Showing papers in "Health Care Financing Review in 2001"

Adjusting Performance Measures to Ensure Equitable Plan Comparisons.

Abstract: When comparing health plans on scores from the Medicare Managed Care Consumer Assessment of Health Plans (MMC-CAHPS®) survey, the results should be adjusted for patient characteristics, not under the control of health plans, that might affect survey results We developed an adjustment model that uses self-reported measures of health status, age, education, and whether someone helped the respondent with the questionnaire The associations of health and education with survey responses differed by HCFA administrative region Consequently, we recommend that the case-mix model include regional interactions Analyses of the impact of adjustment show that the adjustments were usually small but not negligible

Medicare Managed Care CAHPS(®): A Tool for Performance Improvement.

Abstract: The Medicare+Choice (M+C) program, created by the 1997 Balanced Budget Act (BBA), expands Medicare’s health insur­ ance options to include a wider range of health plan options. In this article, we describe the Consumer Assessment of Health Plans Study (CAHPS®) survey and its use with beneficiaries receiving care through Medicare managed care (MMC) plans. We also discuss the implications of these efforts for future quality improvement efforts.

Overview, History, and Objectives of Performance Measurement

Abstract: This article provides an overview of health care performance measurement, including a chronological history of the major developments in the performance measurement field. It is not intended to be all-encompassing in its descriptions of events and organizations but, rather, its purpose is to provide a broad historical context for describing health care performance measurement activities of the past 50 years. The article also highlights the key constituents driving performance measurement (government payers, private sector regulators, business coalitions, health care providers, and health care consumers), how they have influenced what is measured (the content of performance measurement), and why. The article concludes by establishing the commonalities among constituents and forecasts what the foreseeable future may hold regarding performance measurement.

State Medicaid programs offering personal care services.

Abstract: Two Medicaid programs offer personal care services: (1) the Title XIX Personal Care Services (PCS) optional State plan benefit; and (2) the 1915(c) home and community-based services (HCBS) waivers. By 1998-1999, 26 States offered the PCS optional State plan benefit; 45 offered personal care services via a waiver(s). Nationwide, the former program was larger. The latter was the more popular administrative mechanism, possibly because it more reliably controls growth. States vary dramatically in terms of Medicaid personal care. Medicaid personal care participants per 1,000 State population ranged from 7.33 to 0.04. Per capita expenditures ranged from $91.21 to $0.02.

Reconciling medical expenditure estimates from the MEPS and the NHA, 1996.

Abstract: This article compares 1996 estimates of national medical care expenditures from the Medical Expenditure Panel Survey (MEPS) and the National Health Accounts (NHA). The MEPS estimate for total expenditures in 1996 was $548 billion; whereas, the NHA estimate for personal health care (PHC) in 1996 was $912 billion. Much of this apparent difference, however, arises from differences in scope between MEPS and NHA—rather than from differences in estimates for comparably-defined expenditures. We adjusted the NHA for differences in included populations and types of services covered, finding a much smaller difference between MEPS and a comparably-defined NHA.

Long-term care hospitals under Medicare: facility-level characteristics.

Abstract: Though accounting for only a small percentage of total Medicare spending, long-term care hospitals (LTCHs) (defined as having an average length of stay [LOS] of 25 days or more) have been growing, in number and in Medicare expenditures, at a rapid rate in recent years. Because they have not been widely studied, we conducted research to describe the characteristics of this increasingly important Medicare provider type. We found that most LTCHs specialize in the provision of respiratory care or rehabilitation. Information from this study can help inform the development of a Medicare prospective payment system for LTCHs. (Health Care Financing Review 2001 Winter; 23(2):1-18).

Access to Care and Use of Health Services by Low-Income Women

Abstract: Data from the 1997 National Survey of America's Families (NSAF) are used to analyze access to care and use of health care services for low-income women. Three groups of women are examined: those with Medicaid coverage, those with private coverage, and those with no insurance. Findings show that uninsured women faced larger access barriers and utilized fewer services, particularly preventive care services, than women with either public or private coverage. Access and use did not differ greatly between Medicaid and privately covered women. The results suggest that expansions in coverage, either through Medicaid or through private options, could improve access to care for uninsured women.

Measuring beneficiary knowledge in two randomized experiments.

Abstract: This article reports results of two studies that measured beneficiaries' knowledge of the Medicare program and related health insurance options using pre- and post-experimental designs. Knowledge was measured using multiple item indexes before and after receiving new informational materials developed by the Centers for Medicare & Medicaid Services (CMS) as part of the National Medicare Education Program (NMEP). Beneficiaries in both studies showed statistically significant gains in knowledge after receiving the new materials. Policy implications for the measurement of knowledge and creation of future versions of the materials are discussed.

Rates of Hospitalization for Ambulatory Care Sensitive Conditions in the Medicare+Choice Population.

Abstract: This article evaluates the feasibility of developing hospitalization rates for ambu­ latory care sensitive conditions (ACSCs) for the Medicare+Choice (M+C) popula­ tion. M+C inpatient encounter data were used to calculate 15 ACSC rates. We found the initial reporting year of M+C inpatient encounter data had no apparent volume or diagnosis-based biases and over 90 percent of M+C organizations had sufficient enroll­ ment to produce statistically reliable rates. Further, our study results support the premise that ACSCs could be used as sen­ tinel events for potentially vulnerable popu­ lations; the oldest old and the disabled expe­ rienced statistically significant higher rates of ACSC admissions than younger Medicare beneficiaries. BACKGROUND In recent years, HCFA has begun the process of transforming itself from being a passive payer for health services to being an active purchaser of health care. HCFA is also encouraging its beneficiaries to be equally as active. As part of this transfor­ mation, HCFA has broadened its consumer information mission by collecting a variety of data from Medicare managed care enrollees: health status information from the Health Outcomes Survey, satisfaction information from the Consumer

Use of preventive care services, beneficiary characteristics, and Medicare HMO performance.

Abstract: Medicare health maintenance organization (HMO) enrollees use more preventive care services than their fee-for-service (FFS) counterparts. This may be because those who enroll in HMOs have characteristics that make them more disposed to use preventive care. To investigate this possibility, we examined the use of four preventive care services by respondents to the 1996 Medicare Current Beneficiary Survey (MCBS). Unadjusted preventive care use rates for HMO enrollees were slightly higher than rates for non-HMO enrollees with private supplemental insurance. However, after adjusting for enrollee characteristics (sociodemographics, health behaviors, health status, and functioning) we found that preventive care use rates for HMO enrollees were substantially higher--consistent with HMO enrollees being less disposed to use preventive care. In comparing preventive care service rates across groups, managers and policymakers may want to consider taking into account beneficiary characteristics that are correlated with the disposition to use preventive care.

Mammography rescreening among older California women

Abstract: This is the first study to focus on Medicare mammography rescreening using a relatively large population of older women over a long followup period. To assess correlates of regular mammography, we followed all women age 65 or over enrolled continuously in Medicare fee-for-service (FFS) (n = 515,746) over a 7-year period. Data were drawn from the CMS claims data for the period 1992-1998. Irregular mammography intervals were more commonly found among vulnerable Medicare subpopulations--women who were older, minority, living in low income and lower education areas, and who were enrolled in both Medicare and Medicaid. Health care providers must communicate clearly to older women the breast cancer rescreening message: Not just once, but for a lifetime.

Trends in state health care expenditures and funding: 1980-1998.

Abstract: Health care spending estimates constitute an important public policy tool, providing a broad look at historical trends in unique State health care systems. The State health expenditure estimates presented here detail spending for the 50 States and the District of Columbia for calendar years 1980-1998. They include expenditure estimates for specific service types as well as for two major sources of funding—Medicare and Medicaid. In this article, the authors address health care's role in State economies, trends in major service sectors and payers, and factors influencing these trends.

Race and ethnicity and the identification of special needs children.

Abstract: Increasingly, Medicaid and Title XXI Programs are using survey-based approaches to identify children with special health care needs (CSHCN) for quality assurance monitoring and program referrals. However, little work has been done examining how well instruments, like the Questionnaire for Identifying Children with Chronic Conditions and the CSHCN Screener, identify CSHCN among black and Hispanic families. Differences in item interpretation and in response styles could influence the identification of CSHCN from these groups. Our results suggest that children who are black or Hispanic with special health care needs may be underidentified relative to white or non-Hispanic children using currently available survey tools.

Factors influencing mammography use among women in Medicare managed care.

Abstract: This article presents findings about the mammography screening experience of Medicare members of a health maintenance organization (HMO). Based on a mail survey of 309 women, we assessed factors that may be facilitators or barriers to this service for older women. The results indicate that these respondents generally are receiving timely mammograms; over three-quarters (79 percent) reported having a mammogram in the past 2 years. Multivariate analysis showed that women who were younger (under 75 years of age), believed in the importance of screening, had been told by a physician to obtain a mammogram, and were more satisfied with their physician and more likely to report mammography use.

HEDIS performance trends in Medicare managed care.

Abstract: The authors analyzed performance trends between 1996 and 1998 for health plans in the Medicare managed care program Four measures from the Health Employer Data and Information Set (HEDIS ® ) were used to track performance changes: adult access to preventive/ambulatory health services, beta blocker treatment following heart attacks, breast cancer screening, and eye exams for people with diabetes Using a cohort analysis at the health plan level, sta­ tistically significant improvements in per­ formance rates were observed for all mea­ sures Health plans exhibiting relatively poor performance in 1996 accounted for the largest share of overall improvement in these measures across years

Preventing Medical Errors: Communicating a Role for Medicare Beneficiaries

Abstract: This study used a focus group methodology to examine how Medicare beneficiaries reacted to messages on specific kinds of preventive action, including those adopted by public and private section health organizations. Beneficiaries were asked to rank the messages on their own, and then to discuss their rankings in focus groups. The best-received messages advocated a collaborative patient-provider relationship. They also specified which actions to take, and how to implement them. The authors conclude that public health campaigns to reduce errors need not undermine trust in providers.

Beneficiaries' perceptions of new Medicare health plan choice print materials.

Abstract: This article presents findings from a study involving seven focus groups with aged and disabled Medicare beneficiaries in the Kansas City area regarding their impressions of a pilot version of the Medicare & You 1999 handbook and the Medicare Consumer Assessment of Health Plans Study (CAHPS®) survey report. Beneficiaries generally had positive reac­ tions to both booklets and viewed the handbook as an important reference tool. Based on the findings, we present policy recom­ mendations for the development and dis­ semination of Medicare health plan infor­ mation to beneficiaries.

Family members and friends who help beneficiaries make health decisions.

Abstract: People enrolled in Medicare often turn to family members and friends for help in making health decisions, including Medicare health plan choices. To learn how family members and friends participate in decisionmaking, what information they currently use, and what information they would like, we held eight focus groups in San Diego and Baltimore. Although responses were different in the two markets, participants in both cities reported receiving inadequate information and indicated they were largely unaware of available CMS-supported information. Beneficiaries want easy-to-use print materials targeted to their needs and opportunities to participate in seminars and receive personal counseling.

Assessing Medicare beneficiaries' readiness to make informed health plan choices.

Abstract: The Transtheoretical Model (TTM, the "stage model") can guide development of programs to increase Medicare beneficiaries' readiness to make informed health plan choices. In this study, TTM staging algorithms were developed to assess readiness to engage in three types of informed choice: (1) learning about the Medicare program; (2) learning about Medicare health maintenance organizations (HMOs); and (3) reviewing different plan options. Stage of change based on all three algorithms is related to knowledge about the Medicare program and information-seeking. Findings provide evidence for the construct validity of the stage measures and for the applicability of the TTM to informed choice among beneficiaries.

Lessons learned from the National Medicare & You Education Program.

Abstract: In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH).

Use of conventional antipsychotics and the cost of treating schizophrenia.

Abstract: This study documents the drug therapy patterns and 1-year treatment costs for 18,833 Medicaid patients with schizophrenia treated with conventional antipsychotic medications in Michigan, Kentucky, Alabama, and Georgia. One in four patients used no antipsychotic, but had total costs that were less than for treated patients (-$2,576, p<.0001); 18 percent of treated patients delayed therapy for at least 1 month and had significantly higher total costs of $3,994 (p<.0001); 41 percent of treated patients changed therapy with similar results (+$4,067, p<.0001). Only 20 percent of patients were compliant with drug therapy but this had no significant impact on total treatment costs.

Beneficiary survey-based feedback on new Medicare informational materials.

Abstract: In response to the Balanced Budget Act (BBA) of 1997, the Center for Medicare & Medicaid Services (CMS) initiated a massive information and education campaign to promote effective health plan decisionmaking. Early results suggest that the pilot version of the Medicare & You handbook and other new Medicare informational materials were viewed favorably overall. Despite their limitations, most beneficiaries found the information useful. The longer, more comprehensive materials were not perceived to be more useful than the shorter, less complicated version. Additional research is needed to determine which subgroups of beneficiaries may need more and, possibly less, information.

Limitations of and Barriers to Using Performance Measurement: Purchasers' Perspectives.

Abstract: Although health plan performance data are becoming increasingly more available, many purchasers are still not using these data to make their purchasing decisions. In this article, we review barriers that private purchasers face to using performance data. In addition, we consider the effects of the larger health care purchasing environment and employers' quality improvement activities on their use of the data. We conclude that a variety of factors, including trends, the health care purchasing environment, characteristics of firms, and problems with performance data and their presentation to users create barriers to incorporating this information into health care decisionmaking.

Factors affecting physician provision of preventive care to Medicaid children.

Abstract: Medicaid data for California, Georgia, Michigan, and Tennessee were used to analyze changes in fee and non-fee policies on physicians' service provision to children, before and after the enactment of the Omnibus Budget Reconciliation Act of 1989 (OBRA-1989). Only Michigan raised Medicaid preventive fees relative to the private sector. Higher relative fees increased child caseloads of participating physicians and the likelihood of providing preventive care. However, fee policy is less effective in urban poor areas due to residential segregation. Michigan's and Georgia's non-fee policy changes appeared effective in increasing EPSDT participation relative to the other States.

Satisfaction with health care of dually eligible older beneficiaries.

Abstract: Satisfaction with health care was compared for dually eligible older beneficiaries receiving care in three settings: a managed care organization (MCO) that is at risk for providing Medicare and Medicaid benefits (n=200); the fee-for-service (FFS) sector in the same ZIP Code (n=201); and respondents to the national Medicare Current Beneficiary Survey (MCBS) (n=531). Patients in the MCO were more likely to be highly satisfied in three domains—global quality, access to care, and technical skills—compared with patients in the local and national FFS study groups but fewer were highly satisfied with the interpersonal manner of their providers.

Medicare beneficiary satisfaction with durable medical equipment suppliers.

Abstract: CMS has recently launched a series of initiatives to control Medicare spending on durable medical equipment (DME) and prosthetics, orthotics, and supplies (DME­ POS). An important question is how these initiatives will affect beneficiary satisfac­ tion. Using survey data, we analyze Medicare beneficiary satisfaction with DMEPOS suppliers in two Florida coun­ ties. Our results show that beneficiaries are currently highly satisfied with their DME­ POS suppliers. Beneficiary satisfaction is positively related to rapid delivery, train­ ing, dependability, and frequency of service. Results of our analysis can be used as baseline estimates in evaluating CMS initia­ tives to reduce Medicare payments for DMEPOS.

CMS's Consumer Information Efforts

Abstract: In this issue of the Health Care Financing Review, we focus on consumer information for the Medicare population. Over the last several years the Centers for Medicare & Medicaid Services (CMS) has increased its efforts to provide clear and useful information to Medicare beneficia­ ries to help them make more informed health care decisions. The emphasis on consumer information increased dramati­ cally in fall 1998 with the implementation of the National Medicare Education Program (NMEP) called Medicare & You. The goals of the NMEP are to educate Medicare ben­ eficiaries to help them make more informed decisions about Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS phased-in the initial implementation of the NMEP in five States—Arizona, Florida, Ohio, Oregon, and Washington State—in order to obtain feedback from beneficiaries and make improvements prior to the national imple­ mentation. As part of CMS’s ongoing education effort, social marketing techniques have

Relationships Among Performance Measures for Medicare Managed Care Plans.

Abstract: The Health Care Financing Administration (HCFA) has relied primarily on the Health Employer Data Information Set (HEDIS®), the Consumer Assessment of Health Plans Study (CAHPS®), and the Medicare Health Outcomes Survey (HOS) to track health plan performance. However, many relationships among these measures are unknown. We found significant relationships between four HEDIS® measures and many items in the CAHPS® measure as well as items in HOS concerning beneficiary general health ratings. Our study suggests that interpretation of performance data is improved by integrating access, effectiveness of care, beneficiary experience, health status, and risk measures into an analytic framework.

Beneficiary decisionmaking: the impact of labeling health plan choices.

Abstract: One critical health plan decision con­ cerns choosing an original Medicare plan or a Medicare managed care plan. Evidence suggests that people are confused by the phrase “Original Medicare plan.” Using focus group and Q-sort methodology, the authors sought to identify a name for the Medicare fee-for-service (FFS) product. Two key insights were gained. First, par­ ticipants used the word “Medicare” to name the FFS product. Second, participants did not choose between two plans. Rather, they decided between supplemental insurance and a managed care product. These factors should influence how CMS “brands” not only the FFS product but also the overall Medicare program.

Measuring the Quality of Care in Different Settings.

Abstract: As HCFA initiates the next generation of health plan performance measures, the agency must address challenges associated with measuring the quality of care in all of the settings in which Medicare and Medicaid beneficiaries obtain care. One such challenge will be to integrate health plan performance measurement and health care quality measurement initiatives, which have been proceeding separately. Of equal importance is the challenge to improve coordination across the diverse, setting-specific quality measurement initia­ tives now in various stages of development or implementation by HCFA. Finally, HCFA must address the challenge of improving the collection, reporting, and analysis of data needed for health care quality measurement. This article describes these challenges and suggests steps HCFA might take in addressing them.