Quality, Spending, Utilization, and Outcomes Among Dual-Eligible Medicare-Medicaid Beneficiaries in Integrated Care Programs: A Systematic Review

Abstract

Importance: Most dual-eligible Medicare-Medicaid beneficiaries are enrolled in bifurcated insurance programs that pay for different components of care. Therefore, policymakers are prioritizing expansion of integrated care plans (ICPs) that manage both Medicare and Medicaid benefits and spending.

Objective: To review evidence of the association between ICPs and health care spending, quality, utilization, and patient outcomes among dual-eligible beneficiaries.

Evidence review: A search was conducted of PubMed/MEDLINE (January 1, 2010, through November 1, 2023) and Google Scholar (January 1, 2010, through October 1, 2023) and augmented with reports from US federal and state government websites. Three categories of ICPs were evaluated: Programs of All-Inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) and related models aligning Medicare and Medicaid coverage. The review included studies that evaluated beneficiaries dually eligible for and enrolled in full Medicaid; compared an ICP to a nonintegrated arrangement; and evaluated utilization, spending, care coordination, patient experience, or health for 100 or more beneficiaries.

Findings: In all, 26 ICP evaluations met the inclusion criteria and were included in the analysis: 5 of PACE, 13 of MMPs, and 8 of FIDE-SNPs and other aligned models. Evidence generally showed associated reductions in long-term nursing home stays in PACE (3 of 4 studies) and FIDE-SNPs and related aligned models (3 of 5 studies) but was mixed in evaluations of MMPs. Four of 9 studies of MMPs and 2 of 3 studies of FIDE-SNPs found higher outpatient use, although other studies showed no difference. Evidence on Medicaid spending was limited, whereas 8 of 10 studies of MMPs showed an association between these plans and higher Medicare spending. Evidence was mixed or inconclusive regarding care coordination and hospitalizations, and it was insufficient to evaluate patient satisfaction, health, and outcomes in beneficiary subgroups (eg, those with serious mental illness). Furthermore, studies had limited ability to control for bias from unmeasured differences between enrollees of ICPs compared with nonintegrated models.

Conclusions and relevance: This systematic review found variability and gaps in evidence regarding ICPs and spending, quality, utilization, and outcomes. Studies found some ICPs were associated with reductions in long-term nursing home admissions, and several identified increases in outpatient care. However, MMPs were primarily associated with higher Medicare spending. Evidence for other outcomes was limited or inconclusive. Research addressing these evidence gaps is needed to guide ongoing efforts to integrate coverage and care for dual-eligible beneficiaries.

Figure.. Study Inclusion PRISMA Flow Diagram

^aIn all, 25 unique studies were included in this review: 24 that evaluated assessed a single type of ICP and 1 that assessed both PACE and FIDE-SNPs. For our review, we counted the latter study twice (1 set of findings for each program), producing 26 evaluations: 5 of PACE programs, 13 of MMPs, and 8 of FIDE-SNPs and similar managed care models. For 3 of the MMP evaluations, updated reports were published in December 2023, after our initial screening and data extraction was concluded. We incorporated updated findings from these latest evaluations to reflect the most recent set of reported results. ASPE indicates the US Office of the Assistant Secretary for Planning and Evaluation; CMS, the US Centers for Medicare & Medicaid Services; FAI, Financial Alignment Initiative; FIDE-SNPs, Fully Integrated Dual Eligible Special Needs Plans; ICP, integrated care plan; MMPs, Medicare-Medicaid Plans; and PACE, Programs of All-Inclusive Care for the Elderly.