Exploring patient activation among dual-eligible Medicare beneficiaries: studies on the impact of enrollment in dual-eligible special needs plans and care coordination on activation and self-managed care
Embargo Date
2028-01-15
OA Version
Citation
Abstract
Individuals enrolled in both Medicare and Medicaid, or dual-eligible beneficiaries, face complex health and social challenges, including poverty, disability, and unmet social needs. Compared to Medicare-only beneficiaries, they report poorer health, lower educational attainment, greater functional limitations, and higher post-acute care. Although they represent only 19% of the Medicare population, they account for 34.5% of Medicare spending. Dual-Eligible Special Needs Plans (D-SNPs) were created to align Medicare and Medicaid benefits, improve care coordination, and reduce fragmentation. Within this context, patient activation—the knowledge, skills, and confidence to manage one’s health—is critical for promoting self-management, improving outcomes, and reducing costs. Yet little is known about how activation differs by dual-eligibility or plan type, or how care coordination shapes activation for this population. This dissertation used a sequential, multiphase mixed-methods design to examine relationships among dual-eligibility, D-SNP enrollment, care coordination, and patient activation. Quantitative analyses using Medicare survey data employed Fairlie decomposition, propensity scores, and inverse probability weighting to compare activation between dual-eligible and Medicare-only beneficiaries and assess whether D-SNP enrollment was associated with higher activation. Qualitative interviews with care coordinators explored how coordination practices foster activation within these contexts. Quantitative findings showed dual-eligible beneficiaries had significantly lower activation, largely explained by social risk such as low education attainment. Explanatory factors differed by subgroup: for older dual-eligibles, limited English proficiency, living alone, poor perceived health, depression, anxiety, vision impairment, and limitations in activities of daily living (ADLs); for disabled dual-eligibles, intellectual disability and limitations in instrumental ADLs. D-SNP enrollment was associated with lower activation compared to Medicare Advantage, though similar to traditional Medicare. Notably, D-SNP enrollment was associated with lower activation among disabled and historically marginalized dual-eligibles, particularly, non-Hispanic Black enrollees. Qualitative analyses of care coordinators working with dual-eligible beneficiaries identified themes aligned with the Information-Motivation-Behavioral Skills model: (1) relational trust as a catalyst for engagement; (2) seeing the whole person, not the diagnosis; (3) personalization and adaptation in communication; (4) active confirmation of patient comprehension; and (5) collaborative problem-solving and momentum building. Practice and policy implications for dual-eligible beneficiaries include tailoring outreach strategies to specific subgroups, integrating patient activation into the D-SNP Model of Care, and ensuring comprehensive teach-back techniques are embedded within provider practices to reinforce comprehension of self-management behaviors. Systematically addressing modifiable risk factors may enhance activation, equity, and quality of life for high-need Medicare populations.
Description
2026