CMS: Dual Eligible Medicare Advantage Enrollees, Including in Nursing Homes, Received Worse Clinical Care 

Medicare Advantage enrollees, specifically those dually eligible for Medicare and Medicaid and a low-income subsidy, received worse clinical care than those who didn’t fall under these plans.

That’s according to a report released on Tuesday by the Medicare & Medicaid Services’ Office of Minority Health (CMS OMH).

More than one in ten, or 13%, of those jointly enrolled in Medicare and Medicaid, also known as dual enrollees, lived in a long-term care nursing home or other institutional facility, according to a recent KFF report.


And these patients were also likely to have an intellectual or developmental disability and more limitations on activities of daily living, the KFF report found.

The latest CMS OMH report showed that dual enrollees and those receiving a low-income subsidy were most vulnerable in certain areas of clinical care compared to those who a weren’t part of these programs.

The greatest care disparities were found in follow-up visits after a hospital stay for a mental illness as well as medication interactions for residents receiving dementia care and those who were prone to falls.


CMS OMH presented a summary of MA plan performance on specific measures of quality of health care for 2021, which corresponds to care received in 2020. The report was based on an analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data on the quality of care delivered to people with Medicare – specifically those enrolled in MA plans.

Thirty-six clinical care measures, including diabetes, cardiovascular disease and chronic lung disease, were incorporated into the HEDIS analysis.

Overall, dual eligibles and those with low-income subsidy had below-average scores on more than one-third of such measures. Meanwhile, only one or two measures were above average relative to all MA enrollees, according to the CMS OMH report.

Disparities were more commonly seen when screening patients for cancer, mental illness care, care coordination, and an overuse or appropriate use of medication, according to the report.

CMS OMH did mention that the data in the report was likely influenced by the pandemic, especially in long-term care settings.

“The COVID-19 pandemic had an unprecedented impact on the health care system, in terms of both the influx of patients to hospitals and the strain it put on health care workers. Nursing homes and other institutions that provide care for predominantly older patients were at a particularly high risk of outbreaks of COVID-19,” CMS OMH said in its executive summary.

Still, agency researchers said it was worth noting that large disparities – greater than 5% – were most common among MA enrollees with disabilities irrespective of dual eligible status or low-income subsidy coverage.

“Additional research is needed to better understand the mechanisms that drive the disparities reported here,” said CMS OMH researchers. “Such research would benefit from the use of a more nuanced measure of disability than the one used for this report (i.e., one that better captures the full conceptual definition of disability).”

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