Performance Improvement 2003. Office of Disability, Aging, and Long-Term Care Policy


Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans

This case study examined four well-regarded managed care organizations (MCOs). While the innovations utilized by the MCOs appear to have improved care and produced high levels of satisfaction among high-risk seniors, some unmet needs remain. The study found that the four MCOs made numerous innovations to improve care delivery for elderly Medicare beneficiaries with chronic illnesses and disabilities. These MCOs used the flexibility provided by capitation to add new services, including screening and other programs to identify high-risk seniors, care management and disease management, network credentialing, occasional provision of off-policy benefits, and better coordination and flexibility in the delivery of inpatient, subacute, and home health services. The MCOs’ contracts focused on the primarily medical services covered by Medicare and do not obligate (or pay) the MCOs to address seniors’ needs for long-term support services, housing, transportation to routine care, or the myriad of other types of nonmedical assistance high-risk seniors may need to maintain their functioning and independence. The report recommends more comprehensive or intensive methods to address the full spectrum of needs such as more expansive contracts, new payment strategies, and strong evidence of effectiveness.

FEDERAL CONTACT: Jennie Harvell, 202-690-6443 PIC ID: 6391.1

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

Designing and Conducting a Survey of High Risk Seniors: Methodology from an Evaluation of Managed Care Organizations

This was a survey of Medicare beneficiaries enrolled in three managed care organizations (MCOs) that participated in the Medicare+Choice program: Keystone MCO East, Kaiser Permanente--Colorado, and Aspen Medical Group. The study identified three groups of seniors with severe limitations or multiple chronic conditions who had been identified as high risk by their MCO. These beneficiaries had been enrolled in their MCO’s care management program, had attained advanced age (over 84 years old), and had experienced a recent hip fracture or stroke. This group provided a convenient way of illustrating the experiences of seniors whose high-risk status is known to their MCO.

FEDERAL CONTACT: Jennie Harvell, 202-690-6443 PIC ID: 6391

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

How Managed Care Has Affected Working-Age Medicaid Beneficiaries with Disabilities and Chronic Illnesses: A Synthesis of Literature, 1995-2001

The purpose of this study was to synthesize recent research on the performance of managed care plans in caring for persons with disabilities, summarize research on current trends in enrollment of disabled persons into Medicaid managed care programs, and recommend areas for future research. Since the mid- 1990s, a number of research institutions initiated projects to assess how well disabled persons are cared for in managed care settings. Past research has focused on many different aspects of managed care and disability and used a wide variety of research designs. As a step toward developing a new research agenda, areas of concentration were identified. A literature review found that progress in these areas would enhance managed care systems for working-age Medicaid beneficiaries with disabilities and chronic illnesses. These areas of needed concentration are: (1) define needs more clearly for purposes of program planning -- the heterogeneity of needs, capacities, and attitudes within the large population suggests that a range of managed care practices and products is needed to promote positive health outcomes, (2) establishing system goals -- moving toward a shared understanding of the goals for the system of care will be a critical step in establishing a foundation for a national research agenda, (3) improved understand of how to change systems-- given a consensus on important goals, some changes in current practices and procedures will be required. Cutting across all of these areas is the need for adequate data; many critical questions will be answered only with better encounter data for working-age adults in Medicaid managed care plans with databases that shed light on patterns of cost and service use over time and across multiple service providers.

FEDERAL CONTACT: Hunter McKay, 202-690-6443 PIC ID: 7560

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

Medicaid Buy-In Programs: Case Studies of Early Implementer States

Today, individuals with significant disabilities have greater opportunities for employment than ever before in the history of our Nation. Improved public understanding of disability and innovations in assistive technology, medical treatment, and rehabilitation aided these opportunities. The project had several purposes: to examine and describe the early implementation experiences of states that have opted for  the Medicaid Buy-In for working disabled persons. It also used the descriptive information to inform and provide technical assistance to state policy makers. The report informed federal policy makers regarding states’ experiences implementing Medicaid Buy-In programs. It also used the descriptive information to inform others in the state, including persons with disabilities, service providers, and employers about the range of policy options and tradeoffs that can be made in developing and improving Medicaid Buy-In programs as part of efforts to improve systems that support the employment of persons with disabilities. A case study discussed the design features of each state’s Medicaid Buy-In program within the context of the state’s Medicaid program and other initiatives. The study included descriptions of the: (1) SSI state supplementation policies and the regular Medicaid eligibility categories, (2) Medicaid Buy-In program and comprehensive work incentive initiatives, and (3) relationship between the SSI state supplementation program, regular Medicaid eligibility categories and the Medicaid Buy-In program. The findings in these three sections built on the fact that every state with a Medicaid Buy-In program and every state contemplating such a program started from a different baseline against which to measure impact and change.

FEDERAL CONTACT: Andreas Frank, 202-690-6443 PIC ID: 7556

PERFORMER: George Washington University Medical Center, Washington, DC

Medication Use By Medicare Beneficiaries Living in Nursing Homes and Assisted Living Facilities

This study compared medication use by Medicare beneficiaries living in nursing homes and assisted living facilities. Descriptions of medication use included the average number of drug mentions per month of stay (scheduled and PRN drugs), and prevalence and duration of therapy by major drug classes. Characteristics of institutionalized beneficiaries that were studied include: demographic, income, coverage, and residence, level of care, morbidity/mortality, and activities of daily living. Estimates of institutional drug use nationally served as the first benchmarks of prescribing patterns in nursing homes and assisted living facilities. Medicare beneficiaries in these settings typically received many different kinds of medications and at least a third had monthly drug regimens that include more than nine different medications. Future research should assess the appropriateness of these drug therapies. Associations detected between having Medicare supplemental coverage and prescribing practices in assisted living facilities prompt questions about sufficient drug coverage that deserve further investigation.

FEDERAL CONTACT: Andreas Frank, 202-690-6443 PIC ID: 7768

PERFORMER: University of Maryland, College Park, MD

The Contribution of Medication Use to Recent Trends in Old-Age Functioning

The purpose of this study was to explore the extent to which changes in medication use accounted for improvements in functioning among older Americans. In order to understand the consequences of disability declines for such programs, better insight into the causes driving the trend was needed. After nearly a decade of debate among academics and policy makers, a consensus has emerged that disability rates among older Americans have declined over the last fifteen years. However, the implications of such trends for publicly funded programs such as Medicare, Medicaid, and Social Security remain far from clear. Using several waves of the Health and Retirement Study (HRS), a nationally representative survey of non-institutionalized Americans ages 51-61, we examined changes during the 1990s in the prevalence of functional limitations and medication use associated with five highly prevalent and often debilitating chronic conditions: hypertension, diabetes, lung disease, stroke, and arthritis. For Americans of pre- retirement age (51-61) and for subgroups of this age group with specific chronic conditions the study explored the following questions: (1) has functioning improved, (2) has medication use increased, (3) do changes in medication use account for improvements in functioning, (4) have improvements over time been greater for those groups reporting medication use? We found that the average number of functional limitations declined. Statistically significant improvements were found among those reporting hypertension, diabetes, and arthritis. When we limited the analysis to 53-63 year olds in 1994 and 2000, we found no significant improvement in functioning, except among those reporting no arthritis, those who were not married, and those with no liquid assets.  Finally, we found no evidence that improvements in functioning were larger for Americans taking medications.

FEDERAL CONTACT: William Marton, 202-690-6443 PIC ID: 7770

PERFORMER: Philadelphia Geriatric Center, Philadelphia, PA

The Medicaid Buy-In Program: Lessons Learned from Nine “Early Implementer” States

This report discusses findings from case studies of nine states operating Medicaid Buy-In programs for working persons with disabilities. It is the second of three reports. The first included in-depth case studies of nine early implementer states entitled, “Medicaid Buy-In Programs: Case Studies of Early Implementer States.” For many individual Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) recipients, the risk of losing Medicaid coverage linked to their case benefits was a powerful work disincentive. Eliminating barriers to health care and creating incentives to work can greatly improve financial independence and well-being. This paper examines state decisions concerning program eligibility, their approaches to estimating program enrollment and costs, and the patterns of program enrollment. The report seeks to assist stakeholders to design and implement Medicaid Buy-In programs and related work incentive initiatives. Medicaid Buy-In programs typically are managed by state Medicaid agencies with significant input from consumers and assistance from other state agencies. It was found that (1) stakeholder involvement was important in program design, (2) the Medicaid Buy-In program was linked to other employment supports, and (3) the state Medicaid agency usually worked with other state agencies to support persons with disabilities in the workplace. It was also found that eligibility standards and cost-sharing policies show considerable variation across the states and may have a significant impact on program enrollment. Finally, state policies on general Medicaid eligibility, SSI, and state SSI supplementation and federal policies on SSDI affected Medicaid access for working persons with disabilities.

FEDERAL CONTACT: Andreas Frank, 202-690-6443 PIC ID: 7556.1

PERFORMER: George Washington University, Washington, DC

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