News > United Hospital Fund Report Offers Insights into a High-Cost Population of Medicaid Beneficiaries

A new report from the United Hospital Fund presents insights into the challenges facing New York's Medicaid program as it considers options to improve care and rein in costs for some of its highest-cost enrollees—a subset of elderly individuals who are dually enrolled in Medicare and Medicaid (and therefore often termed dual enrollees or duals). Of the 259,000 duals in New York City, the highest-cost 20 percent (about 52,000 beneficiaries) account for about $3.5 billion in Medicaid spending, or $68,000 per person.

“The growing fiscal challenges facing New York will no doubt mean increasing pressure on Medicaid, and over 40 percent of New York's program costs are for persons dually eligible for Medicare and Medicaid,” said James R. Tallon, Jr., president of the United Hospital Fund. “Our policymakers will need clear, thoughtful information to develop a strategy for serving these New Yorkers effectively in a time of resource constraints. We expect this report will be helpful to that process.”

“The more we look at high-cost duals, the more we realize how complex these cases are,” says Michael Birnbaum, director of policy for the Medicaid Institute at United Hospital Fund and author of the report, “Managing Care for High-Cost Elderly Duals: A Challenge for Medicaid.” “Answers won't come easily, but developing a framework to assess the effectiveness of service delivery and the level of spending relative to health outcomes, as well as other benchmarks and program goals, will be key.”

According to the report, high-cost duals present three distinct challenges:

1. Because these beneficiaries rely heavily on long-term care to cope with activities of daily living, management has more to do with maintaining health status over time than avoiding illness and costly episodes of care.

2. As the secondary insurer to Medicare, Medicaid, absent specific provisions to coordinate care, has no authority to influence how high-cost duals access primary, preventive, or hospital services.

3. Because New York City is already a national leader in the availability of alternatives to nursing home care, it is unclear whether significant savings could be generated by transferring many of those beneficiaries who remain in nursing homes to community settings, if such transfers were even feasible.

In addition to challenges facing New York's Medicaid program, the report presents spending snapshots of eight high-cost duals, existing programs for managing long-term care, and related issues for policymakers to consider. The full report “Managing Care for High-Cost Elderly Duals: A Challenge for Medicaid,” is available online.


About the United Hospital Fund: The United Hospital Fund is a health services research and philanthropic organization whose mission is to shape positive change in health care for the people of New York.

About the Medicaid Institute™: The Medicaid Institute™ at United Hospital Fund provides information and analysis explaining New York's Medicaid program, with the goal of helping all stakeholders redesign, restructure, and rebuild the program.

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