Performance Improvement 1996. Health Care Financing Administration

02/01/1996

Contents

Comparative Study of the Use of Early and Periodic Screening, Detection, and Treatment and Other Preventive and Curative Health Care Services by Children Enrolled in Medicaid

Evaluation of the Maryland Access to Care Demonstration: Managed Care for Medicaid Recipients

Evaluation of the Medicaid Extension Demonstrations

Evaluation of United Mine Workers of America Demonstration

Expanded Cross-Cutting Evaluation on Medicare Prevention Demonstrations Under Consolidated Omnibus Budget Reconciliation Act

Final Evaluation Report of the 1989 Grant Program for Rural Health Transition: Send Us More Doctors, Please

Interim Report of the Evaluation of the Essential Access Community Hospital/Rural Primary Care Hospital Programs

Medicare Participating Heart Bypass Center Demonstration: Appropriateness Study

Medicare Participating Heart Bypass Center Demonstration: Data Collection Design

Medicare Participating Heart Bypass Center Demonstration: Evaluation Design

Medicare Participating Heart Bypass Center Demonstration: Final Evaluation Report--Volume One, The First Three Years

Medicare Participating Heart Bypass Center Demonstration: Final Evaluation Report--Volume Two, Marketing Activities of Participating Hospitals

Medicare Risk Program for HMOs: Final Summary Report on Findings From the Evaluation

Monitoring the Impact of Medicare Physician Payment Reform on Utilization and Access

TITLE: Comparative Study of the Use of Early and Periodic Screening, Detection, and Treatment and Other Preventive and Curative Health Care Services by Children Enrolled in Medicaid

ABSTRACT NUMBER: 058

ABSTRACT: This project was comprised of a series of individual research projects that studied the effect of the changes in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program introduced by the Omnibus Budget Reconciliation Act of 1989 on the process of providing health services to children and on the appropriateness of expenditures for the services provided in Tennessee, Georgia, Michigan, and California. These projects compared Medicaid-enrolled children in four EPSDT programs with other Medicaid-enrolled children in the four States who are not receiving EPSDT services, regarding enrollment patterns, service utilization, and expenditures, with a particular emphasis on preventive health services. They also compared Medicaid-enrolled children with non-Medicaid-enrolled children, insured and uninsured, on the use of and expenditures for preventive services and other health care services, using national survey data.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Feather Ann Davis, Ph.D.

PHONE NUMBER: 410/786-6590

PIC ID: 6236

PERFORMER ORGANIZATION: SysteMetrics Division of MedStat, Inc., Ann Arbor, MI

TITLE: Evaluation of the Maryland Access to Care Demonstration: Managed Care for Medicaid Recipients

ABSTRACT NUMBER: 059

ABSTRACT: The Maryland Access to Care (MAC) demonstration became operational in December 1991 and eventually covered about two-thirds of Medicaid recipients in the State. The targeted population was Aid to Families with Dependent Children (AFDC) recipients, Supplemental Security Income (SSI) participants, and Sixth Omnibus Budget Reconciliation Act-eligible children. The MAC program was mandatory for recipients in the MAC-eligible categories. The program matched MAC recipients with a primary medical provider (PMP) that acted as the recipient's gatekeeper to the health care system. These PMPs also continued under the standard Medicaid fee-for-service reimbursement systems, but, to encourage their participation, Medicaid fees for primary care services were increased by an average of 50 percent under the MAC program. Specialists were reimbursed for nonemergency specialty care provided to MAC patients only if these services were referred by the patients' PMPs. The evaluation employed a pre-/post-test comparison and a post-test description of program operations. The data came primarily from Medicaid enrollment and claims files and from provider surveys. The project was extended to allow the performance of additional analyses to compare the performance of office-based and hospital outpatient providers under the MAC program.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Paul J. Boben, Ph.D.

PHONE NUMBER: 410/786-6629

PIC ID: 6235

PERFORMER ORGANIZATION: People-to-People Health Foundation, Inc., Bethesda, MD

TITLE: Evaluation of the Medicaid Extension Demonstrations

ABSTRACT NUMBER: 060

ABSTRACT: This project was an evaluation of three demonstrations mandated under section 6407 of the Omnibus Budget Reconciliation Act of 1989. They evaluated alternative models for extending health insurance coverage to children under 20 years of age who lacked insurance. The demonstrations occurred in the States of Florida, Maine, and Michigan. Each State used a different strategy for providing the new coverage. Florida tested the effectiveness of marketing a school-based affordable insurance package that delivers services through a managed care network. Maine conducted a statewide program that subsidized comparable private employer-based group coverage, where such insurance was believed to be cost effective. Michigan tested the effectiveness of a public/private partnership between the State and Michigan Blue Cross and Blue Shield, using donated funds to subsidize a mainstream outpatient insurance package. The evaluation examined the effect of these demonstrations on various outcome and process measures of access to care, private insurance coverage, and cost of care. The methodology took into account the distinctiveness of the three demonstrations while incorporating a strategy that allowed for comparisons between programs in terms of penetrating the eligible population. Case studies were coupled with analysis of program data to describe the structure and processes of the demonstrations. In addition, primary data were collected through surveys of both program participants and controls. Separate analyses of program costs and program effectiveness were included.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Paul J. Boben, Ph.D.

PHONE NUMBER: 410/786-6629

PIC ID: 6234

PERFORMER ORGANIZATION: Abt Associates, Inc., Cambridge, MA

TITLE: Evaluation of United Mine Workers of America Demonstration

ABSTRACT NUMBER: 061

ABSTRACT: This is an evaluation of the United Mine Workers of America (UMWA) Health and Retirement Funds (the UMW Funds) Medicare Part B capitation demonstration. This demonstration replaced the Funds' Health Care Prepayment Plan arrangement with the Health Care Financing Administration (HCFA), in which it had been reimbursed for Medicare Part B services on a cost basis. In its place, the Funds assumed risk for Medicare Part B services under a capitated payment mechanism. The evaluation addressed the cost-effectiveness of capitation based on an analysis of changes in utilization and cost resulting from the demonstration. It also undertook a detailed case study describing the cost management programs and changes occurring in the organization as a result of the demonstration. Based on this approach, the evaluation was unable to discern a causal relationship between the demonstration and the events that occurred subsequent to its implementation. Events that happened during the demonstration may have been independent or could have been related in complicated ways. Thus, in an interim report the evaluation concluded that the demonstration had no measurable operational effect on the Funds beyond the obvious effect of ending the reimbursement dispute between HCFA and UMW Funds. The final report indicated that there was no evidence to clearly support a conclusion about the cost-effectiveness of capitation for UMW Funds' beneficiaries.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Ronald W. Lambert

PHONE NUMBER: 410/786-6624

PIC ID: 6233

PERFORMER ORGANIZATION: Abt Associates, Inc., Cambridge, MA

TITLE: Expanded Cross-Cutting Evaluation of Medicare Prevention Demonstrations Under Consolidated Omnibus Budget Reconciliation Act

ABSTRACT NUMBER: 062

ABSTRACT: This project was a cross-cutting evaluation of the five Medicare prevention demonstrations mandated by the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. These demonstrations tested the effectiveness of providing disease prevention and health promotion services to Medicare beneficiaries. Congress stipulated that the preventive health service package was to include health screenings, health risk appraisals, immunizations, and counseling and instruction in diet and nutrition, stress reduction, exercise programs, sleep regulation, injury prevention, substance abuse and mental disorders prevention, self-care (including medication use), and smoking cessation. In May 1988, cooperative agreements were awarded to five schools of public health to implement the demonstrations. Waivered services were provided between May 1989 and April 1991. A preliminary Report to Congress was submitted in July 1989. While the original legislation mandated 4-year demonstrations, the Omnibus Budget Reconciliation Act (OBRA) of 1990 extended them to 5 years. This extension allowed for an additional year of followup for purposes of evaluation, added an interim Report to Congress (which was submitted in September 1993), and required that the final Report include a comprehensive evaluation of the long-term effects of the demonstration.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Deborah C. Van Hoven

PHONE NUMBER: 410/786-6625

PIC ID: 6237

PERFORMER ORGANIZATION: Abt Associates, Inc., Cambridge, MA

TITLE: Final Evaluation Report of the 1989 Grant Program for Rural Health Transition: Send Us More Doctors, Please

ABSTRACT NUMBER: 063

ABSTRACT: This report evaluates the impact of the Rural Health Care Transition (RHCT) grant program on the cohort of 181 rural hospitals that received grants in September 1989. The report uses three methods to evaluate the program: (1) a trend analysis of all grantees to determine whether the program improved their utilization rates and finances; (2) a pregrant/postgrant comparison to examine managerial improvements; and (3) a case study, descriptive analysis of projects implemented. The report finds that (1) the grant program does not seem to affect hospital finances or managerial capacity in a measurable way, but it does help some hospitals and areas where the majority of patients served would have had to travel or go without services in the absence of the grant program projects; (2) adult day care programs are least likely to be implemented and, if implemented, to be retained; (3) patient services such as community education programs are fairly easy to implement, but are likely to be abandoned because of high cost; and (4) outpatient, home health, emergency rooms, and emergency transportation programs are most frequently implemented and retained. The report concludes that the grant program does not address fundamental problems facing rural hospitals. The program cannot change the hospitals' financial weakness, their high numbers of uninsured patients, the low demand for their services, the high cost of providing low-volume emergency services, or the shortage of rural physicians. (Final report 168 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Siddhartha Mazumdar

PHONE NUMBER: 410/786-6673

PIC ID: 5283

NTIS ACCESSION NUMBER: PB 94-142312

PERFORMER ORGANIZATION: Mathematica Policy Research, Inc., Plainsboro, NJ

TITLE: Interim Report of the Evaluation of the Essential Access Community Hospital/Rural Primary Care Hospital Programs

ABSTRACT NUMBER: 064

ABSTRACT: This report documents the initial development of the Essential Access Community Hospital (EACH) and the Rural Primary Care Hospital (RPCH) programs, which are Federal-State initiatives to maintain access to health care services in rural areas by developing rural health networks and by integrating health care. Through qualitative and quantitative analysis of background information provided by program grantees, secondary data from HCFA's Medicare Cost Reports (1987-89) and Market Area File (1988-89), and site visits to State agencies and hospitals in California, Colorado, Kansas, New York, North Carolina, South Dakota, and West Virginia, the report examines program development at the State and local levels. It finds that (1) States have made uneven progress in program development; (2) program planning and network development are difficult, labor intensive, and time consuming; and (3) the program has encouraged the development of other non-EACH, non-RPCH networks. However, the report also finds that (1) hospital commitment to RPCH conversion is weak; (2) financial stresses encourage hospitals to convert; (3) networks are shaped by competitive relationships between hospitals and by local circumstances; and (4) physicians' support, or at least their nonopposition, is critical to the success of the program. (Final report 115 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Sheldon Weisgrau

PHONE NUMBER: 410/786-6675

PIC ID: 5200

NTIS ACCESSION NUMBER: PB 94-117959

PERFORMER ORGANIZATION: Mathematica Policy Research, Inc., Plainsboro, NJ

TITLE: Medicare Participating Heart Bypass Center Demonstration: Appropriateness Study

ABSTRACT NUMBER: 065

ABSTRACT: This series of reports was prepared as part of the preapproval package for HCFA's Medicare Participating Heart Bypass Center Demonstration. The reports in this series deal with the appropriateness of coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) surgery prior to approval of the demonstration. The reports in this series include "Model for the Use of CABG and PTCA"; "Appropriateness Rating Scale for CABG and PTCA"; "Indications for Coronary Artery Bypass Graft Surgery"; "Review of Literature for Efficacy and Risks of CABG Surgery"; and "Review of Literature for Efficacy and Risks of PTCA." See also PIC ID 5958-5958.3.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Armen H. Thoumaian, Ph.D.

PHONE NUMBER: 410/966-6672

PIC ID: 5958.4

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Medicare Participating Heart Bypass Center Demonstration: Data Collection Design

ABSTRACT NUMBER: 066

ABSTRACT: This report provides information on the data collection methodology to be used in the HCFA Medicare Participating Heart Bypass Center Demonstration. This report presents the rationale for the evaluation, the data elements required, and the procedures for collecting them. It discusses several economic issues of interest to HCFA, including sources of volume increases at the demonstration sites and the relevant savings to the Medicare program (if any), and the demonstration administrative costs anticipated at the original four participating hospitals. The report also presents data collection related to the evaluation of the appropriateness of coronary artery bypass graft surgery. Finally, the report discusses the assessment of the hospitals' marketing activities in order to measure their varying levels of success at promoting the demonstration. See also PIC ID 5958-5958.2 and 5958.4. (Final report 32 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Armen H. Thoumaian, Ph.D.

PHONE NUMBER: 410/966-6672

PIC ID: 5958.3

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Medicare Participating Heart Bypass Center Demonstration: Evaluation Design

ABSTRACT NUMBER: 067

ABSTRACT: This report provides information about the design of the evaluation of HCFA's Medicare Participating Heart Bypass Center Demonstration. The report summarizes the nature of the demonstration, the number of sites that will participate, and other background information. It also discusses how the evaluation will measure (1) the economics of the demonstration; (2) the quality and appropriateness of care received under the demonstration; and (3) the marketing of the program carried out by the participating hospitals. Three primary data collection efforts are proposed, including (1) onsite case studies; (2) beneficiary telephone surveys; and (3) referring physician telephone surveys. The report also explicates a model of behavior under a global payment mechanism. See also PIC ID 5958-5958.1 and 5958.3-5958.4. (Final report 56 pages.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Armen H. Thoumaian, Ph.D.

PHONE NUMBER: 410/966-6672

PIC ID: 5958.2

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Medicare Participating Heart Bypass Center Demonstration: Final Evaluation Report--Volume One, The First Three Years

ABSTRACT NUMBER: 068

ABSTRACT: This report presents findings from the first three years of the Medicare Participating Heart Bypass Center Demonstration. This program is one of HCFA's cost-containment demonstrations. It was implemented to test the feasibility and cost-effectiveness of a negotiated package price for coronary artery bypass graft (CABG) surgery. Hospitals and physicians participating in the demonstration received a global payment for all hospital and physician services related to CABG surgery. The report finds that (1) the Medicare program saved $15.3 million on bypass patients treated in four of the seven participating hospitals from May 1991 through December 1993; (2) beneficiaries and their insurers saved another $2.3 million in Part B coinsurance payments during this same period; (3) no statistically significant trend in inpatient mortality rates was found (holding many patient risk factors constant); and (4) 97.7 percent of demonstration patients were treated appropriately with CABG surgery (assuming that none of the patients was a candidate for angioplasty--if all were assumed to be angioplasty candidates, then only 72.7 percent of the surgeries would have been considered appropriate). The report concludes that the results of the demonstration were mixed: only two of the four hospitals increased their market shares for CABG surgery, but hospital costs were significantly reduced. See also PIC ID 5958.1-5958.4.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Armen H. Thoumaian, Ph.D.

PHONE NUMBER: 410/966-6672

PIC ID: 5958

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Medicare Participating Heart Bypass Center Demonstration: Final Evaluation Report--Volume Two, Marketing Activities of Participating Hospitals

ABSTRACT NUMBER: 069

ABSTRACT: This report presents information on the marketing activities of hospitals participating in the Medicare Participating Heart Bypass Center Demonstration program, in which Medicare was charged a global fee for all hospital and inpatient physician services related to coronary artery bypass graft surgery. Seven hospitals participated in the demonstration. The report presents an overview of the participating hospitals and the markets in which they are located; the focus, structure, and content of the hospitals' marketing programs; patient volume and physician referral patterns; and consumer satisfaction. The report finds that (1) all seven hospitals have developed and are implementing marketing plans for their CABG surgery programs to increase community awareness of their institutions and promote the benefits of choosing their facilities for CABG surgery; (2) the hospitals have not addressed product attributes, price, and consumer needs and desires, but have changed the ways in which they define the content and duration of services provided in conjunction with CABG surgery; and (3) while hospitals want to use their participation in the demonstration to increase their general standing in the community and to increase patient volumes in every category, HCFA wants to determine if the program can attract CABG patients away from higher priced competitors. See also PIC ID 5958 and 5958.2-5958.4.

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Armen H. Thoumaian, Ph.D.

PHONE NUMBER: 410/966-6672

PIC ID: 5958.1

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Medicare Risk Program for HMOs: Final Summary Report on Findings From the Evaluation

ABSTRACT NUMBER: 070

ABSTRACT: Since the early 1980's, HCFA has been encouraging health maintenance organizations (HMOs) to provide Medicare coverage to enrolled beneficiaries in return for fixed prepaid premiums. This report evaluates these Medicare risk plans and their impacts on beneficiaries, the Federal Government, and participating plans. The report finds that (1) risk plans attract healthier-than-average Medicare beneficiaries, thus saving the program less than expected--in fact, HCFA paid HMOs approximately 5.7 percent more than it would have spent for these patients under a fee-for-service (FFS) plan; (2) HMOs reduce the number of hospital days and average lengths of stay, but do not reduce admissions; (3) Medicare risk plans increase the likelihood that beneficiaries receive some services, but reduce intensity or frequency of the service; (4) risk plans may spend about 10 percent less than HCFA would spend for all medical services; (5) HMOs and FFS plans produce similar outcomes for inpatients, but HMOs use fewer resources; (6) HMOs provide comparable access to ambulatory care and produce similar patient results, with fewer resources; (7) HMO enrollees are somewhat less satisfied with their care than others, but are happier with costs and benefit coverage; and (8) one-half of HMO risk plans appear to be profitable. (Final report 192 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: James Hadley

PHONE NUMBER: 410/786-6626

PIC ID: 5957

PERFORMER ORGANIZATION: Mathematica Policy Research, Inc., Plainsboro, NJ

TITLE: Monitoring the Impact of Medicare Physician Payment Reform on Utilization and Access

ABSTRACT NUMBER: 071

ABSTRACT: This report monitors changes in use of and access to physician services by population groups, geographic areas, and types of services. It also monitors possible sources of inappropriate use. The report seeks to discover whether reforms in Medicare physician payment policies have negatively influenced use of and access to services. Several measures are used to discover whether access to care has been affected, and several vulnerable population groups are monitored. The report finds that (1) the introduction of the Medicare fee schedule (MFS) has resulted in a relative increase in allowed charges for visits and consultations and a relative decrease in allowed charges for procedure-based services; (2) MFS has not caused new barriers to care for vulnerable populations, although these groups still face difficulties in accessing and using services; (3) MFS has resulted in a move away from delivery of physician services in the inpatient setting to delivery of those services in the outpatient setting; (4) the disabled have a higher percentage of those needing medical care and not receiving it than any other group; (5) vulnerable populations are at risk of not receiving Medicare-covered preventive services; and (6) beneficiaries who live in low-income areas or who are eligible for Medicaid are likely to be in poor health, and many need more continuous and appropriate ambulatory care to avoid hospitalization. (Final report 47 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research and Demonstrations

FEDERAL CONTACT: Marian Gornick

PHONE NUMBER: 410/786-6686

PIC ID: 5493

PERFORMER ORGANIZATION: Health Care Financing Administration, Baltimore, MD