‘Double-eligible’ patients may have worse outcomes, higher spending, even in the highest quality hospitals

They are old enough to qualify for Medicare and their income is low enough to qualify for Medicaid.

And when they have surgery to remove a cancerous tumor, a new study shows, they suffer more complications, stay in hospital longer and are less likely to be discharged home instead of a care facility. nurses than Medicare-only patients — even when they go to a hospital that typically has low complication rates for their surgery. And that ends up costing the healthcare system more.

The results suggest that hospitals should do more to assess and support the needs of these “dual-eligibility” patients before, during and after their operations, to improve equity and reduce avoidable costs. Previous research has shown that dual-eligibility patients account for a disproportionate share of federal healthcare spending, totaling $300 billion in 2018 alone.

The study, recently published in JAMA Surgery by a team from Michigan Medicine, the academic medical center of the University of Michigan, is looking at the fate of patients operated on for four types of cancer.

We found that while outcomes and spending are improved for dual-eligibility patients in the highest quality hospitals, inequities persist and quality improvement alone will not completely close this gap. Given that we know that dual eligibility is an indicator of social risk, interventions targeted to unmet social health needs are likely needed to improve outcomes in this population, such as screening and connection to resources for insecurity. food, housing instability and transportation.

Kathryn Taylor, MD, surgeon and health care researcher

Taylor is a National Clinician Scholar at the UM Institute for Healthcare Policy and Innovation and a Fellow of the UM Center for Healthcare Outcomes and Policy, as well as a surgical resident at Stanford University.

The study used data from nearly 120,000 older people who underwent surgery for lung, colon, pancreatic or rectal cancer between 2014 and 2018; 11% had dual eligibility for both public insurance programs. These patients were less likely to have surgery at a hospital that the researchers deemed “high quality” for this operation, meaning that complication rates for all patients undergoing this operation were in the fifth lowest.

Overall, patients with dual eligibility had more complications, longer hospital stay, higher likelihood of being discharged to a nursing facility, and higher costs for their total episode of care. , with average differences of more than $2,000.

These differences narrowed — but did not disappear — when the researchers focused on dual-eligibility patients who had surgery in high-quality hospitals.

This suggests, Taylor says, that continuous quality improvement programs for all types of hospitals — such as the Michigan Value Collaborative led by lead author Hari Nathan, MD, Ph.D. — are important. But the persistence of outcome and cost disparities between dual-eligibility patients and traditional Medicare patients treated at high-quality hospitals suggests that more needs to be done, even at such facilities.

In an invited comment, a team from Northwestern University said, “Medicare and Medicaid must continue to test new models of care delivery that better serve ED patients, and society must invest in robust upstream solutions for ED patients. social determinants of health”.


Michigan Medicine – University of Michigan

Journal reference:

Taylor, K. et al. (2022) Association of dual eligibility for Medicare and Medicaid with cancer surgery outcomes and expenditures in high-quality hospitals. JAMA surgery. doi.org/10.1001/jamasurg.2021.7586.

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