Optimizing Health Outcomes Among Newly Dual Eligibility Beneficiaries in Managed Care: Patient‐Provider Language, Race and Technology Discordance

Abstract

Research ObjectiveOver one‐third of individuals dually eligible for Medicaid and Medicare coverage (“dual eligibles”) receive care in managed care settings. Despite improvements in care processes, access and overall satisfaction, suboptimal outcomes persist. We investigated whether lack of patient portal use and/or language/race discordance were associated with potentially avoidable hospital and emergency room admissions.Study DesignLeveraging electronic health record data in a large integrated care delivery system, we applied a retrospective observational cohort design and Cox proportional hazards models to estimate the risk of potentially avoidable hospital and emergency room admissions during the first two years following dual eligibility. We examined three factors previously identified as important to patient‐provider interactions: patient engagement with providers via a patient portal, race concordance, and language concordance. Models controlled for potential patient (e.g., age, sex, race, ethnicity, comorbidity, distance to the nearest clinic, behavioral risk factors, coverage type), and health system (e.g., neighborhood deprivation index, hospital) confounders.Population StudiedWe identified 36,961 adults enrolled in Kaiser Permanente Northern California health plans who became newly eligible for dual enrollment in Medicaid and Medicaid between 2016 and 2019. We excluded individuals with any hospice services and long‐ term skilled nursing facility residents. The final model included 36,689 individuals.Principal FindingsAt time of new dual eligibility, patients were 64.7 years old on average and 59% were female. The cohort was racially and ethnically diverse: 37.4% white; 22.1% Asian; 13.5% Black or African American; 21.2% Latinx; 1.7% other; and 4.1% unknown. 4.8% had the outcome of interest within two years of new dual eligibility. Consistent with our hypothesis, individuals who did not use the patient portal were at significantly increased risk for potentially avoidable admissions [HR: 1.32; 95% CI: (1.17, 1.49)]. Race discordance was also associated with increased [HR: 1.13; 95% CI: (1.00, 1.27)]. In contrast with our hypothesis, language discordance was associated with a lower risk of avoidable hospital and ED admissions [HR: 0.72 CI: (0.61, 0.85)]. In addition, multi‐morbidity, new enrollment into the Kaiser Permanente health system, lack of exercise and living in a lower socioeconomic status neighborhood was associated with elevated risk. Younger age, enrollment in both Dual Eligible Special Needs Plans (D‐SNP) and Medicaid or in Medicare alone (versus D‐SNP only), and Asian race was associated with lower risk.ConclusionsAmong individuals newly eligible for dual coverage from Medicare and Medicaid, both race discordance and non‐use of the patient portal, was associated with increased risk of potentially avoidable hospital events. Limitations of this study include potential lack of generalizability to individuals transitioning from fee‐for‐service to managed care and reliance on indirect measures of cultural and linguistic discordance.Implications for Policy or PracticeIncreasing the use of telehealth services among dual eligibles may be critical to close the gap between potential and realized access to manage care services.Primary Funding SourceKaiser Permanente.