Performance Improvement 2000. Disability, Aging and Long-Term Care Policy

01/01/2000

A Primer for States and Consumers on Medicaid Home and Community-Based Services

Medicaid, the principal source of financing for long-term care services, has frequently been said to have an "institutional bias," because State spending on nursing homes and institutions outweighs spending on home and community-based supports by a ratio of approximately 80 to 20. Many States have, however, demonstrated that it is possible to work within a Medicaid framework to expand home and community-based services, (HCBS) providing consumers with greater choice and control. Decreased dependence on unnecessary institutional long-term care and the expansion of consumer responsive home and community-based long-term care options are important policies of both the White House and the Secretary for the Department of Health and Human Services. To address this priority, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) proposes to develop a "primer" on existing long-term care options in Medicaid that promote consumer choices in long-term care. The primer will be an important and useful development tool for State Medicaid and aging policy and program staff, consumers and their representatives, and providers interested in the expansion of choices in long-term care, including the promotion of home and community-based options.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Kennedy, Gavin
202-690-6443

PIC ID: 7162

PERFORMER: George Washington University Medical Center, Center for Health
Outcomes Improvement Research, Washington, DC

EXPECTED DATE OF COMPLETION: 02/20/2000

A Study of Home Health Practice Variations Study

Medicare home health has been the subject of considerable research, but the actual practice of home health care has not been extensively examined. What takes place during a visit and between visits as "actual practice" has never been measured. Furthermore, the extent to which various parties participate in the decision making process, is also unknown. Such information is needed to improve understanding about actual practice and explain its variations. This study will analyze variations in home health care services, focusing on patient characteristics, provider characteristics, agency characteristics and market characteristics. Primary data will be collected at the patient and agency levels. Data from this study and the Health Care Financing Administration's (HCFA) Outcomes of Home Care Study will be used to assess the relationships between the process of home health care and its outcomes and resource use.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Katz, Ruth
202-690-6613

PIC ID: 6168

PERFORMER: Center for Health Policy Research
Denver, CO

EXPECTED DATE OF COMPLETION: 12/20/2000

Analysis of Patterns of Post-Acute and Chronic Care Services Use Among Disabled and Non- Disabled Medicare Beneficiaries: 1989-1994

This study uses the 1989 and 1994 National Long-Term Care Surveys to analyze factors that predicted growth in Medicare post-acute (i.e., home health and skilled nursing facility) benefits from the late 1980s through the mid-1990s.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Doty, Pamela
202-690-6613

PIC ID: 6768

PERFORMER: Medstat Group
Cambridge, MA

EXPECTED DATE OF COMPLETION: 09/30/2000

Analysis of the Disability Supplement to the National Health Interview Survey

The disability supplement to the National Health Interview Survey (NHIS-D) is the first comprehensive survey on disability in the United States. The survey is unique in that it focuses on several populations of persons with disabilities who are generally omitted or under-represented in national survey efforts: children, persons with mental retardation and other developmental disabilities and the working-age population. The goal of this project is to conduct a series of analyses and produce both short- term products and final reports that will inform ongoing Assistant Secretary for Planning and Evaluation (ASPE) departmental and administrative research and policy initiatives. The analyses will address a specific set of questions in four topical areas using the NHIS-D: (1) welfare receipt and disability (including chronic illness); (2) disability and chronic illness among low income populations; (3) childhood disability and chronic illness; and (4) employment and disability.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Marton, William
202-690-6613

PIC ID: 7153

PERFORMER: Urban Institute
Washington, DC

EXPECTED DATE OF COMPLETION: 03/27/2000

Assessment of Home Care Benefits Used by Holders of Private Long Term Care

This study will examine formal and informal home and community-based long-term care (LTC) services use among private insurance policy holders "in claim" (i.e., those who are receiving insurance benefits). It will compare patterns of formal and informal services use among these insurance claimants with those of a nationally representative sample (from the 1994 National Long-Term Care Survey) of disabled elders living in the community. Statistical processes will be employed to match claimants with particular characteristics (e.g., age, marital status, disability level) to elders in the national sample. The purpose of the comparison will be to measure the effects of private long-term care insurance on access to formal home care services and to determine whether or to what extent insurance-financed formal services supplement or substitute for informal family care. The study will also examine the interaction between insurance financed home care and the use of Medicare home health services.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Doty, Pamela
202-690-6613

PIC ID: 6399

PERFORMER: Lifeplans
Waltham MA

EXPECTED DATE OF COMPLETION: 03/20/2000

Characteristics of Nursing Home Residents

Caring for persons with disabilities in the least restrictive setting is a major long-term policy objective. It is important to identify nursing home residents who could be discharged to the community if appropriate home and community-based services were available. This project will analyze data from the Minimum Data Set (MDS). The MDS consists of assessments which have been conducted on all nursing home residents in selected States as part of a HCFA demonstration (and starting the summer of 1998, the data will be collected in all 50 States). Using this new data set will also more information about the medical conditions, functional needs, and specific services used by nursing home residents than was possible with previous data sets. It will also be possible to study important subpopulations, especially the nonelderly. the policy implications of the findings will be assessed.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Drabek, John, Ph.D.
202-690-6613

PIC ID: 6275

PERFORMER: University of Michigan
Ann Arbor MI

EXPECTED DATE OF COMPLETION: 09/30/2000

Development and Validation of a Performance Measure Set for the Evaluation of Medicaid Services Rendered to People with Developmental Disabilities

This project is to select and validate a performance measure set that will be used to evaluate the quality and appropriateness of Medicaid services rendered to people with developmental disabilities. It is expected that the measure set developed will be useful within HCFA's regulatory quality monitoring programs and to inform quality improvement activities. The measure set will also be available to provide information to consumers, to provide information on system wide strengths and weaknesses, and to provide information to payers of health care, including HCFA, States and private payment sources, for use in evaluating the quality and value of services. The project will first recommend and then alpha test a performance measure set to determine its utility and feasibility for use in Intermediate Care Facilities for the Mentally Retarded (ICF/MR). Effort will be made to assess information currently collected by States to determine how such information can be used as performance measures.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Couchoud, Elizabeth
410-786-6722

PIC ID: 7391

PERFORMER: Research Triangle Institute
Research Triangle Park, NC

EXPECTED DATE OF COMPLETION: 09/29/2002

Evaluation of Practice in Care (EPIC)

From 1989 to 1992, there was a 210 percent increase in Medicare expenditures for home health services. This increase in utilization has generated policy interest in measures to control expenditures without compromising quality. Medicare home health has been the subject of considerable research, but the actual practice of home health care has not been extensively examined. This study will: (1) analyze "episodes" of care under the Medicare home health benefit, (2) assess the actual practice of care, (3) determine the extent to which there is variation in practice between acute and long-term care patients, and (4) uncover the factors accounting for that variation. The study will also examine decision-making processes between patients, providers and physicians. The events that take place during a visit and between visits as "actual practice" have never been measured. Furthermore, the function of decision-making by various parties has not been observed in "actual practice". This effort to understand issues surrounding regional and practice variations of home health care delivery will aid the Department of Health and Human Services and the industry in combating fraud and abuse, as well as contribute valuable data to a future prospective payment system.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Katz, Ruth
202-690-6613

PIC ID: 5888

PERFORMER: Center for Health Policy Research
Denver, CO

EXPECTED DATE OF COMPLETION: 06/30/2000

Evaluation of the District of Columbia's 1115 Waiver for Children with Special Health Care Needs

This project, co-sponsored by ASPE and HCFA's Office of Research and Demonstrations (ORD) is an evaluation of the District of Columbia's 1115 waiver demonstration. The District's waiver is the first approved demonstration to integrate acute and long-term care services for SSI eligible children with disabilities in a single capitated payment system. The study analyzed enrollment data and documented the experiences of the District, the health plan, providers, and children and their families. The study will be used to inform both State and Federal policy makers who increasingly regard managed care as a means of containing growing health care expenditures. The first report is now available on the HHS website: http://aspe/hhs.gov/daltcp/reports/dc-yr1 es.htm.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Kennedy, Gavin
202-690-6443

PIC ID: 7361

PERFORMER: Abt Associates, Inc.
Cambridge, MA

EXPECTED DATE OF COMPLETION: 09/30/2000

Evaluation of the Oregon Medicaid Reform Demonstration

The disability supplement to the existing Health Care Financing Administration (HCFA) evaluation of the Oregon Medicaid Reform Demonstration attempts to add a disability focus to the Statewide evaluation. This supplement will focus on the experiences of disabled children and adults (physically disabled, mentally retarded, or developmentally disabled) who are enrolled in the Oregon Health Demonstration. The disability supplement will examine cost and utilization data, and will link this data to functional data collected by State agencies and managed care plans. In addition, the supplement will conduct a survey of consumers and providers to examine issues of satisfaction, access, quality, health status and functioning. See PIC ID 6166 and the 6289 series.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: McKay, Hunter
202-690-6613

PIC ID: 6166.1

PERFORMER: Health Economics Research, Inc.
Waltham, MA

EXPECTED DATE OF COMPLETION: 12/31/2000

Long Term Care Microsimulation Model

The Long-Term Care Financing Model is a resource which has been extensively used by ASPE to project future long- term care utilization and expenditures and simulate various long term care policy options. These include expansions of public financing, such as those proposed during health care reform, as well as changes to Medicaid and Medicare. The model has also been used extensively to study private sector policy options, such as the impact of further growth on private long-term care insurance and the impacts of changing trends in disability rates on long-term care use and expenditures. Recent data on disability rates, nursing home use, and home care use will be used to update existing portions of the model. In addition, the model will be expanded to include acute care use, thereby increasing the Assistant Secretary for Planning and Evaluation's (ASPE's) ability to simulate a wide range of policy options. ASPE will use this computer model for projections and policy simulation and a series of policy simulations from the revised model will be presented in reports. In addition to its previous long-term care policy uses, the revised model will enable ASPE to address acute care issues, such as the combined burden of acute and long-term care spending on the elderly. Since the model simulates the income and assets of the population, including pension and Social Security payments, the model will also be used to study other aging-related issues, such as the impact of changes in employer-sponsored health insurance for retirees.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Drabek, John, Ph.D.
202-690-6613

PIC ID: 7143

PERFORMER: The Lewin Group
Fairfax, VA

EXPECTED DATE OF COMPLETION: 09/30/2000

Longitudinal Study of Welfare Reform and Its Implications for Persons with Disabilities

This project will explore how welfare reform affects the well-being of persons with disabilities. Relevant questions to be addressed in this study include: How will welfare reform affect the well-being of adult TANF recipients with disabilities? What types of accommodations are being made to increase the work capacity of individuals with disabilities? Are persons with disabilities receiving appropriate job training that would enable them to move into the workforce? How will the well- being of children or adults with disabilities be affected if their primary caregiver has to work? How do families that contain persons with disabilities adapt to the new welfare environment? What types of changes in support systems occur to maintain the medical and other care needs of dependents with disabilities? What role do programs for persons with disabilities, such as early intervention programs and Supplemental Security Income (SSI), play following welfare reform?

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Marton, William
202-690-6613

PIC ID: 7362

PERFORMER: Johns Hopkins University
Baltimore, MD

EXPECTED DATE OF COMPLETION: 09/30/2000

Managed Delivery Systems for Medicare Beneficiaries with Disabilities and Chronic Illnesses

This project will study the experiences of elderly Medicare beneficiaries with disabilities and chronic illnesses in a managed delivery system (MDS) at four separate sites. An MDS is broadly defined as a health care system that integrates the financing and/or delivery of primary, acute and long-term care of persons for the purpose of controlling costs and improving access to, and coordination of, services across a continuum of providers. The specific goals of the study are to: (1) foster a better understanding of the unique characteristics and health/long-term care needs of elderly persons with disabilities and chronic illnesses among health plan administrators, providers and policymakers; (2) assess how managed care delivery systems meet the needs of this population and the factors that promote or impede success; and (3) describe the health care experiences of disabled elderly Medicare beneficiaries in MDS.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Harvell, Jennie
202-690-6613

PIC ID: 6391

PERFORMER: Mathematica Policy Research, Inc.
Plainsboro, NJ

EXPECTED DATE OF COMPLETION: 05/30/2001

Medicare Home Health Practice Variations

The main goal of this study is to examine how patient, provider, agency and market/regulatory forces relate to variations in Medicare home health care practices and outcomes. Three key questions form the basis of the study: (1) What is the actual practice of home health care in terms of amount, type and decision-making? (2) How are decisions about care made in light of the Health Care Financing Administration's (HCFA) Medicare home health care coverage rules? and (3) What elements of practice are associated with long lengths of stay in the home health benefit? The study will use a range of quantitative and qualitative methods to address these questions, including longitudinal data collection on samples of home health agencies and home health patients at those agencies, focus groups, case studies and analyses of secondary data.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Doty, Pamela
202-690-6613

PIC ID: 6720

PERFORMER: Center for Health Policy Research
Denver, CO

EXPECTED DATE OF COMPLETION: 03/31/2000

Medicare Post-Acute Care: Quality Measurement

This project will specify performance measures that can be used to determine the cost-effectiveness of post-acute care (PAC) services. The specific measures and data elements will apply to patient conditions that are prevalent within and across PAC settings. In addition, this project will identify the data collection methods that could be used with respect to these elements. Finally, this project will identify issues that need to be considered in applying these measures, including whether there is the need to engage in validity and reliability testing, and, if so, how.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Harvell, Jennie
202-690-6613

PIC ID: 7363

PERFORMER: Urban Institute
Washington, DC

EXPECTED DATE OF COMPLETION: 12/31/2000

Monitoring the Health Outcomes for Disabled Medicare Beneficiaries

The Balanced Budget Act (BBA) of 1997 mandated major changes in home health payment requiring the implementation of a Prospective Payment System (PPS) by October 1999 (later delayed until October 2000) and an Interim Payment System (IPS) prior to the implementation of PPS. It also contained changes in eligibility and coverage for home health services. These changes, while intended to reduce Medicare home health costs. run the risk of reducing beneficiaries' access to appropriate care and adversely affecting health outcomes, especially for beneficiaries needing the most care. Disabled Medicare beneficiaries are most vulnerable. The purpose of this project is to study the impact of recent payment policy changes on disabled Medicare beneficiaries' satisfaction and quality of life with a view toward formulating inferences that will inform national home health care policy for the disabled. The study will build on a research project recently funded by the Home Care Research Initiative of The Robert Wood Johnson Foundation that examines the direct and indirect effects of the BBA changes. The main focus is to examine BBA impacts on Medicare beneficiaries' access to care, costs, satisfaction, and quality of care.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Doty, Pamela
202-690-6613

PIC ID: 7364

PERFORMER: Laguna Research Associates
San Francisco CA

EXPECTED DATE OF COMPLETION: 09/30/2001

Outcomes and Costs Associated with Medicare Post-Acute Services in Skilled Nursing Facilities, Rehabilitation Hospitals/Units, and Home Health Settings

This project will study the cost-effectiveness of Medicare post-acute care services for Medicare beneficiaries with certain conditions, within and across post-acute care settings and over episodes of care. The study will examine the: (1) demographic and health-related characteristics of Medicare beneficiaries who use post-acute services following a hospital stay to examine how much overlap there is in the patient populations treated by each provider type and across provider types; (2) patterns of service use and costs associated with the treatment of similar patients in each setting and across episodes of care; (3) outcomes for similar Medicare beneficiaries by each post-acute provider type and across episodes including those in which multiple providers are used; (4) relationship between outcomes for similar patients and differences in the mix and intensity of services provided, and level of reimbursement across post-acute care providers and episodes of care; and (5) core measures that are most useful to incorporate into on-going reporting requirements to monitor outcomes in each post-acute care setting and across episodes of care.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Harvell, Jennie
202-690-6613

PIC ID: 6836

PERFORMER: Mathematica Policy Research, Inc.
Washington, DC

EXPECTED DATE OF COMPLETION: 08/31/2003

Personal Assistance Services "Cash and Counseling" Demonstration/Evaluation

This study will employ a classical experimental research design (i.e. random assignment of participants to treatment and control groups) in order to test the effects of "cashing out" Medicaid-funded personal assistance services for the disabled. Arkansas and New York are expected to participate in the demonstration, with an option to expand to include New Jersey and Florida. Control group members will receive "traditional" benefits in the form of case-managed home and community- based services where payments for services are made to vendors. Treatment group members will receive a monthly cash payment in an amount roughly equal to the cash value of the services that they would have received under the traditional program. It is hypothesized that cash payments will foster greater client autonomy and that, as a result, consumer satisfaction (particularly among disabled persons under age 65) will be greater. It is also hypothesized that States will save Medicaid monies (mostly in administrative expenses) from cashing out benefits.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Doty, Pamela
202-690-6613

PIC ID: 6161

PERFORMER: University of Maryland, Center on Aging
College Park MD

EXPECTED DATE OF COMPLETION: 01/20/2001

Private Payers Serving Disabled Individuals and Research Synthesis on Managed Care for Persons with Disabilities

This project serves two major purposes: (1) examine the experiences of disabled persons in managed care plans sponsored by selected large employers, and (2) synthesize the results of all components of the Office of the Assistant Secretary for Planning and Evaluation (ASPE) research plans on managed care and disability and other relevant research in order to analyze their implications for policy development. The employer-based portion of the project will: (1) develop a methodology for identifying individuals with disabilities from the health care databases maintained by several large employers and health insurers; and (2) track the impact of managed care enrollment on disabled participants and their access to appropriate services, service utilization patterns, health care expenditures and quality of care. The policy synthesis will use the information gathered in the employer-based part of the project in conjunction with Medicaid evaluations, Department of Health and Human Services (HHS) research and other relevant information in order to draw lessons for policy research on several issues. These issues include: (1) the performance of managed care in serving people with disabilities compared to fee- for-service plans; (2) how, and to what extent, managed care plans can provide comprehensive services to this population in a financially viable manner; (3) the development of risk adjustment and risk sharing in order to provide incentives to clinically appropriate and cost-effective care; and (4) the policies and practices most likely to contribute to an appropriate balance between clinical and financial success.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Drabek, John, Ph.D.
202-690-6613

PIC ID: 6398

PERFORMER: Medstat Group
Cambridge, MA

EXPECTED DATE OF COMPLETION: 09/28/2000

Research on Employment Supports for People with Disabilities

The goal of this contract is to provide information to help improve the employment rate of adults with disabilities. This includes: (1) gathering descriptive data about public and private sector employment programs, (2) examining successful employment supports, and (3) investigating factors affecting the ability to work. The products from this study will benefit the disabled and those interested in improving employment opportunities for people with significant disabilities.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Brown, Floyd
202-690-6613

PIC ID: 4917.2

PERFORMER: The Lewin Group
Fairfax, VA

EXPECTED DATE OF COMPLETION: 04/20/2000

State Activities in Serving Persons with Disabilities in Managed Care Arrangements

The goal of this project is to obtain four papers from the National Academy for State Health Policy (NASHP) and link them to the DALTCP's managed care and disability website. Three of these papers have been previously prepared by NASHP, and require updating and reformatting. The fourth paper, analyzing trends in the State Medicaid managed care programs related to disability, will require analysis of previously collected State level data. DALTCP intends, through this project, to build a collaborative relationship with NASHP as a technical assistance and case study resource for the managed care and disability research agenda within the Office of the Assistant Secretary for Planning and Evaluation. The specific objectives of this task order are as follows: (1) to re-analyze current managed care work and to glean specific information about disability policy and practice in the areas of elderly, dual eligibles, emerging practices/policies, and NASHP's State survey; and (2) to develop the appropriate mechanisms to link the NASHP web page to ASPE's web page.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: McKay, Hunter
202-690-6613

PIC ID: 7366

PERFORMER: George Washington University
Washington, DC

EXPECTED DATE OF COMPLETION: 09/30/2000

Synthesis and Analysis of Medicare Hospice Benefit

The rapid rise in Medicare hospice expenditures, particularly on behalf of nursing home residents, has drawn the attention of a wide variety of health policymakers and the Office of the Inspector General (OIG). The OIG has advanced recommendations to modify how Medicare and Medicaid will pay for these services. However, a larger study is needed to examine key hospice trends nationally and in selected States. Additional information on the Medicare hospice benefit, including trends in utilization and expenditures, who is covered, and where, will help inform health policymakers as they consider alternative hospice benefit and payment designs. This project will describe trends and issues with the Medicare hospice benefit, particularly with respect to nursing home residents who elect this benefit. Information will be gathered through a review of the literature, discussion with key informants, and an analysis of claims, assessment and provider data. This project will: (1) examine trends in Medicare and Medicaid hospice and non-hospice utilization and expenditures for hospice and other similar beneficiaries; and (2) compare the quality of care for hospice beneficiaries.

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Harvell, Jennie
202-690-6613

PIC ID: 7154

PERFORMER: Urban Institute
Washington, DC

EXPECTED DATE OF COMPLETION: 01/31/2000