OBJECTIVES : Compare characteristics, healthcare utilization, cost, and quality outcomes among dual eligible and non-dual eligible Medicare beneficiaries enrolled in Medicare Advantage (MA) plans.

METHODS : A retrospective cross-sectional analysis using a nationally representative sample of 1,813,937 MA enrollees from 103 contracts/512 benefit packages in 2015; 18% were full-benefit duals. Centers for Medicare and Medicaid Services (CMS) monthly membership reports were used to identify dual status and original reason for entitlement to Medicare.

RESULTS : A larger percent of full-dual beneficiaries were under age 65, while a similar proportion were 85 or older. Duals had higher prevalence of chronic conditions, including depression (2.3x), Alzheimer’s disease (2.4x), asthma (1.9x), heart failure (1.7x), stroke (1.5x), and diabetes (1.5x); 24% duals had Charlson Comorbidity Index (CCI) ≥5 versus 13% non-duals, and duals were also more likely to have complicating risk factors (e.g., obesity, severe mental illness, substance abuse). Based on top 10^th percentile of annual spending, 17.1% duals were high-cost compared to 9.2% non-duals. Duals had higher utilization of emergency room visits (2.8x), hospitalizations (1.8x), and outpatient visits (1.5x). Costs were 1.7x higher; Part D drug costs 2.7x higher. Duals performed worse on all but one quality measure (QM), including 70% more likely to use high risk medications, 18% more likely to be hospitalized for potentially preventable complications, and less likely to receive preventive screenings or treatment for rheumatoid arthritis.

CONCLUSIONS : MA plans that serve a large number of duals face significant challenges. Duals are nearly twice as likely to be high-cost, and their lower performance on QMs impacts CMS Five Star Ratings and Bonus Payments. Starting in 2019, regulatory changes expand the scope of supplemental benefits MA plans can offer (e.g., non-health related). A better understanding of high-cost, high-need patients is essential to developing innovative benefit programs aimed at reducing costs and improving outcomes in this growing population.