Three Essays on Managed Care and Dual Eligibles
Levinson, Zachary
2019
Abstract
Over the past several years, Medicare beneficiaries have increasingly chosen to receive their coverage through subsidized, private Medicare plans, rather than through the traditional, government-administered version of program. At the same time, some states have turned to private managed care plans to provide Medicaid benefits for the elderly and disabled. This dissertation explores the consequences of these trends for beneficiaries who receive coverage through both Medicare and Medicaid, also known as “dual eligibles.” In the first chapter, I identify factors associated with dual eligibles’ enrollment in private Medicare plans and explore potential explanations for the sustained growth in enrollment over time. To do so, I estimate linear regression models relating enrollment patterns with various supply-side, demand-side, and state policy factors, as well as an event-year study relating enrollment with the introduction of dual-eligible special needs plans (D-SNPs), which are exclusively available to dual eligibles. Results highlight the important role of D-SNP availability and the maturation of county D-SNP markets over time in pulling dual eligibles into the private Medicare market. Private Medicare enrollment among dual eligibles was also associated with improvements in plan offerings, decreases in supplemental plan options, increases in their premiums, and changes in state policy. In the second chapter, I evaluate the effect of enrollment in private Medicare Advantage (MA) plans on utilization and quality of care among dual eligibles. To do so, I exploit a discontinuous increase in government payments to plans—and subsequently in MA enrollment rates—in regions that exceeded a particular population threshold. I find that increases in MA enrollment reduced inpatient utilization among dual eligibles, while I fail to find evidence that this came at the expense of average care quality. However, I also find that MA enrollment was associated with a shift towards lower-quality hospitals and an increase in mortality rates in counties with historically-low traditional Medicare spending. These results advise caution as policymakers debate whether to further encourage enrollment in private plans among dual eligibles. In the third chapter, I evaluate the effect of requiring dual eligibles to enroll in Medicaid managed care on their use of inpatient and long-term nursing home care. To do so, I rely on a difference-in-differences approach to assess the introduction of an enrollment mandate in the state of New Jersey. I find that Medicaid managed care shaped dual eligibles’ utilization in meaningful ways, despite the fact that these plans play a secondary role to Medicare for many services. In particular, the enrollment mandate led to lower inpatient use among full dual eligibles, and I provide suggestive evidence that this change included reductions in potentially-preventable hospitalizations and in 30-day readmission rates. The mandate was also associated with a decrease in the share of full dual eligibles residing in nursing homes. This study highlights the important role of Medicaid managed care for dual eligibles and suggests that further aligning incentives between these plans and Medicare could have a meaningful effect on dual eligibles’ use of care.Subjects
Dual eligibles Medicare Advantage Health economics Health policy Health services research
Types
Thesis
Metadata
Show full item recordCollections
Remediation of Harmful Language
The University of Michigan Library aims to describe library materials in a way that respects the people and communities who create, use, and are represented in our collections. Report harmful or offensive language in catalog records, finding aids, or elsewhere in our collections anonymously through our metadata feedback form. More information at Remediation of Harmful Language.
Accessibility
If you are unable to use this file in its current format, please select the Contact Us link and we can modify it to make it more accessible to you.