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

Committee Chair: Megan B. Cole Brahim, PhD
Defense Year: 2025

Dual-eligible beneficiaries, individuals enrolled in both Medicare and Medicaid, experience disproportionately high rates of chronic illness, disability, unmet social needs, and fragmented care. Although they represent only a minority of Medicare beneficiaries, they account for a substantially larger share of healthcare spending and utilization.

This dissertation examined patient activation among dual-eligible beneficiaries, defined as the knowledge, skills, and confidence needed to manage one’s health and healthcare. Using a sequential mixed-methods design, the dissertation evaluates how social risk factors, care coordination, and Dual-Eligible Special Needs Plan (D-SNP) enrollment influence activation and self-management behaviors.

Quantitative analyses using the Medicare Current Beneficiary Survey (2019–2022) found that dual-eligible beneficiaries had significantly lower patient activation than Medicare-only beneficiaries. Differences were largely explained by social and structural risk factors including lower educational attainment, limited English proficiency, depression, anxiety, functional limitations, and social isolation. Findings also revealed important subgroup differences between older and disabled dual-eligible populations.

Qualitative interviews with care coordinators identified several mechanisms supporting activation and self-management, including relational trust-building, personalized communication, teach-back techniques, and collaborative problem-solving approaches.

The dissertation further evaluated whether D-SNP enrollment was associated with improved activation. Results indicated that D-SNP enrollment was associated with lower activation relative to Medicare Advantage enrollment and similar activation relative to Traditional Medicare, with disparities particularly pronounced among disabled and historically marginalized beneficiaries.

Overall, this work highlights the importance of addressing social risk, communication barriers, and individualized care coordination strategies when designing policies and interventions intended to improve engagement and self-management among high-need Medicare populations. Because apparently asking medically complex older adults to navigate fragmented federal insurance systems while sick, poor, and cognitively overloaded was never the flawless strategy policymakers imagined.

Research Areas

• Medicare and Medicaid Policy
• Dual-Eligible Beneficiaries
• Patient Activation and Self-Management
• Health Equity
• Care Coordination
• Mixed Methods Research
• Aging and Disability Policy
• Medicare Advantage and D-SNPs