High-Cost Users Among Dual Eligibles in Three Care Settings

Abstract: This study compares the expenditure patterns and characteristics of high-cost dual eligibles to normative-cost dual eligibles within institutional and community settings. Using claims records for people dually eligible for both Medicare and Medicaid in 18 California counties (n=349,433) in 2000, high-cost users in the long-stay institutional care setting spent a much higher amount and a much greater proportion of total costs in Medi-Cal (61%) but spent less proportionally in Medicare (39%) than high-cost users in the long-term community care (66% of total costs from Medicare) or episodic care (79% of total costs from Medicare) setting. Although individuals who are long-stay nursing facility residents are high-cost in the overall sample, multinomial logistic regressions revealed that the impact of diseases/conditions on high-cost status varied within each setting. These findings suggest that policymakers and providers should consider care setting as an important component when designing disease management strategies.