Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts.
Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts.
JAMA. 2020 Mar 10;323(10):961-969. doi: 10.1001/jama.2020.1021.
Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries).
To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries.
DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018.
Dual vs nondual enrollment status.
Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates.
There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period.
Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.
同时参加医疗保险（双重参保受益人的 Medicare 受保人）和医疗补助计划的 Medicare 受保人引起了政策制定者的关注，因为他们构成了 Medicare 人群中最贫困的一部分;然而，目前尚不清楚与仅参加 Medicare（非双重参保受益人的 Medicare 受保人）的受保人相比，他们的预后在过去几年中是如何变化的。
评估双重参保受益人和非双重参保受益人在全因死亡率、住院率和与住院相关的死亡率方面的年度变化。
设计、地点和参与者：2004 年 1 月至 2017 年 12 月期间 Medicare 按服务收费计划中年龄在 65 岁或以上的 Medicare 受益人的一系列横断面研究。最后随访日期为 2018 年 9 月 30 日。
双重与非双重参保状况。
全因死亡率年度比率;全因住院率;以及住院、30 天、1 年与住院相关的死亡率。
2004 年至 2017 年期间，有 71017608 名年龄在 65 岁或以上的 Medicare 受益人为 Medicare 至少有 1 个月的服务（平均年龄为 75.6[SD，9.2]岁；54.9%为女性）。其中，11697900（16.5%）的受益人至少有 1 个月同时参加了 Medicare 和医疗补助计划。在调整年龄、性别和种族后，2004 年至 2017 年期间，双重参保受益人的全因死亡率从 8.5%（95%CI，8.45%-8.56%）降至 8.1%（95%CI，8.05%-8.13%），而非双重参保受益人的全因死亡率从 4.1%（95%CI，4.08%-4.13%）降至 3.8%（95%CI，3.76%-3.79%）。2004 年（调整后的优势比，2.09[95%CI，2.08-2.10]）和 2017 年（调整后的优势比，2.22[95%CI，2.21-2.23]）之间，双重和非双重参保受益人的全因死亡率差异均有所增加（P<0.001，双重参保状况与时间的交互作用）。2004 年至 2017 年期间，双重参保受益人的每 100000 名受益人的全因住院人数从 49888 降至 41121（P<0.001），而非双重参保受益人的全因住院人数从 29000 降至 22601（P<0.001）；然而，2004 年（调整后的风险比，1.72[95%CI，1.71-1.73]）和 2017 年（调整后的风险比，1.83[95%CI，1.82-1.83]）之间，这两组之间的差异有所扩大（P<0.001，双重参保状况与时间的交互作用）。在住院受益人中，30 天的风险调整死亡率从 2004 年的 10.3%（95%CI，10.22%-10.33%）降至 2017 年的 10.1%（95%CI，10.02%-10.20%），而非双重参保受益人的死亡率从 2004 年的 8.5%（95%CI，8.50%-8.56%）降至 2017 年的 8.1%（95%CI，8.06%-8.13%）。相比之下，2004 年至 2017 年期间，住院受益人的 1 年死亡率从 23.1%（95%CI，23.05%-23.20%）上升至 26.7%（95%CI，26.58%-26.84%），而非双重参保受益人的死亡率从 18.1%（95%CI，18.11%-18.17%）上升至 20.3%（95%CI，20.21%-20.31%）。2004 年至 2017 年期间，住院相关结局的双重和非双重参保受益人的差异持续存在。
在 65 岁或以上的 Medicare 按服务收费计划的受益人中，双重参保受益人的全因死亡率、全因住院率和与住院相关的死亡率均高于非双重参保受益人的 Medicare 受保人。2004 年至 2017 年期间，这些差异并未缩小。
