My research interests are in the broad areas of health policy and health economics. More specifically, I am interested in how Medicaid and Medicare policies impact program beneficiaries and long-term care policy.

Job Market Paper

Effects of Medicaid Managed Care on Outcomes for the Dually Enrolled

Link coming soon

Abstract: Beneficiaries that are Medicare-Medicaid dually eligible (duals) account for a disproportionately large share of Medicaid and Medicare spending due to their poor health and propensity to use expensive long-term care services. In order to control program costs, many state Medicaid agencies have recently expanded their Medicaid managed care (MMC) programs to include duals. Enrollment in MMC could result in better health outcomes if health plans improve care coordination and emphasize routine and/or preventative care to avoid costly care in the future. However, if quality of care declines due to financial incentives to restrict access to high-quality care, health could decline. In this study, I provide the first national estimates of the effects of MMC expansion from 2005 to 2012 on outcomes for duals using claims data. Because the majority of duals have fee-for-service Medicare coverage, I am able to examine hospital use using FFS Medicare claims. I use difference-in-differences (DID) and instrumental variables (IV) methods to estimate plausibly causal impacts of three different types of MMC: comprehensive managed care (CMC), managed long-term service and supports (MLTSS), and primary care case management (PCCM). Expansion of CMC plans that exclude long-term care services are associated with small declines in hospitalization rates in non-metropolitan counties but no change in metropolitan counties. Stratification reveals that these decreases are driven by effects among: beneficiaries first eligible for Medicare due to age (versus disability); duals with four or more chronic conditions; users of Medicaid-paid long-term care services; and individuals with high cholesterol, diabetes, anemia and COPD. MLTSS enrollment, however, is not associated with a change in hospital use. Finally, IV results where treatment is enrollment in a PCCM plan shows no change in hospital use is associated with PCCM enrollment. This study provides the first national estimates of how a major financing change, the inclusion of duals in MMC, impacts hospital use, providing policymakers with much needed evidence as they face the challenges of rising health care costs and demographic changes.

Completed work

Rebecca J. Gorges, Prachi Sanghavi,R. Tamara Konetzka. “A National Examination of Long-Term Care Setting, Outcomes and Disparities among Elderly Dual-Eligibles.” Health Affairs. July 2019. doi: 10.1377/hlthaff.2018.05409

Abstract: The benefits of expanding funding for Medicaid long-term care home and community-based services (HCBS) relative to institutional care are often taken as self-evident. However, little is known about the outcomes of these services, especially for racial and ethnic minority groups, whose members tend to use the services more than whites do, and for people with dementia who may need high-intensity care. Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, we found that overall hospitalization rates were similar for HCBS and nursing facility users, although nursing facility users were generally sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites were, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than for nonwhites, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. Our findings suggest that home and community-based services need to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS. Policy makers should consider the full costs and benefits of shifting care from nursing facilities to home and community settings and the potential implications for equity.

For a full list of my publications, see my Google Scholar profile.