Higher risk of death among rural dual-eligible Medicare beneficiaries

Purpose: Beneficiaries who are eligible for both Medicare and Medicaid constitute a high need population. In rural areas, reduced provider availability may lead to poorer health outcomes among these vulnerable adults. Our research explored potential mortality disparities associated with rural residence.  

Method: Using the 2009 5% sample of Medicare beneficiaries (n=2,424,512), we identified 397,816 beneficiaries who were continuously eligible for both Medicare and Medicaid. The outcome studied was death from any cause during the year. Rural residence was defined at the county level using Urban Influence Codes. Multiple logistic regression models were used to analyze rural-urban differences in risk of death after adjusting for demographic (age, race, sex, region) and clinical (presence/absence of ESRD, Alzheimers, hospitalization during year) confounders.

Results: Rural dual-eligible Medicare beneficiaries had a higher risk of death than their urban counterparts (7.19% vs 6.07%).  Rural beneficiaries living in remote rural counties had the highest risk of death (7.56%); those living in micropolitan or small adjacent counties also experienced higher risk than urban beneficiaries (7.11% and 7.12%, respectively, p<.0001). In multivariable analysis, this disparity persisted, with rural dual-eligibles more likely to die than urban dual-eligible beneficiaries (OR 1.036, CI 1.003-1.071). When analyzed across rurality, higher risk was found only for micropolitan counties (OR 1.58, CI 1.016-1.101). 

Conclusion: Rural dual-eligible beneficiaries face an increased risk of death, even after adjusting for clinical condition.  Further research is needed to determine the degree to which this disparity may be associated with provider availability and with quality of care metrics.