U.S. Department of Health and Human Services

Study of the Impact of Monitoring the Health Outcomes for Disabled

Executive Summary

Nelda McCall, Jodi Korb, Andrew Petersons and Stanley Moore

Laguna Research Associates

May 2002

This report was prepared under contract #HHS-100-99-0021 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of California, Los Angeles. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Andreas Frank, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: Andreas.Frank@hhs.gov.

ACKNOWLEDGMENTS

This report is based on work funded by the Office of the Assistant Secretary of Planning and Evaluation (ASPE) under contract number HHS-100-99-0021. Additional funding was also provided by the Robert Wood Johnson Foundation through the Home Care Research Initiative at the Center for Home Care Policy of the Visiting Nurse Service of New York, and the Centers for Medicare and Medicaid Services (CMS) under contract number HCFA-00-0108. The analysis and conclusions are solely those of the authors and do not express any official opinion of or endorsement by the funders.

The authors would like to thank RoperASW for its effort in conducting the survey and Caroline Davis for conducting the literature review on satisfaction, as well as Arden Hall and Richard West for consultation on econometric issues. We are also grateful to Diana Valenzuela and Rena Korb for their aid in the production and editing of the report. Special thanks to Sydney Galloway of CMS for his help in gaining and maintaining access to these data and to our project directors at ASPE, Kamal Hijjazi and Floyd Brown. We are also grateful to Hakan Aykan for his comments on an earlier version of this report.

EXECUTIVE SUMMARY

Introduction

Home health is an important and popular service for Medicare beneficiaries. In the early part of the 1990s, dramatic growth in program expenditures for home health care raised concerns not only about the strain on the Medicare trust fund but also about the quality of care delivered and the efficiency of service provision.

From 1990 to 1996, expenditures for home health services grew 350%. The number of home care agencies also almost doubled during this period, thus increasing the supply of available services. Policy makers voiced concerns about the appropriateness the increases in home health care use. In 1995, the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), and the Administration on Aging (AOA) jointly implemented Operation Restore Trust (ORT), an effort to identify fraud and abuse in home health agencies, nursing homes, and medical equipment suppliers. Later efforts expanded ORT, imposed penalties on physicians for knowingly certifying patients for Medicare home health who did not meet the eligibility requirements, and initiated a moratorium on the certification of new home health agencies.

While these measures focused on compliance initiatives within the home health industry, there also was a belief that much of the problem of the increasing expenditures rested with the relatively open-ended reimbursement system. The Balanced Budget Act (BBA) of 1997 addressed this issue by legislating the implementation of a prospective payment system (PPS) to reimburse home health agencies. The legislation also mandated the use of an interim payment system (IPS) to limit costs while the PPS was being developed. The IPS was phased in beginning in October 1997 with the start of each agency's cost reporting period. Under the IPS, agency reimbursement was constrained by the tightening of an already existing aggregate per-visit cost limitation and by the addition of an aggregate per-beneficiary cost limit. The IPS continued until the PPS went into effect in October 2000.

Purpose of the Study

Because of these IPS home health reimbursement limits, executive agencies and policy analysts expressed concern that access to home care could be endangered, especially for those beneficiaries needing the most care. There was also concern that the quality of care provided might be adversely impacted. It was these issues that led to studies of the effects of the BBA during the period when the IPS was in place.

This Executive Summary reports on the results of the Office of Assistant Secretary for Planning and Evaluation (ASPE) funded study of Medicare home health users who are eligible because of disability. This study examines their satisfaction with the home health care received and the quality of their lives. It is part of a larger comprehensive project funded by the Robert Wood Johnson Foundation (RWJF), ASPE, and CMS to better understand the Medicare home health benefit and the impact of the BBA changes on Medicare beneficiaries, home health agencies, and the overall health care system.

Immediately after IPS implementation, home health utilization decreased dramatically. Beneficiaries were screened more carefully for eligibility for services, resulting in more than 20% fewer patients being seen for any home health services. Overall, expenditures were reduced by more than 50%. With these dramatic decreases, there were concerns that beneficiary satisfaction with the care received or with the quality of life might be impacted, especially for vulnerable beneficiaries such as the disabled.

This study focuses on three questions that address these concerns:

• Did disabled Medicare home health users before the BBA differ from disabled home health users after the full implementation of the IPS in their satisfaction with home health care and quality of life?

• Did disabled Medicare home health users differ from elderly Medicare home health users in their levels of satisfaction with home health care and quality of life?

• What characteristics were related to disabled Medicare home health users' satisfaction with the home health care received and quality of life?

Multivariate analyses were conducted to study these questions. The satisfaction measures analyzed examined 18 specific aspects of the beneficiary's satisfaction with home health care received and about the quality of their lives. Sixteen measures related to satisfaction with home health care received. These included questions about overall care from the agency, agency discharge, staff interpersonal relationships, aides' work quality, and nurses' and therapists' work quality. Two quality of life questions asked about satisfaction with life and satisfaction with present personal care arrangements.

Results

Pre-BBA vs. Post-BBA. Between the two time periods, there were no significant differences for disabled Medicare beneficiaries' satisfaction with the agency or with their discharge. Rates of satisfaction with the agency were higher than 90% in both periods, and rates of satisfaction with elements of the discharge were actually as high in post- BBA as pre-BBA. Nine of the 12 aspects of satisfaction that related to staff interpersonal and technical skills also remained at essentially the same level in pre- and post-BBA periods and were not affected by changes due to BBA. However, beneficiaries were less satisfied on the remaining three aspects after the implementation of the IPS. That is, a greater proportion of disabled Medicare home health users believed that there were problems with staff arriving late and with staff rushing through work; dissatisfaction with these measures rose by 12 percentage points. There was a 9 percentage point increase for disabled Medicare home health users who believed that nurses and therapists did not come often enough post-BBA. There was also a significant difference for the quality of life measure relating to satisfaction with present personal care arrangements, which fell among disabled Medicare home health users by 12 percentage points.

Disabled vs. Aged. Significantly worse satisfaction levels were found for the disabled as compared to the aged for 9 of the 16 aspects of satisfaction with their home health care and both of the quality of life measures. For the nine questions relating to satisfaction with home health care, the percentages were lower by 5-13 percentage points, and for the two quality of life questions the percentages were lower by 16 and 18 percentage points. The disabled were significantly less satisfied both on overall satisfaction with the agency measures and with their discharge. They also were less satisfied with two staff interpersonal care aspects (staff arriving late, staff paying attention), with aides completing all work, and with nurses and therapists staying long enough and coming often enough.

Factors Affecting Satisfaction. Only one variable had a consistent significant effect on the satisfaction measures: having the interview conducted with a proxy. Interviews conducted with proxies reported significantly more dissatisfaction on 6 of the 16 home health care satisfaction measures and on both of the quality of life measures. In general, among the other variables occasionally found significant, there was more dissatisfaction for those patients with debilitating diseases and for those with less functional ability.

Conclusion

The substantial cutbacks in Medicare home health utilization did not result in problems in the satisfaction of those beneficiaries eligible for Medicare because of disability. None of the satisfaction measures that related to overall agency satisfaction or satisfaction with agency discharge was affected by the implementation of IPS, and most aspects of satisfaction with agency staff remained at comparable levels in the pre- and post-BBA periods. However, there were some increases in dissatisfaction with certain interpersonal aspects of home health care (staff coming late and paying attention) and with the amount of skilled services received post-BBA.

The increases in dissatisfaction with staff arriving late and paying attention to patients may reflect the agency's increased emphasis on efficiency, which has resulted in more closely scheduled appointments that leave the staff less time for patient interactions. Disabled Medicare beneficiaries' dissatisfaction with not receiving enough skilled services may suggest the need to examine more closely whether their perceived need for skilled nursing and therapy services pertained to areas where more skilled services would be appropriately provided under the Medicare program or were for more chronic care outside the scope of the program's benefits.

The disabled also were more dissatisfied post-BBA with the quality of life measure relating to satisfaction with current personal care arrangements. A substantial percentage, 28% (up from 16% in pre-BBA), felt their personal care needs were not being met. While these concerns may not be able to be accommodated within the Medicare home health benefit, they still may identify important perceived needs of the disabled population that were vocalized when aide and other home health services available through the Medicare program were contracted. It is also possible, however, that these decreases instead may reflect differences in the underlying populations pre- and post-BBA.

Comparison of the satisfaction of disabled Medicare home health users with that of aged home health users indicated that the disabled were a more critical, less satisfied group. Because they are younger, more disabled, and may be more assertive about articulating their dissatisfaction, they express significantly more dissatisfaction with various aspects of their care and with life in general. In addition, because they are, by definition, chronically disabled when most of their age group is functional, they may have greater expectations than the aged that receiving more care would be beneficial in increasing their functional level.

Satisfaction studies are always plagued by the inability to determine if beneficiaries' expectations are appropriate when dissatisfaction is found. This is especially true in this study as it examined these levels before and after a major contraction in services provided and focused on a service that was widely believed to be overprovided pre-BBA. However, despite the large decreases in the number of services provided, this study did not identify substantial increases in dissatisfaction with home health care during the IPS. If these problems were not evidenced during the more restrictive IPS, they are not likely to be of significant concern during the home health PPS now in place.