The SASH intervention group for this evaluation memorandum consists of Medicare FFS beneficiaries residing in SASH properties who have also been attributed to practices participating in the Blueprint for Health and the MAPCP Demonstration from July 1, 2011 through June 30, 2013. Only SASH participants who have signed a consent form to share their personal information are included in this analysis. There are several reasons for this restriction. First, beneficiaries who consent to have sharing of their personal information with other medical and service providers are considered full participants and are most likely to receive the most benefit from the SASH program. Second, for this subset of SASH participants, CSC was able to provide us with name, date of birth, Medicare identification number, and Social Security number (SSN). We use these variables in addition to information obtained from the Medicare EDB to link the SASH participant lists to Medicare claims data and HUD data. Community residing SASH program participants are excluded from this current analysis but consideration will be given to including them in subsequent analyses. The primary reason for exclusion is the difficulty linking comparison group beneficiaries to housing properties in the same geographic area. Under the SASH program, only Medicare beneficiaries residing near a SASH property can participate.
The SASH program sites included in this year's analysis are those that implemented the SASH program prior to July 1, 2013. Designated SASH sites include a range of non-profit affordable housing properties funded through a variety of sources, including HUD, the Low Income Housing Tax Credit (LIHTC), the U.S. Department of Agriculture Rural Development (USDA), and other sources available through the State of Vermont. Sites also include a few mobile home parks. This current analysis includes only properties that receive funding assistance from HUD. This includes properties receiving assistance through HUD's multi-family programs, such as Section 202 and Section 8, and the public housing program.
The analysis is currently limited to these types of communities because we were able to obtain information on both the properties and the residents in the properties, which allows us to link to the residents' Medicare data. This is necessary, in particular, to draw the comparison group sample and to create a propensity score (PS) for matching on property characteristics and to adjust estimation standard errors for clustering at the property level. Properties that receive multiple forms of funding assistance are included in the analysis, if one of the funding sources is HUD. For example, if a property receives LIHTC funding and also receives Section 8 assistance, that property is included. It also includes individuals living in a non-HUD-assisted SASH housing site who are receiving rental assistance through a project-based voucher or tenant-based voucher (i.e. housing choice voucher) provided by the public housing authorities. For example, a property that is funded through the LIHTC program may have project-based vouchers for some of their units and/or may accept housing choice vouchers. These individuals are represented in the "voucher" count under the "SASH program properties" in Table 1. These voucher recipients are included only because they reside in a designated SASH housing site. No other voucher recipients are included in the SASH or comparison group samples.
In future analyses, we will be able to access data on LIHTC-funded properties and residents and will be able to expand our analyses to include these additional properties and residents. We will be unable to include properties funded through the USDA, the State of Vermont (other than LIHTC) or the mobile home parks that do not also receive assistance through HUD or LIHTC. This is because we cannot identify comparable properties and residents in our comparison areas for these properties. These excluded properties will represent a small portion of the total SASH properties.
|TABLE 1. Characteristics of Properties in Which Medicare FFS SASH Program Participants and Comparison Group Beneficiaries Reside|
|Property Characteristics|| SASH Program
|Properties Associated with
|Properties Associated with
|Total Number of Properties in TRACS||37||104||124|
|Mean Number of Units||38||25||70|
|Mean Occupancy Length||6||6||6|
|Mean Household Size||1||2||1|
|Mean Household Income||$14,296||$14,771||$13,863|
|Mean Tenant Rent||$303||$311||$256|
|Mean Percent Elderly Residents||72%||41%||59%|
|Section 8 (%)||81%||88%||76%|
|Other Financing (%)||19%||12%||24%|
|Mean OPIIS Risk Score||6.9||6.4||7.1|
|Median Household Income (by County)||$51,617||$50,618||$44,393|
|Average Annual Medicare Expenditures||$6,878||$6,954||$7,673|
|Mean Primary Care Physicians per 100,000 Population||108||102||45|
|Total Number of Properties in PIC||11||3||37|
|Mean Number of Units||159||155||151|
|Mean Occupancy Length (years)||6.4||11.9||6.8|
|Mean Household Size||2||3||2|
|Mean Household Income||$16,901||$22,241||$16,716|
|Mean Tenant Rent||$325||$367||$269|
|Elderly Residents (%)||34%||26%||38%|
|Public Housing (%)||91%||100%||100%|
|NOTE: HUD supplied data are from calendar year 2012.|
We would like to note that important CSC properties are excluded from this analysis because we do not have resident-level data available for LIHTC properties. For example, the SASH pilot was conducted at a LIHTC community, Heineberg, and this property and its residents are currently excluded. Thus, we may not have a representative sample of SASH participants for this early evaluation and have excluded some Medicare beneficiaries with the longest exposure to the SASH program. Future analyses will include a greater percentage of SASH participants.
As of June 30, 2013, 1,502 Medicare FFS beneficiaries were participating in the SASH program. After applying a number of beneficiary and property exclusion filters as noted above, the SASH program sample for this analysis is 549 Medicare beneficiaries. The two primary reasons for exclusion include: (1) not being attributed to a Blueprint for Health practice participating in the MAPCP Demonstration as of June 30, 2013; and (2) a resident in non-HUD housing. A comparison of health status and demographic characteristics of SASH participants with Medicare beneficiaries not included in this year's analysis found them to be similar.
The comparison group comprises Medicare FFS beneficiaries residing in non-SASH program HUD properties. Comparison beneficiaries are separated into two distinct groups. The first comparison group was drawn from residents of non-SASH program properties in Vermont and consists of 1,143 Medicare FFS beneficiaries participating in the MAPCP Demonstration. The second group of beneficiaries was drawn from a rural geographic area in upstate New York State that does not have a MAPCP Demonstration program but are residents of similar supported properties. A total of 1,903 Medicare FFS beneficiaries comprise the second comparison group.
We use these two comparison groups to evaluate the following two SASH program effects:
SASH/MAPCP Demonstration beneficiaries versus non-SASH/MAPCP Demonstration beneficiaries: this comparison yields estimates of the SASH program effect (among MAPCP Demonstration beneficiaries).
SASH/MAPCP Demonstration beneficiaries versus non-SASH/non-MAPCP Demonstration beneficiaries: this comparison yields estimates of the combined SASH/MAPCP Demonstration effect.
Since the comparison group may differ from the intervention group in terms of baseline characteristics, all descriptive statistics and outcome analysis are re-weighted using weights from a PS model (see Appendix C). PS weights attempt to balance the intervention and comparison groups with respect to baseline characteristics to reduce the potential for bias in the estimate of the intervention effect.
Descriptive analyses present unweighted and weighted beneficiary characteristics at baseline. Baseline is defined as the year before the launch of the MAPCP Demonstration and the SASH program (July 1, 2010 - June 30, 2011). Variation between SASH program beneficiaries and the comparison groups are quantified using standardized differences (Austin, 2011). A standardized difference greater than 0.10 or less than -0.10 reflects a meaningful difference between group means. For this memorandum, we also report average quarterly outcomes during baseline and the first 24 months of the SASH program. Regression results for these outcomes are given in Section 4.2.