Beyond the Water's Edge: Charting the Course of Managed Care for People with Disabilities - Conference Resource Book. Access, Use, and Satisfaction of the Under 65 Medicare-Disabled in HMOs and Fee-for-Service

11/01/1996

Leonard Gruenberg, Ph.D.
Leonard Gruenberg is the President and founder of DataChron Health Systems, Inc. Dr. Gruenberg received his doctoral degree in theoretical physics from Columbia University, and has worked for more than 20 years as a Researcher and Consultant in the field of applied health services research. His primary research focus has been associated with financing of health services for elderly and disabled populations. He has developed payment models for managed care programs for elderly and disabled populations that are being used by the Health Care Financing Administration in demonstration programs including the SHMO, PACE, and CNO projects.

Prior to establishing DataChron, Dr. Gruenberg headed up research on Medicare's TEFRA payment formula (i.e., the AAPCC) at the Brandeis University Institute for Health Policy, served as Director of Research for Elderplan (the SHMO in Brooklyn, NY), conducted evaluation and operations research at the Hebrew Rehabilitation Center for the Aged in Boston, and directed long-term care research at the Massachusetts Department of Public Health.

COMMON VARIABLES FOR HMO 1 AND MCBS

  • Demographics
    • Age, gender, race/ethnicity, educational level, marital status
  • Health Status
    • Self-reported health
    • Diagnoses: high blood pressure, heart problems, cancer, diabetes, rheumatoid arthritis, other arthritis
    • Impact of health on social activities
  • Functional Activity
    • Bending, kneeling, or stooping, lifting or carrying groceries, walking several blocks
    • Bathing and dressing
  • Satisfaction
    • Overall satisfaction
    • Satisfaction with information given
  • Usual Source of Care
    • Have regular doctor
    • Doctor is interested in overall health
  • Preventive Care
    • Mammogram, pap smear, hysterectomy, flu shot, pneumonia vaccine shot, smoking behavior

RESEARCH QUESTION

Did those in poor health and those with functional limitations report lower levels of satisfaction?...more problems with access?

MEASURES OF POOR HEALTH, FUNCTIONAL LIMITATIONS

  • Poor Health
    • Self-reported health status
    • Report having serious or chronic condition
    • Impact of health on social activities
  • Functional Limitations
    • ADL: limited a lot in bathing and dressing
    • Limited a lot in walking one block
TABLE 1. Enrollment by Medicare Category: U.S. and HMO: 1991-1995
Year U.S. Medicare Disabled Population* HMO 1 HMO 2
Disabled Aged Disabled Aged Disabled Aged
1991 3,385
9.7%
31,485
90.3%
1,090
2.4%
45,112
97.6%
0
-
0
-
1992 3,579
10.1%
32,019
89.9%
1,410
3.0%
45,161
97.0%
71
0.4%
18,362
99.6%
1993 3,863
10.6%
32,477
89.4%
1,567
3.4%
45,069
96.6%
186
0.9%
20,423
99.1%
1994 4,151
11.2%
32,799
88.8%
1,763
3.8%
44,773
96.2%
339
1.4%
23,963
98.6%
1995 4,500
12.0%
33,100
88.0%
1,918
4.1%
45,054
95.9%
667
2.5%
26,256
97.5%
*U.S. data are given in 1,000s.

 

TABLE 2. Enrollment by Age and Gender
Age U.S. Medicare Disabled HMO 1 HMO 2
Female Male Total Female Male Total Female Male Total
<20 years 0.18 0.07 0.12 0.00 0.52 0.28 1.28 1.97 1.69
20-34 years 12.95 14.27 13.76 5.67 6.70 6.23 7.26 7.02 7.12
35-44 years 18.75 22.90 21.29 9.51 12.24 10.99 22.65 19.38 20.68
45-54 years 29.25 23.82 25.92 27.30 20.36 23.53 20.51 18.82 19.49
55-59 years 15.02 17.04 16.26 22.85 18.17 20.31 40.17 45.51 43.39
60-64 years 23.85 21.90 22.66 34.66 42.01 38.66 8.12 7.30 7.63
Total 100.0
(1,451)
100.0
(2,294)
100.0
(3,745)
100.0
(652)
100.0
(776)
100.0
(1,428)
100.0
(234)
100.0
(356)
100.0
(590)
*U.S. Medicare population data is given in 1,000s.

 

TABLE 3. Total Enrollment of the Disabled Population: 1991-1995
Year HMO 1 HMO 2
Enrolled at Start of Year New Enrollees During Year Disenrollees During Year Enrolled at Start of Year New Enrollees During Year Disenrollees During Year
Voluntary Death Voluntary Death
1991 1,090 453 98 35 0 272 1 0
1992 1,410 330 116 57 271 382 10 3
1993 1,567 383 108 79 640 354 18 8
1994 1,763 385 158 72 968 629 20 24
1995 1,918 591 199 89 1,553 258 85 31

 

TABLE 4. Disenrollment Rate by Medicare Category: 1991-1995
Year HMO 1 HMO 2
Disabled Aged Disabled Aged
1991 7.84% 5.29% 0.74% -
1992 7.79% 4.59% 2.20% -
1993 6.49% 4.86% 2.24% -
1994 8.58% 4.62% 1.59% -
1995 9.61% 4.69% 5.23% -
* Not includes disenrollments due to death

 

TABLE 5. Utilization Rates: A Comparison of the U.S. and HMO 1
  U.S. Medicare HMO 1 State FFS
Disabled Aged Disabled Aged Total
1992
Inp.adm* 364 311 486 284 241
Inp.days* 3,134 2,587 2,932 1,520 1,360
SNF adm* 11 28 16 23 23
SNF days* 311 767 501 503 542
1994
Inp.adm* 370 337 451 259 305
Inp.days* 2,774 2,291 2,638 1,396 1,573
SNF adm* 13 43 25 29 40
SNF days* 353 1,169 523 596 867
per 1,000

 

TABLE 6. Utilization Rates by Medicare Category for HMO 1 (1994)
Health Service HMO 1
Disabled Aged
Hospital admissions* 451 259
Hospital days* 2,638 1,396
Day surgeries* 267 164
SNF admissions* 25 29
SNF days* 523 596
ER visits* 862 531
Physician visits 23.8 11.3
Prescriptions 31.3 18.3
* per 1,000

 

TABLE 7. Repeated Hospitalizations: 1991-1994
# of Hospital Episodes HMO 1 MCBS
Disabled Aged Disabled Aged
Percent of Persons by Number of Hospital Episodes
0 episodes 53.8% 62.6% 63.0% 58.2%
1 episode 18.2% 17.3% 15.9% 20.5%
2 episodes 10.0% 10.5% 7.7% 9.6%
3 episodes 5.7% 4.8% 3.5% 5.0%
4+ episodes 12.3% 4.9% 10.0% 6.8%
#Obs 942 2,293 3.054,920 24,201,805
Number of Hospital Days/1,000 per year
0 episodes 0 0 0 0
1 episode 1,169 1,103 1,600 1,525
2 episodes 2,595 2,345 3,475 3,875
3 episodes 3,650 3,682 5,850 5,600
4+ episodes 9,333 7,527 12,650 10,775
#Obs 942 2,293 3.054,920 24,201,805

 

TABLE 8. Distribution of Hospital Days by Number of Episodes
# of Hospital Episodes MCBS HMO 1
Disabled Aged Disabled Aged
1 episode 12.7% 18.5% 11.6% 19.5%
2 episodes 13.4% 22.0% 14.2% 25.1%
3 episodes 10.4% 16.5% 11.4% 17.9%
4+ episodes 63.5% 43.0% 62.8% 37.6%

 

TABLE 9. Services Utilization in HMO 1 by Number of Episodes: 1991-1994
# Episodes 0 1 2 3 4
Aged
SNF days* 0 485 877 924 2,022
Day surgeries* 103 130 177 216 275
ER visits* 208 408 831 1,167 1,719
Physician visits 7.5 9.7 13.0 16.7 22.5
Prescriptions 12.5 16.8 23.7 28.1 34.7
Disabled
SNF days* 0 149 202 236 1,489
Day surgeries* 92 164 277 434 474
ER visits* 323 797 738 1,648 2,032
Physician visits 10.9 16.5 25.7 30.7 51.4
Prescriptions 18.2 28.5 39.2 44.5 50.8
* per 1,000 persons

 

TABLE 10. Distribution of Services in HMO 1 by Number of Episodes: 1991-1994
# Episodes 0 1 2 3 4
Aged
Inpatient days 0.0% 19.52% 25.1% 17.9% 37.6%
SNF days 0.0% 26.3% 28.8% 13.8% 31.0%
Day surgeries 50.0% 17.4% 14.3% 7.9% 10.4%
ER visits 30.5% 16.5% 20.4% 13.0% 19.7%
Physician visits 48.8% 17.5% 14.1% 8.2% 11.4%
Prescriptions 48.1% 17.9% 15.3% 8.2% 10.5%
Disabled
Inpatient days 0.0% 11.6% 14.1% 11.4% 62.8%
SNF days 0.0% 11.1% 8.3% 5.5% 75.1%
Day surgeries 26.1% 15.6% 14.5% 13.1% 30.7%
ER visits 23.6% 19.6% 10.0% 12.8% 34.0%
Physician visits 30.0% 15.4% 13.1% 9.0% 32.5%
Prescriptions 35.4% 18.7% 14.1% 9.2% 22.6%

 

TABLE 11. A Comparison of Those Age 65-69 Who Were Disabled and Those Age 65-69 Who Were Not Disabled: Health Service Utilization
1995 Utilization Rates Disabled 65-69 Aged 65-69
Hospital admission* 432 150
Hospital days* 2,096 645
Day surgeries* 227 114
SNF admissions* 46 6
SNF days* 999 74
ER visits* 703 365
Physician visits 16.6 9.1
Prescriptions 29.8 16.2
* per 1,000 persons

 

TABLE 12. A Comparison of Payments Made by Age in HMO 1 Health Plan
HMO 1 AAPCC Rates
HMO 1 60-64 65-69
Part A
Male $182.29 $156.90
Female $227.86 $132.76
Part B
Male $116.28 $101.17
Female $146.88 $88.52

 

TABLE 13. Comparing HMO 1 Questionnaires to MCBS
Health and Functional Status
In general, compared to other people (your/sp's) age would you say your health is excellent, very good, good, fair, or poor? In general, would you say your health is excellent, very good, good, fair, poor?
How much of the time during the past month has (your/sp's) health limited (your/sp's) social activities, like visiting friends or close relatives?... none of the time, some, most, all During the past four weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors or groups? not at all, slightly, moderately, quite a bit, extremely
How much difficulty, if any, (do you/sp) have stooping, crouching or kneeling? Would you say; no difficulty at all, a little difficulty, a lot of difficulty, not able to do it Does your health now limit you in any of these activities? If so, how much?--bending, kneeling or stooping--yes limited a little, yes limited a lot, no not limited at all
How much difficulty, if any, (do you/sp) have lifting or carrying objects as heavy as ten pounds, like a sack of potatoes? Would you say: no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, not able to do it Does your health now limit you in any of these activities? If so, how much?--lifting or carrying groceries--yes limited a little, yes limited a lot, no not limited at all
What about walking a quarter of mile, that is, about 2 or 3 blocks? no difficulty at all, a little difficulty, some difficulty, a lost of difficulty, not able to do it Does your health now limit you in any of these activities? If so, how much?--walking several blocks--yes limited a little, yes limited a lot, no not limited at all
Because of a health or physical problem do you/sp have any difficulty...(yes, no, doesn't do) Is this because of a health or physical problem? Do you/does sp receive help from another person? Does someone usually stay nearby just in case you need/sp needs help... Do you/does sp use special equipment or aids to help you/him/her with...? Who helps?--bathing or showering, dressing Does your health limit you in bathing or dressing yourself? yes limited a little, yes limited a lot, no not limited at all
Preventive Care
Have you/has sp a mammogram or breast x-ray since a year ago? (yes, no, refused, DK) When was last time you had a mammogram? (never, within last 12 months, within last two years, within last three years, within last five years, more than five years ago)
Have you/sp had a pap smear since a year ago? (yes, no, refused, DK) When was last time you had a pap smear? (never, within last 12 months, within last two years, within last three years, within last five years, more than five years ago)
Have you/sp ever had a hysterectomy? (yes, no, refused, DK) Have you had a hysterectomy (surgical removal of uterus)?...yes, no
Did you/sp have a flu shot for last winter (between September and December)? (yes, no, refused, DK) Did you get a flu shot during the last 12 months? yes, no
Have you/has sp ever had a shot for pneumonia? (yes, no, refused, DK) Have you ever had a pneumonia vaccine shot (pneumococcal vaccine, pneumovax)? yes, no
Have you/has sp ever smoked cigarettes, cigars, or pipe tobacco? (yes, no, refused, DK) Do you/does sp smoke now? (yes, no, refused, DK) Do you currently smoke cigarettes? yes, no never smoked
Diagnosis
"Has a doctor ever told you..." "Has a doctor ever told you..."
Hypertension or high blood pressure Hypertension or high blood pressure
Myocardial infraction or a heart attack Heart problems
Angina pectoris or coronary heart disease Heart problems
Other heart conditions such as congestive heart failure, problems with the values in the heart, or problems with the rhythm of your heart Heart problems
Skin cancer Cancer
Any other kind of cancer, malignancy or tumor Cancer
Diabetes, high blood sugar, or sugar in your urine Diabetes diagnosed before age 40.
Diabetes diagnosed at age 40 or later.
Rheumatoid arthritis Rheumatoid arthritis
Arthritis other than rheumatoid Arthritis
Satisfaction and Access to Care
Is there a particular doctor you/sp usually see(s)? Do you have a HMO 1 doctor you consider to be your regular doctor?
Now I am going to read some statements people have made about their medical care... For each statement please tell me whether you strongly agree, agree, disagree, or strongly disagree--The doctor(s) often seem to be in a hurry. Doctor does not explain your medical problems to you In general how satisfied with each of the following items related to quality of care at HMO 1? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied--Amount of time doctors spend with you. Amount of explanation or information provided.
The overall quality of the medical care (you have/sp has) received in the last year? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied. Overall, how satisfied are you with HMO 1? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied.
The information given to (you/you or sp) about what was wrong with (you/sp)? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied. Amount of explanation or information the doctors give you? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied.
The concern of doctors for your overall health rather than just an isolated symptom or disease? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied. Personal interest and attention the doctors give you? Very satisfied, satisfied, neutral, dissatisfied, very dissatisfied.

 

TABLE 14. Age and Gender Composition of Survey Respondents, %
Age HMO 1 MCBS
Male Female Total Male Female Total
Less than 20 years 0.3 0.3 0.3 0.1 0.0 0.1
20-34 years 7.4 5.3 6.5 8.4 7.6 8.1
35-44 years 12.7 12.9 12.8 19.8 18.8 19.5
45-54 years 18.2 24.7 21.1 24.2 23.7 24.0
55-59 years 19.6 20.2 19.9 17.0 18.6 17.6
60-64 years 41.9 36.5 39.5 30.4 31.3 30.7

 

TABLE 15. Race and Ethnic Composition, %
  HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
White 97.3 95.1 92.3 79.9
Black/African American 0.8 2.3 6.1 14.6
Other 1.9 2.6 1.6 5.5

 

TABLE 16. Educational Level, %
  HMO 1 MCBS
Aged 65 and over Under age 65 Age 65 and over Under age 65
Grades 0-8 7.8 7.9 24.9 25.7
Grades 9-11 12.0 12.5 16.3 21.0
High school graduate 35.2 31.8 32.6 35.4
Some college 24.4 30.4 13.3 11.8
College graduate 8.3 8.5 7.2 3.8
Post-college work 12.4 9.0 5.8 2.4

 

TABLE 17. Marital Status, %
  HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Currently married 69.1 58.0 57.4 53.2
Widowed 22.3 6.9 33.9 8.2
Divorced/separated 6.6 19.8 5.0 18.3
Never married 2.0 15.3 3.6 20.3

 

TABLE 18. Overall Health Status of Survey Respondents, %
Rating of Health HMO 1 MCBS*
Aged 65 and over
(n=1,429)
Under age 65
(n=838)
Aged 65 and over
(n=22,757*)
Under age 65
(n=1,558*)
Excellent 5.5 3.2 17.8 4.2
Very good 26.2 9.6 25.4 8.4
Good 43.4 31.4 30.6 18.1
Fair 20.3 36.5 18.6 30.9
Poor 4.6 19.3 7.6 38.5
* in 1,000s

 

TABLE 19. Diagnoses, %
Diagnosis HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
High blood pressure 45.8 47.5 47.9 41.8
Heart problems 32.5 33.7 33.9 36.0
Cancer 21.2 16.4 17.2 13.0
Diabetes 14.7 27.9 13.8 15.8
Rheumatoid arthritis 17.3 22.1 9.4 17.2
Arthritis other than rheumatoid 51.5 44.1 45.3 40.6

 

TABLE 20. Functional Difficulty: Percent Reporting Some Degree of Difficulty
Functional Activity HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Bending, kneeling, stooping 62.0 78.7 67.9 80.5
Lifting or carrying groceries 38.5 72.5 37.8 63.9
Walking several blocks 41.4 70.7 43.3 70.3
Bathing and dressing 14.4 35.5 8.8 24.5

 

TABLE 21. Impact of Health on Social Activities: Percent Reporting Some Degree of Impact
  HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Health has limited social activities 39.8 66.8 32.8 71.7

 

TABLE 22. Overall Satisfaction, %
Level of Satisfaction HMO 1 MCBS*
Aged 65 and over
(n=1,465)
Under age 65
(n=843)
Aged 65 and over
(n=22,786*)
Under age 65
(n=1,558*)
Very satisfied 32.0 38.4 38.2 27.3
Satisfied 55.6 47.3 49.2 53.1
Neutral 10.5 9.1 3.8 8.4
Dissatisfied 1.5 3.7 1.1 3.2
Very dissatisfied 0.4 1.4 7.7 8.0
* in 1,000s

 

TABLE 23. Levels of Satisfaction for Aspects of Care, %
Aspect of Care Aged 65 and Over Under Age 65
Very satisfied/ satisfied Neutral Dissatisfied/ very dissatisfied Very satisfied/ satisfied Neutral Dissatisfied/ very dissatisfied
HMO 1
Amount of explanation or information provided 79.3 14.0 6.6 80.8 11.8 7.5
Time spent with doctor 80.8 14.1 5.1 78.6 13.0 8.4
Doctor's interest in overall health 88.4 10.1 1.5 83.9 11.4 4.8
MCBS
Amount of explanation or information provided 85.1 N/A 13.7 82.4 N/A 16.1
Time spent with doctor 83.0 N/A 16.5 77.0 N/A 21.7
Doctor's interest in overall health 85.5 N/A 6.6 80.4 N/A 9.4

 

TABLE 24. Preventive Care, %*
Preventive Practice HMO 1 MCBS
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Mammogram* 57.9 59.8 37.5 33.5
Pap smear* 39.7 49.8 32.5 41.3
Hysterectomy 51.1 44.9 40.5 44.5
Flu shot* 80.6 71.2 43.4 25.1
Pneumonia vaccine shot* 64.7 46.2 22.1 18.2
* Percent who answered "yes" to experiencing preventive care item within the past year.

 

TABLE 25. Smoking Behavior, %
  HMO 1 MCBS*
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Currently smoke 8.6 23.1 26.1 57.5
Ever smoked 52.4 57.6 57.3 70.0

 

TABLE 26. Regular Physician, %
  HMO 1 MCBS*
Aged 65 and over Under age 65 Aged 65 and over Under age 65
Have Primary Care Physician 91.2 91.1 81.5 69.9

 

TABLE 27. Significant Correlations
Measures of Satisfaction/Access Significant Variables Sign
Overall satisfaction    
Overall quality of service Asthma
Depression
+
+
Quality of care provided by doctors Asthma
Arthritis
+
+
Quality of care provided by physician assistants    
Quality of care provided by nurses Arthritis +
Time spent with doctors Asthma
Diabetes at age 40 or later
+
-
Overall access to care Bathing and dressing Arthritis +
+
Getting night and weekend care Asthma +
Getting emergency care Bathing and dressing
Bronchitis
+
+
Have regular doctor Age
Gender
Arthritis
-
+
-

View full report

Preview
Download

"96cfpk01.pdf" (pdf, 147.17Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"96cfpk02.pdf" (pdf, 45.07Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"96cfpk04.pdf" (pdf, 50.53Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"96cfpk05.pdf" (pdf, 52.03Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"96cfpk06.pdf" (pdf, 1.02Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®