Unmet Long-Term Care Needs ofMedicare–Medicaid Dual Eligibles

Chartpack

Harriet L. Komisar, Judith Feder, Judith D. Kasper, and Susan Mathieu

Georgetown University Health Policy Institute

October 2005

Authors’ Note

This chartpack draws upon information from H. L. Komisar, J. Feder, and J. D. Kasper, “Unmet Long-Term Care Needs: An Analysis of Medicare–Medicaid Dual Eligibles,” Inquiry 42 (Summer 2005): 171–82. In addition, it presents new information of unmet needs for long-term care amongdual eligibles.

Support for this research was provided by The Commonwealth Fund.The views presented here are those of the authors and not necessarilythose of The Commonwealth Fund or its directors, officers, or staff.

Commonwealth Fund pub. no. 866.

Medicare and Medicaid are crucial sources of support for low-income seniors. Although “dual eligibles”—those who are eligible for enrollment in both programs—constitute less than one-fifth of each program’s enrollees, they consume a large share of each program’s resources: 24 percent of Medicare spending in 2000 and 42 percent of Medicaid spending in 2002.

A large proportion of dual eligibles have long-term care needs, requiring assistance from other people with basic life tasks. While many receive long-term care in nursing homes, many others live at home and receive informal assistance from family members or friends, or formal assistance from paid helpers.

When people do not receive adequate assistance with basic activities—when they are unable to bathe or change clothes,fall due to lack of help, or go hungry—their quality of life is greatly diminished and their health put at risk.

• Most community-based dual eligibles with long-term care needs are women, live alone or with people other than a spouse, and are in poor or fair health (Figure 1).

• Forty percent are age 80 or older, and a similar proportion live alone.

• Two-thirds are in poor or fair health, and more than half used the hospital in the past year.

Figure 1. Characteristics of Community-BasedElderly Dual Eligibles Who Need Help

with Activities of Daily Living

80

40 40

14

65 60

0

20

40

60

80

100

Percent

Female Age 80or older

Livealone

Livewith

spouse

Fair orpoor

healthstatus

Hospitaluse in

past year

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

• More than one-half (58%) of community-based elderly dual eligibles who need help with activities of daily living (ADLs) report unmet need. More than one-quarter report they frequently need more help (Figure 2).

• Unmet need is more likely among people with greater levels of disability. Among those needing help with three or more ADLs, 71 percent have any level of unmet need and 50 percent frequently need more help.

• Among those with unmet needs, more than half (53%) need help with three or more ADLs, compared with 30 percent of those with met need. Three-quarters of people with unmet need are in fair or poor health, compared with just over half of those with met needs (Figure 3).

Figure 2. Prevalence of Unmet Need for Help with Activities of Daily Living Among Community-Based Elderly

Dual Eligibles Who Need Help with Activities of Daily Living

27519

2824

501328

0

20

40

60

80

100Frequently

Occasionally

Seldom

Percent

Total 1–2 ADLs 3–6 ADLs

Number of activities withwhich person needs help

5848

71

Need more helpwith ADLs:

Source: H. Komisar et al., “Unmet Long-Term Care Needs: An Analysis of Medicare–MedicaidDual Eligibles,” Inquiry 42 (Summer 2005): 171–82.

Figure 3. Disability and Health Status of Community-Based Elderly Dual Eligibles With Unmet and Met Needs

for Help with Activities of Daily Living

5365

74

2330

47 525454

1218

70

0

20

40

60

80

100

People with unmet need

People with met need Percent

1–2ADLs

3–4ADLs

5–6ADLs

Use 5 ormore Rx

drugs

Fair orpoor

healthstatus

Hospitaluse in

past yearNumber of activities withwhich person needs help

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

• Access to paid care appears to make a difference in meeting people’s needs, especially for those with greater levels of disability. Among people needing help with three or more ADLs, far fewer people with unmet needs receive paid care than those with met needs—58 percent of people with unmet needs compared with 78 percent of people with met needs (Figure 4).

• Unmet need can have serious adverse consequences. Overall, 56 percent of people with unmet need for help with ADLs reported at least one of five serious consequences because of lack of assistance. Thirty-three percent were not able to bath or shower and 28 percent fell out of a bed or chair (Figure 5).

• Among dual eligibles needing help with three or more ADLs, 71 percent experience one or more adverse consequences.

Figure 4. Type of Help Received byCommunity-Based Elderly Dual Eligibles

with Unmet and Met Needs

3922

46

51

14 19 1227

02112

4947

3127

0

20

40

60

80

100

Paid only

Both paidand unpaid

Unpaid only

None

Percent

People withunmet need(need help

with1–2 ADLs)

Type of help:

People withmet need(need help

with1–2 ADLs)

People withunmet need(need help

with3–6 ADLs)

People withmet need(need help

with3–6 ADLs)

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

Figure 5. Adverse Consequences Resulting from Unmet Need for Help with Activities of Daily Living

15

56

3

2814

3324

71

5

39

21

37

0

20

40

60

80

100 All

People who need help with 3 or more ADLs

Percent of community-based elderly dual eligibleswho experience adverse consequence

Not ableto bathe

or shower

Not ableto put on

cleanclothes

Fell outof bed

or chair

One ormore

adverseconsequences

Wet orsoiled self

Wenthungry

Source: H. Komisar et al., “Unmet Long-Term Care Needs: An Analysis of Medicare–MedicaidDual Eligibles,” Inquiry 42 (Summer 2005): 171–82; authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

• Slightly higher proportions of African Americans (38%) and Hispanics (37%) need help with ADLs, compared with whites. The proportion of those with a severe level of disability—those who need help with three or more ADLs—is greatest for Hispanics, followed by African Americans and whites (Figure 6).

• Demographics vary among the different groups. Women constitute the majority of all three, but the proportion varies. Age varies, too, with African Americans younger on average than Hispanics or whites (Figure 7).

• In terms of living situations, African Americans are least likely to live alone (35%, compared with 45% for both the other groups), and the most likely to live with friends or relatives other than a spouse (Figure 8).

Figure 6. Proportion of Community-BasedElderly Dual Eligibles Needing Assistance

with Activities of Daily Living, by Race/Ethnicity

122117

191621

0

20

40

60

80

100 1–2 ADLs

3 or more ADLs

Percent

African American(non-Hispanic)

Hispanic White(non-Hispanic)

38 3731

Need help with:

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

Figure 7. Characteristics of Community-BasedElderly Dual Eligibles Who Need Help

with Activities of Daily Living

33

86

42

93

44

77

0

20

40

60

80

100

African American (non-Hispanic) Hispanic White (non-Hispanic)

Percent

Female Age 80 or older

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

Figure 8. Living Arrangements ofCommunity-Based Elderly Dual Eligibles Needing Help

with Activities of Daily Living, by Race/Ethnicity

158

57

35

20

3545 4045

0

20

40

60

80

100

African American (non-Hispanic) Hispanic White (non-Hispanic)

Percent

Lives alone Lives with others Lives with spouse

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

• African Americans are much more likely to rely exclusively on informal assistance—more than one-half do, compared with one-third of Hispanics and just over one-third of whites (Figure 9).

• African Americans are also less likely to rely exclusively on paid care—only 9 percent receive paid care only, compared with more than one-fifth of those in the other two groups.

Figure 9. Type of Assistance Received byCommunity-Based Elderly Dual Eligibles Needing Help

with Activities of Daily Living, by Race/Ethnicity

3

52

35

9 6

3339

22

4

3639

21

0

20

40

60

80

100

African American (non-Hispanic) Hispanic White (non-Hispanic)

Percent

Paidassistance

only

Both paidand unpaid assistance

Unpaid assistanceonly

None

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

• Higher proportions of African Americans and Hispanics experience unmet need—65 percent and 69 percent, respectively, compared with 52 percent of whites(Figure 10).

• For people needing help with three or more ADLs, unmet need is greatest among African Americans (78%), followed by Hispanics (74%) and whites (65%).

Figure 10. Prevalence of Unmet Need for Helpwith Activities of Daily Living, by Race/Ethnicity

6578

5465

7463

69

4352

0

20

40

60

80

100

African American (non-Hispanic) Hispanic White (non-Hispanic)

Percentage of those with specified level of need who have unmet need

Need help withany ADLs

Need help with1–2 ADLs

Need help with3 or more ADLs

Source: Authors’ analysis of data from the 1999 Survey of Dual Enrollees in Six States.

Appendix: The 1999 Survey ofDual Enrollees in Six States

The results presented here are based on a survey of community-based elderly dual eligibles, which was supported by The Commonwealth Fund and The Robert Wood Johnson Foundation. Data were collected in 1999 in six states: Georgia, Iowa, Massachusetts, New Jersey, Wisconsin, and Washington. The survey was designed by Judith Kasper at the Bloomberg School of Public Health, Johns Hopkins University, and conducted by Westat, a research company in Rockville, Maryland.

The surveyed population consists of seniors who are not living in nursing homes or other facilities, and who had been continuously enrolled in both Medicare and Medicaid for at least one year.

Interviewers talked with most respondents by telephone, but conducted one-fifth of the interviews in person to include people who did not have phones or available phone numbers, or were only willing to participate in person. Proxy respondents were interviewed when the subject person was unable to participate because of illness, cognitive impairment, or other reasons; one-fourth of interviews were conducted with proxy respondents. The sample size for the analysis was 2,123 people, among whom 738 needed help with ADLs. The survey data were adjusted to be representative of the community-based elderly dual eligible population in each state.