Race-Based Disparities in Risk of Death Among Rural Dual Eligible Beneficiaries: Different Disease Burdens or Disparate Paths to Dual-Eligibility?

Purpose: Rural dual-eligible Medicare beneficiaries have a higher risk of death than their urban counterparts, but the role of race in this disparity is complex. Our research examines utilization patterns and beneficiary characteristics to better understand if race-based disparities originate in higher disease burden or disparate paths to dual-eligibility.

Methods: Using the 2009 5% sample of Medicare beneficiaries, we identified 118,848 rural residents who were Medicaid-eligible. Rural residence was defined at the county level using Urban Influence Codes. Morbidity status was defined by number of chronic condition diagnoses. Multiple logistic regression models analyzed differences in utilization of skilled nursing facility services (SNFS), morbidity status, and odds of becoming dual-eligible during the study year, adjusting for demographic and clinical confounders.

Results: Rural white beneficiaries were more likely to become dual eligible during the year than rural African American beneficiaries (OR 1.22, CI 1.16-1.28).  Rural white dual-eligible beneficiaries were also more likely to have two or more chronic conditions (OR 1.31, CI 1.22-1.40) and to utilize SNFS (OR 1.23, CI 1.03-1.46) than their African American counterparts.  However, in an adjusted analysis including these three confounders along with demographic and clinical confounders, white rural dual-eligible beneficiaries were still at a greater risk of death compared to their African American counterparts (OR 1.20, CI 1.11-1.30).

Discussion: While the data suggest that rural white beneficiaries are more likely to become dual-eligible via Medicaid spend-down, this path to dual-eligibility did not account for the persistent higher risk of death among rural white dual-eligible beneficiaries.