[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 34.204.176.125. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Views 2,210
Citations 0
Original Investigation
March 10, 2020

Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017

Author Affiliations
  • 1Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
  • 2Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
  • 3Department of Health Policy and Management, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
  • 4Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
  • 5Center for Health Economics and Policy, Institute for Public Health and Cardiovascular Division, School of Medicine, Washington University in St Louis, St Louis, Missouri
JAMA. 2020;323(10):961-969. doi:10.1001/jama.2020.1021
Key Points

Question  Did mortality or hospitalization rates differ between beneficiaries dually enrolled in Medicare and Medicaid compared with nondually enrolled (Medicare only) beneficiaries aged 65 years or older from 2004 to 2017, and did these differences decrease over time?

Findings  In this serial cross-sectional study that included 71 017 608 Medicare fee-for-service beneficiaries, dually enrolled beneficiaries compared with nondually enrolled beneficiaries had higher all-cause mortality (odds ratio, 2.22), all-cause hospitalizations (41 121 vs 22 601 per 100 000 beneficiary-years), and hospitalization-related 30-day mortality (odds ratio, 1.15) in 2017. Between 2004 and 2017, these differences did not decrease.

Meaning  Between 2004 and 2017, there were persistent differences in mortality and hospitalizations between dually enrolled beneficiaries and nondually enrolled beneficiaries.

Abstract

Importance  Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries).

Objective  To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries.

Design, Setting, and Participants  Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018.

Exposures  Dual vs nondual enrollment status.

Main Outcomes and Measures  Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates.

Results  There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period.

Conclusions and Relevance  Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.

×