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

Abstract: Beneficiaries that are Medicare-Medicaid dually enrolled (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 high-value routine care to avoid costly care in the future. However, quality of care could decline if plans restrict access to needed services due to financial incentives to increase profits. In this study, I provide the first national estimates of the effects of MMC expansion from 2005 to 2012 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). I find different effects of MMC on hospital use for the three different plan types. First, MLTSS plans are associated with increases in the rates of hospitalization and potentially avoidable hospitalization. For example, mandatory MLTSS programs are associated with increases in hospitalization of 1.7-4.2% of the baseline rate of hospitalization of 11.7%. Increases are concentrated among beneficiaries with many (as opposed to few) chronic conditions. I find mixed effects of CMC program expansions that exclude long-term care services: in mandatory enrollment settings, I find modest increases in hospitalization while in voluntary enrollment settings, I find decreases in hospitalization. Finally, PCCM plans are not associated with changes in hospital use. 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 challenge of financing public health insurance programs as health care costs rise and the population ages.

Link coming soon

Published Papers

Gorges RJ and Konetzka RT. Racial Differences in Deaths Among Nursing Home Residents with COVID-19 in the US. JAMA Network Open. February 2021. doi: 10.1001/jamanetworkopen.202037431

R. Tamara Konetzka, Daniel H. Jung, Rebecca J. Gorges and Prachi Sanghavi. “Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles.” Health Services Research. December 2020. doi: 10.1111/1475-6773.13573

R. Tamara Konetzka and Rebecca J. Gorges. “Nothing Much Has Changed: COVID-19 Nursing Home Cases and Deaths Follow Fall Surges.” Journal of the American Geriatrics Society. November 2020. doi: 10.1111/jgs.16951

Rebecca J. Gorges and R. Tamara Konetzka. “Staffing Levels and COVID-19 Cases and Outbreaks in US Nursing Homes.” Journal of the American Geriatrics Society. August 2020. doi: 10.1111/jgs.16787

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.