The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries.

One of the most disadvantaged subgroups of older Americans is the population of persons who are covered by both Medicare and Medicaid health insurance, often referred to as the “dual eligible” population. A recent report reveals them to be significantly poorer, less educated, and to have lower levels of social support than their “Medicare only” counterparts (Congressional Budget Office, 2013). The social and economic disadvantage of dual eligibles relative to Medicare-only beneficiaries is mirrored in disparities in both physical and cognitive health status. Compared to older adults who are eligible for Medicare only, dual eligible persons have a higher prevalence of physical and cognitive impairments, including mental illness, are more likely to have multiple chronic conditions, and are more likely to have qualified for Medicare due to disability or kidney disease before the age of 65 (Congressional Budget Office, 2013; Meyer, 2012). Rates of potentially preventable hospitalization and rehospitalization are high in this population, suggesting problems of access to and quality of care (Jiang, Wier, Potter, & Burgess, 2010; Konetzka, Karon, & Potter, 2012; Walsh et al., 2012; Wysocki, Kane, Dowd, et al., 2014). Utilization of both institutional and community-based long-term services and supports (LTSS) is also high among dual eligibles. In 2009, more than half of dual eligible persons over the age of 65 used home and community-based services (HCBS), and one-quarter lived in an institution (Congressional Budget Office, 2013). Considerable research indicates that dual eligible beneficiaries are served in poorer quality nursing homes, both for short term and permanent placement (Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Rahman et al., 2014; Rahman, Grabowski, Gozalo, Thomas, & Mor, 2014), with higher rates of hospitalization (Carter & Porell, 2003) than is the case for nursing homes in which Medicare-only residents are predominant. Despite rapidly growing emphasis on the development of HCBS and recent policies to encourage discharge of nursing home residents who can manage in the community with HCBS (Reinhard, 2010; Watts, Reaves, & Musumeci, 2014), little is known about the adequacy of such care to meet the disability-related assistance needs of dual eligible persons given lower levels of family support and financial resources in comparison to persons covered by Medicare only (Congressional Budget Office, 2013). However, given the complex care needs of persons eligible for both Medicare and Medicaid, and in light of poor coordination between acute and long-term care systems, adequate assistance may be lacking for a substantial proportion of this population (Gold, Jacobson, & Garfield, 2012; Meyer, 2012). Prior research has demonstrated that unmet need for assistance among adults with disabilities can result in a range of adverse consequences that can compromise health status (Allen & Mor, 1997; Desai, Lentzner, & Weeks, 2001; LaPlante, Kaye, Kang, & Harrington, 2004). More recent research indicates an increased risk of preventable hospitalizations among dual eligibles receiving Medicaid HCBS than among comparable dual eligible nursing home residents (Wysocki, Kane, Golberstein, et al., 2014), and among dual eligibles following transition from the nursing home to the community, likely due to situations in which available HCBS are inadequate to meet these older persons’ assistance needs (Wysocki, Kane, Dowd, et al., 2014). The purpose of this article is to estimate and compare the prevalence of need for assistance and selected adverse consequences associated with unmet need for assistance among older adults who are dually eligible for Medicare and Medicaid with those who are eligible for Medicare only. Implications for current and emerging care models that integrate health care and LTSS are discussed. Conceptual Framework The Commission on the Social Determinants of Health (CSDH) clearly delineates the mechanisms by which low socioeconomic position in a given nation, indicated in the United States by one’s education, income, occupation, gender, and ethnicity, has implications for their living and working conditions, food adequacy, health behaviors, and psychosocial factors that lead to population differences in both exposure to, and vulnerability to, health compromising conditions. Unhealthy exposures and high vulnerability to illness and injury, in turn, lead to disparities in health, disabilities, and well-being (World Health Organization, 2010). We extend CSDH’s framework to incorporate the impact of the greater severity of illness and impairment experienced by disadvantaged social groups on the level of need for assistance required to perform everyday tasks. More severe impairment necessarily requires a higher level of need for assistance than lower levels of impairment (Figure 1). In the case of dual eligibles, a group that is characterized by a composite of factors indicating socioeconomic and health status disadvantage, with a resulting high burden of disease and impairment, levels of need for assistance are higher than are those experienced by the Medicare only population. Whether or not needs for assistance are adequately met is dependent on the availability of adequate family care and/or access to sufficient LTSS, a moderating effect. The challenge of adequately meeting the assistance needs of dual eligibles is compounded by the low levels of social support available to them, resulting in disparities in unmet need and their adverse consequences relative to the Medicare only population. It is this challenge that emerging models of care that integrate health care and LTSS are attempting to meet. Figure 1. Pathway to unmet need and its adverse consequences.