Long-term care integration for dually eligible individuals with Alzheimer's disease and related dementias

Project Summary: A lack of coordination between Medicare and Medicaid services creates a fragmented care system for dually eligible beneficiaries and can increase their risk for poor health outcomes. Dually eligible individuals with Alzheimer's disease and related dementias (ADRD) are exceptionally vulnerable under this fragmented care system. They often need extensive acute care (paid by Medicare) and long-term care (paid by Medicaid) but experience functional and cognitive declines, which compound the challenges of navigating the complex, bifurcated systems of Medicare and Medicaid. Integrating Medicaid-paid long-term care into Medicare services (termed “long-term care integration” hereafter) can improve care coordination for dually eligible individuals with ADRD. Under long-term care integration, people receive Medicaid-paid long-term care and Medicare services from the same insurance company. In this case, the single company bears financial risk for both Medicare services and Medicaid long- term care and is therefore incentivized to coordinate Medicare services and Medicaid long-term care. A common mechanism for long-term care integration is the dual-eligible special needs plan (D-SNP). Long-term care integration occurs through D-SNPs in two ways. First, some D-SNPs bear financial risk for both Medicare services and Medicaid long-term care (which we refer to as “single-capitated D-SNPs”). Second, people can receive Medicare services from a D-SNP and long-term care from a separate managed care plan, both of which are operated by the same parent insurance company (which we refer to as “aligned D-SNP”). D-SNPs is a significant force in long-term care integration, with substantial increases in enrollments in single-capitated or aligned D-SNPs over the past decade. Recognizing their importance, Congress permanently authorized and refined the utilization of the D-SNP for long-term care integration in 2018. However, this rapid adoption of the D-SNP for long-term care integration lacks rigorous empirical evidence. Our long-term goal is to provide a rigorous empirical evaluation of single-capitated and aligned D- SNPs, ultimately supporting evidence-based policies that can improve outcomes for dually eligible individuals with ADRD. Leveraging 2018-2024 Medicare claims linked with Medicaid claims, this proposal will adopt a staggered difference-in-differences approach to obtain the causal effects of single-capitated and aligned D- SNPs on key outcomes. We will accomplish three aims. First, we assess the effect of single-capitated D-SNPs. Second, we assess the effect of aligned D-SNPs and compare the effect of aligned vs single-capitated D- SNPs. Third, we assess the effect of aligned D-SNPs by plan characteristics. As an increasing number of dually eligible individuals continue to enroll in single-capitated or aligned D- SNPs, our study will provide urgently needed information about the effects of single-capitated and aligned D- SNPs for dually eligible individuals with ADRD.