Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. B. Characteristics of the Survey Sample of Seniors with Hip Fracture or Stroke

01/01/2002

We also used information collected in the survey of 301 seniors, 104 of whom had a recent hip fracture and 201 of whom had experienced a recent stroke (4 respondents had both a hip fracture and a stroke). These seniors are a representative sample of all the hip fracture and stroke cases at the MCOs during the months in 1999 when we selected the sample. Thus, our samples provide a good indication of the experiences of hip fracture and stroke cases at these MCOs, despite the fact that the overall samples are small.23

This survey had two waves, one 3 to 4 months after the event and the other 10 months after (see Appendix A Exhibits A.3 through and A.6). This length of follow-up should be sufficient to capture the recovery period for the vast majority of hip fracture and stroke patients. While a proportion of hip fracture patients do not regain pre-fracture activity levels by this time, most recovery in ability to walk and to perform activities of daily living occurs by six months (Magaziner et al. 1990). Similarly, studies suggest that the best functional recovery is achieved within 8.5 weeks of a mild stroke, within 13 weeks of a moderate stroke, within 17 weeks of a severe stroke, and within 20 weeks of a very severe stroke (Jorgensen et al. 1995).

For analytic purposes, we compared the survey responses from the two group MCOs (Aspen and Kaiser Colorado) with those from the IPA model MCO (Keystone East). This analytical grouping reflects the fact that we observed structural differences between these two types of MCOs, as well as the fact that the small sample sizes available for the two group MCOs make it difficult to analyze them separately. The structural differences were described in Chapter IV. We found that the group models appeared to foster a higher level of mutual purpose and vision between the health plan and physicians than did the IPA model, which contracts with independent physicians and group practices. At the same time, the group MCOs appeared to be more restricted in their networks and delivery capacity, while the IPA model MCOs had a bigger network and offered members more choice. (In this discussion, we focus only on Aspen Medical Group and not on the broader network provided by Medica. As noted in Chapter V, our sample of high-risk seniors from Aspen appeared to think of choice in terms of what the medical group could provide rather than what Medica could provide).

Our samples of seniors with hip fracture or stroke differed substantially between the group and IPA MCOs (Table VI.1), although those differences generally reflect differences in the overall populations at the MCOs and the populations in their service areas. For example, seniors in our sample from the IPA model MCO (Keystone East) were more likely to be nonwhite, reflecting the population differences between Philadelphia (where Keystone East is based) and the other two sites. Similarly, the hip fracture and stroke samples from the group models tended to be slightly older than those from the IPA model. This reflects the high average age among all enrollees at Aspen and Kaiser Colorado (Table II.6).

It is particularly interesting to note that a substantial fraction of our sample of seniors report having had a hip fracture or stroke prior to the one that led to their inclusion in our survey. Among the group MCOs, about a quarter of the sample had a prior stroke, and almost as many had a prior hip fracture. The sample from Keystone East was slightly more likely than the sample from the two group MCOs to have had a prior stroke and about half as likely to have had a prior hip fracture. This differential experience should be kept in mind when comparing the experience of our samples from the two types of MCOs.

TABLE VI.1. Characteristics of Members with Hip Fracture or Stroke Three Months Prior to Their, by Type of MCO
(Percentages)
    Group or Delegated  
Model MCO (n=109)
IPA Model
  MCO (n=278)  
Age
   65 to 84 71.4 81.1
   85 or older 27.4 18.9
Race White 85.4 76.5
Education High School or Less 58.5 81.2
Reports Having Medicaid Coverage   27.6 15.7
Income Less than $20,000/year 58.5 72.0
Married 51.0 47.0
Lives Alone 31.7 20.7
Previous Stroke 27.1 32.1
History of Hip Fractures 21.3 11.0
History of Dementia 11.7 14.0

We also find substantial evidence of the organizational complexity of the care received by seniors who have had a stroke or hip fracture (Table VI.2). As would be expected, most of these sample members have seen a specialist and a therapist in the four months since their event.

TABLE VI.2. Organizationally Complex Care among Sample Members with Hip Fracture or Stroke in the Three Months Following Their Event, by Type of MCO Model
(percentages)
    Members with Hip Fracture or Stroke (n=395)  
  Group or Delegated  
Model HMO (n=112)
IPA Model
  HMO (n=283)  
Four or More Prescription Medications 59.0 58.7
Uses More than One Assistive Device 59.4 58.6
Has One or More Caregivers 24.9 30.7
Received Transportation to Medical Appointments in Past 12 Months   13.5 9.9
Received Home Health Services in Past 12 Months 59.8 71.0
Received Home-Delivered Meals in Past 12 Months 9.6 5.3
Seen by One or More Specialists Since Event 65.7 75.4
Seen by One or More Therapists Since Eventa 73.7 76.5
  1. “Therapists” includes physical therapists, occupational therapists, and speech therapists.

We noted that a fair number of seniors (13 to 14 percent) in our hip fracture and stroke sample reported instances where a lack of assistance led to a problem, such as being unable to bathe as often as they wanted (Table VI.3). In general, the pattern of problems was similar for the two types of MCOs, although sample members from the group MCOs were more likely to have reported lacking assistance with transferring. This difference may be due to chance, because we saw nothing in our site visits or focus groups that would explain why there should be more transfer-related problems at the group models. The estimates in Table VI.3 were regression adjusted to ensure that the differences in unmet need among MCOs were not due to underlying differences in the characteristics of the sample members.

TABLE VI.3. Unmet Needs of Members with Hip Fracture or Stroke, Three Months after Their Event, by MCO Type
    Members with Hip Fracture or Stroke (n=395)  
  Group or Delegated  
Model MCOs (n=112)
  IPA Model  
MCO (n=283)
Identified Inadequate Assistance with One or More ADLs 14.8 13.1
Unable to Bathe Due to Inadequate Assistance 20.4 23.5
Unable to Transfer Appropriately Due to Inadequate Assistance 30.2 12.7
Unable to Take Recommended Dose of Medication Because of Financial Reasons in Past 12 Months   8.7 9.4
Unable to Afford Prescription Medication in Past 12 Months 4.9 4.0
NOTE: Estimates have been regression adjusted to control for case mix differences among the different types of MCOs. The control variables are listed in Appendix Table A.1.

We also found that many of the seniors in our sample would have been willing to pay an additional premium to obtain additional services, particularly for help traveling to medical appointments (Table VI.4). Between 20 and 25 percent of the seniors would have paid an extra $5 a month for transportation assistance, and 9 to 14 percent would have paid $20 a month extra. At the same time, the survey data imply that most of the seniors in our sample would not be willing to pay extra for these services, despite dealing with their recovery from a recent hip fracture or stroke. None of the small differences between the group and IPA model were statistically significant.

TABLE VI.4. Willingness to Pay Out-of-Pocket Expenses for Additional Services among Members with Hip Fracture or Stroke, Comparing Group or Delegated Model HMO with IPA Model HMO
  Service and Price Options     Members with Hip Fracture or Stroke (n=395)  
  Group or Delegated  
Model HMO (n=112)
IPA Model
  HMO (n=283)  
Proportion of Members Willing to Pay Additional Fee for Professionals to Assist with Treatment Compliance
   Willing to pay $5 a month 7.2 12.2
   Willing to pay $20 a month 4.5 7.5
Proportion of Members Willing to Pay Fee for Regular Exercise Program
   Willing to pay $5 a month 15.9 19.0
   Willing to pay $20 a month 5.8 6.6
Proportion of Members Willing to Pay Additional Fee for Transportation Service to Medical Appointments
   Willing to pay $5 a month 24.8 20.0
   Willing to pay $20 a month 13.8 9.4
Proportion of Members Not Enrolled in Care Management Who Would Pay Additional Fee for Similar Services
   Willing to pay $5 a month 17.3 15.7
   Willing to pay $20 a month 8.8 8.5
NOTE: Estimates have been regression adjusted to control for case mix differences among the different types of MCOs. The control variables are listed in Table II.6

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