Service Use and Transitions: Decisions, Choices and Care Management among an Admissions Cohort of Privately Insured Disabled Elders. III. SAMPLE AND STUDY DESIGN


Ten LTC insurance companies contributed sample to this study. These companies generate in excess of 80% of all LTC claims and are among the major sellers of insurance in the market (LifePlans 2005). These include: (1) Aegon; (2) Aetna; (3) Bankers Life and Casualty; (4) Conseco Senior Health Services; (5) Genworth Financial; (6) John Hancock; (7) MedAmerica; (8) Penn Treaty; (9) Prudential; and (10) UnumProvident. The sample of individuals is therefore representative in that it was drawn from companies accounting for diverse market segments and policy designs that employ differing underwriting and claims management strategies.

In order to qualify for sample inclusion, the following criteria had to be met:

  1. An individual had to have begun using paid services in their current service setting within the last 120 days or had to anticipate beginning paid service use within 60 days; and,
  2. They had to have an LTC policy that covered care in all three service modalities, that is, nursing home, home care, and assisted living; and,
  3. They intended to file a claim or had already filed a claim with their LTC insurance company.

To accomplish sample fulfillment, each of the companies sent referrals of individuals filing a claim or requesting claims packages in order to file a claim. These referrals were received by the company and sent to LifePlans randomly. There was no up-front sample selection. We then called to determine if they met the above criteria. If an individual was “qualified” they were then asked if they would be willing to participate in a national study that involved a series of in-person and telephonic interviews. Of the total qualified sample, 1,474 individuals agreed to participate, this representing an 81% response rate. Table 1 below shows the distribution of the referral sample and ultimate study sample.

TABLE 1: Referral and Study Sample
Sample Status Number
Total Referrals 2,523
Non-Qualified Referrals 700
Qualified Referrals 1,823
Refused to Participatea 349
Study Sample 1,474
Response Rateb 81%
  1. We obtained basic demographic, ADL and IADL information on those who refused and they did not differ significantly on these measures from those who agreed to participate.
  2. This is calculated by taking the total study sample divided by the number of qualified referrals.

All of these individuals were classified into one of four categories:

  1. Receiving paid services and making claims for nursing home care;
  2. Receiving paid services and making claims for assisted living;
  3. Receiving paid services and making claims for community-based care;
  4. Not yet receiving paid services but expected to within the next 60 days.

Within two days after an individual agreed to participate in the study, an appointment was scheduled with a nurse to conduct a full in-person assessment. All interviewers were experienced nurses with a minimum of two years of experience in geriatric assessment. All had previous experience in assessing the functional (e.g., ADLs and IADLs) and cognitive (e.g., Short Portable Mental Status Questionnaire (SPMSQ)) status of disabled elders. Moreover, these nurses were trained to administer specific study questions related to service choice, provider evaluation, care management, and other questions related to the attitudes and opinions of the claimant. When a respondent could not answer questions due to cognitive impairment or physical weakness, interviewer nurses worked with proxy respondents, typically a spouse or daughter.2

The major categories of information collected on the admissions cohort of claimants included basic demographic information (i.e., age, gender, marital status, education, income level, presence of children near household, etc.); service use data (i.e., type, intensity, duration, and start date of formal and family care); use of care management (i.e., was it offered, was it used, is there a care plan, developed, etc.); and health and disability data (i.e., ADLs, IADLs, SPMSQ, behavioral assessment, information on number of medications, etc.). We also obtained information on aspects of their current living situation and physical environment.

The interview focused on the reasons why a particular choice was made regarding service use and the extent to which it had to do with the availability and/or quality of existing service infrastructure, family support, insurance coverage, and care manager recommendation. We also asked a series of evaluative questions about the role of the care manager (if indeed one was used) and in cases where an individual opted not to use a care manager, the reasons behind that decision.

After the initial in-person assessment was completed, we began a period of follow-up that consisted of a telephonic interview every four months. The follow-up period was expected to last for approximately a two-year period, that is, seven additional phone interviews after the baseline interview was completed. The purpose of these interviews was to track the functional, cognitive, medical, and service use status of the claimant. In this way, we could gain a “real-time” understanding of the factors behind various transitions, in cases where they occur.

Participating insurers agreed to provide administrative data on LTC policy designs and on claims payments. We have worked with the companies on a common format and many of the computer programs have already been developed so that data transfer can occur electronically. All participants initially agreed to provide data in this jointly developed format.

In this report, we present findings derived from the in-person baseline assessments of individuals entering the LTC system. We have completed two telephone interviews with all of the participants at the writing of this report and are continuing with the remaining follow-up. Another report will be issued on the findings from the first two telephone follow-ups once the data has been cleaned and analyzed.

It is important to note that the findings below are based on weighted data. Once all of the responses were collected, we developed a standard weight based on the in-force market share of each of the participating companies. Most of the data collection for the admissions cohort occurred in 2003 and 2004 (with a small number occurring in 2005), therefore we used the in-force market share of the companies for these two years to compute a weight for each company. These market share numbers were obtained from the 2003 and 2004 National Association of Insurance Commissioners (NAIC) experience exhibits, as well as the 2003 and 2004 Top Writers Survey conducted by LifePlans. In this manner, we assure that we are not giving too much weight to companies with smaller market shares that contributed larger samples to the survey and alternatively, too little weight to companies with larger market shares, but smaller samples. All of the tables and charts that follow are based on analyses done with the weighted sample unless otherwise noted.

For the purposes of this report, the term claimant refers to all LTC insurance policyholders whose names were forwarded by their insurance company for inclusion in the study based on the aforementioned criteria. However, it should be noted that a certain number of these “claimants” will not become paid claimants for reasons such as not meeting their policy’s claim eligibility requirements, getting better before their policy’s elimination period has expired or because they simply changed their mind about filing a claim with the LTC insurance company. During subsequent telephone waves, we will ask each respondent whether or not they have filed a claim with their insurance company and whether or not it has been approved and will report on these findings in future reports. We will also be obtaining insurance company provided claim data and will know from that whether any claims had been paid out under the policy during the study period. We did make the decision to continue to follow everyone, regardless of whether they actually receive payment for covered services under their policy so that we can observe the health status and use of paid services of all those who met the criteria at baseline.

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