteristics of Medicaid programs and state LTC systems influence transitions to dual eligibility and nursing home care.
This analysis identified nursing home use and ER visits leading to an inpatient stay as significant predictors of the transition from Medicare-only eligibility to MME status. Moreover, these predictors were particularly strong among younger Medicare beneficiaries (under 65) compared to older (65 and above) beneficiaries. To the extent that nursing home admissions causally affect the transition to Medicaid coverage, then policies and programs that limit admissions to nursing home care or shorten nursing home stays may reduce the rate of transition to MME status among individuals at increased risk for becoming Medicaid eligible. For example, interventions that help people at risk for becoming dually eligible avoid undesirable events such as acute emergencies that lead to an inpatient admission and entry into nursing home care would likely reduce entry into dual eligibility. Such interventions might need to focus on minimizing preventable emergencies (such as those due falls and other types of injuries).
The results also indicate that dementia disorders and depression play important roles in predicting the transition to MME status and entry into nursing home care. Services and care coordination programs may need to be tailored to meet the needs of beneficiaries with these particular conditions. Beneficiaries and their loved ones frequently need assistance in learning how to cope with these conditions.
Many policymakers and other stakeholders advocating for an improved LTC system have focused on nursing home diversion and transition programs. To the extent that these programs reduce nursing home stays, they may also reduce the likelihood of becoming dually eligible. Whether such initiatives and other care innovations are effective at reducing entry into dual eligibility remains to be seen; being able to effectively identify people at risk for long-term nursing home stays appears to be a fruitful first step.