Medicare prevention demonstration : final report

128 Pages·2002·5.4 MB·English

by  Shalala, Donna E

MEDICAREPREVENTIONDEMONSTRATION
FinalReport
CMSUtswy
Saftnors,mO2-1244
DonnaE.Shalala
Secretary
HealthandHumanServices
1998
TABLEOFCONTENTS
1.0 EXECUTIVESUMMARY I"1
1.1 OverviewoftheProject 1-1
1.2 ThePreventionInterventions 1-2
1.3 ResearchDesign,Sampling,andMeasurementIssues 1-3
1.4 EffectsoftheDemonstrationsonPreventionandAcuteCare
ServiceExpendituresandUtilization 1-5
1.5 EffectsoftheDemonstrations: VariationsAmongthe
DemonstrationProjects 1-9
1.6 FinancingPrevention: OptionsfortheMedicareProgram 1-14
2.0 OVERVIEWOFTHEPROJECT 2"1
2.1 LegislativeBackground 2-1
2.2 ImplementationoftheCOBRADemonstration 2-2
3.0 PREVENTIONINTERVENTIONS 3"1
3.1 DeliveryoftheIntervention 3-3
3.2 HRA 3-7
3.3 ClinicalScreening
3.4 HealthEducationandPromotion 3-10
3-12
3.5 Discussion
4.0 RESEARCHDESIGN,SAMPLINGANDMEASUREMENTISSUES 4-1
4.1 DataPooling 4-1
4.2 FactorsAffectingtheInternalValidityof
DemonstrationFindings:EnrolleeSampling 4-3
4.3 TheRepresentativenessofDemonstrationEnrollees 4-11
5 EAFCFUETCETSCAORFETEHXEPDEENMDIOTNUSRTERSATAINODNUOTNILPIRZEATVIEONNTIONAND • 5-1
55..12 ODavtearvSioeuwrces f-/-JI
5.3 UtilizationofDemonstrationServices 5-4
5.4 NetTotalMedicareExpendituresDuringtheFirst
Year 5-13
5.5 EffectsoftheDemonstrationonMedicareExpenditures
andUtilization
5-34
5.6 Discussion
TABLEOFCONTENTS(Cont.)
6.0 EFFECTSOFTHEDEMONSTRATION:
VARIATIONSAMONGTHEDEMONSTRATIONPROJECTS 6-1
6.1 AnalyticApproachestotheEvaluation 6-1
6.2 BeneficiaryEnrollmentandUtilizationofWaiveredServices 6-5
6.3 MedicareExpendituresandUtilizationofNon-WaiveredServices 6-7
6.4 HealthOutcomes 6-10
6.5 Health-RelatedBehavior 6-14
6.6 Conclusions 6-17
7.0 FINANCINGPREVENTION:OPTIONSFORTHEMEDICARE
PROGRAM 7-1
1.0 EXECUTIVESUMMARY
ThisSummaryEvaluationReportpresentsfindingsfromthecross-cuttingevaluation
of the Consolidated Omnibus Budget Reconciliation Act (COBRA) Medicare Prevention
Demonstration,a4-yeardemonstrationmandatedinCOBRA1985totesttheeffectivenessof
offeringdiseasepreventionandhealthpromotionservicestoelderlyMedicarebeneficiaries. This
reportalsoincludesasummaryoffindingsfromevaluationsconductedbytheindividualCOBRA
demonstrationprojects1. Twopreviousreports,submittedin1990and1992,describedthe5
COBRA demonstration projects and presented preliminary findings from 2 years of the
demonstration. ThisreportmeetstheOmnibusBudgetReconciliationAct(OBRA)of1990
requirementsforafinalreport.
1.1 OverviewoftheProject
Insupportofthedemonstration,COBRA1985authorized$5.9millionovera
4-yearperiodtofundprojectadministrationandfundingfor2 yearstocollecthealthrisk
assessment(HRA)information;thedeliveryofdiseasepreventionservices(suchasimmunizations
andclinicalscreens)andhealthpromotionandeducationservices(suchasdietandnutrition
workshops,andalcoholanddrugabusecounseling)toPartB-eligibleMedicarebeneficiaries;and
thecompletionofproject-levelandcross-cuttingevaluationsofthedemonstrations. OBRA1990
extendedtheevaluationphaseofthedemonstrationsandincreasedfundingto$10.5million,in
responsetoconcernsthattheeffectsofthedemonstrationsmightnotbemeasurableduringthe
initial2-yearperiod. Thecross-cuttingevaluationwasexpectedtoanswertwomajorquestions:
(1)dideligiblebeneficiariesusepreventionservicesofferedthroughthedemonstration,and(2)
didaccesstoprevention serviceshavepredictableeffectson Medicareexpenditures, health
servicesutilization, overall healthstatus, andhealth-relatedbehaviors? Eachdemonstration
1 Alsoincludedarefindingsfroma6-yearpreventiondemonstrationconductedinNorthCarolinafrom1986
through1992,fundedthroughacooperativeagreementwiththeHealthCareFinancingAdministration. This
demonstrationimplementedanexperimentaldesignandpreventionservicesinterventionsimilartothosethatwere
implementedbythe5COBRAdemonstrationprojects.
1-1
projectcompleteditsownevaluation,addressingboththeseandmanymorenarrowly-focused
questionsrelatedtotheprojects'owninterventions.
InApril1988,theHealthCareFinancingAdministration(HCFA)awardedcooperative
agreementstofiveacademicinstitutionstomanageandevaluatethedemonstrationprojects. Two
wereimplementedincooperationwithmanagedcareplans(theUniversityofWashingtonandSan
DiegoStateUniversity)andthreewereimplementedinfee-for-servicehealthcaredelivery
systems(JohnsHopkinsUniversity,theUniversityofPittsburgh,andtheUniversityofCalifornia
atLosAngeles(UCLA)). ThedemonstrationsendedinApril1994(servicedeliverybeganin
1989andendedin1991).
1.2 ThePreventionInterventions
TheCOBRAdemonstrationprojectsoffered enrolleesassignedtoexperimentalgroups
accesstofreediseasepreventionandhealthpromotionservices2overa2-yearperiod,fromMay
1989throughApril1991. EachprojectusedsurveysandHRAstocollectbaselineandfollowup
dataforbothexperimentalandcontrolsubjects. Thedemonstrationinterventionsdifferedamong
theprojects,reflectingarangeofoptionsregardingdesign,measurement,andimplementation.
Theprojectsdevelopeddifferentmethodsofdeliveringandpayingfordemonstration
services. IntheJohnsHopkinsandPittsburghdemonstrations,physiciansdeliveredmostofthe
services. Inotherprojects,alliedhealthpersonnelsubstitutedforphysicians. JohnsHopkins
subjectshadtoscheduletheirowndemonstrationvisits; forthemostpart, projectstaffor
cooperatingprovidersscheduledvisitsfortheexperimentalsubjectsintheotherprojects. In
UCLA,SanDiego,andthehospitalportionofthePittsburghdemonstration,providerswereat
riskundercapitatedpaymentsforthecompletepackageofdemonstrationservices. Intheother
demonstrations,providerswerepaidforpartiallyunbundledservices. Forexample,Washington
providerswerepaidacapitatedrateforthepreventiveservicespackage,plus$20forthebaseline
HRA.
2Servicesofferedvariedamongthedemonstrationprojectsites. Allsitesofferedamedicalhistoryanda
physicalexamincludingheight/weightandbloodpressure/pulse. Healthpromotionactivitiesofferedbyallfive
sitesincludedcounselingonnutrition,weightreduction,smokingcessationandalcoholuse. Adetaileddescription
ofservicesofferedbyallofthedemonstrationprojectsisprovidedinChapter3.
1-2
Projectsdifferedinthesequenceandmechanicsofservicedelivery. Forexample,
JohnsHopkinsandPittsburghexperimentalsubjectsreceivedvouchersfortheirdemonstration
visits. InWashington,participatingclinicsmanagedallschedulingandserviceprovision. UCLA
usedannualHealthPromotionandScreeningClinicstoprovidesubjectswithdemonstration
servicesatonetimewithinasinglesite.
TheCOBRAprojectsuseddatafromtheHRAsinvariousways. Pittsburghprovided
itsexperimentalsubjectsinformationontargetedinterventionstailoredtoidentifiedrisks. Johns
HopkinsprovidedallexperimentalsubjectssummariesoftheirHealthBehaviorProfilesand
mailedcopiestotheappropriatephysicians. SanDiegoreferredbothexperimentalandcontrol
subjectswithconfirmedhighbloodpressureforclinicalfollowup. However,noneoftheCOBRA
projectsstudiedhowprovidersusedinformationfromtheseHRAsinprovidingcare.
Theorderinwhichprojectsdelivereddemonstrationservicesvaried. Exceptfor
Washington,theCOBRAprojectsprovidedaclinicalscreeningvisitbeforeanycounselingvisits.
However,Washingtonofferedacounselingvisitbeforetheclinicalvisit. Thecontentofclinical
screeningandmedicalinterventionsalsovaried. AllprojectsexceptUCLAprovidedinfluenza
immunizations. OnlyUCLAprovideddentalscreenings. TheCOBRAprojectsconcentratedtheir
effortsinhealthcounselingonsixorsevenpriorityareas. Alloftheprojectspromotedsmoking
cessation. Othercommonareascoveredincludednutritionanddiet,alcoholuse,mentalhealth
andsleepdisturbance,exercise,andinjuryprevention.
1.3 ResearchDesign,Sampling,andMeasurementIssues
TheinterpretationoffindingsbasedondatafromtheCOBRAdemonstrationsrequires
someunderstandingoftheoriginal researchdesign, thesamplingstrategiesadoptedbythe
projects,andtheshortcomingsofdemonstrationdata.
DataPooling. Althoughthecross-cuttingevaluationestimateddemonstrationeffects
usingdatathatwerepooledacrossallfiveCOBRAprojects,project-levelanalyseswerecritical
toabalancedassessmentofthedemonstration. Asnoted, theprojectsvariedintheirinitial
demonstration designs, servicepackages, andenrollee riskprofiles. Totryto standardize
measuresanddatacollectionmethods,theevaluatorworkedwiththeindividualprojectstodefine
1-3
aminimumdataset(MDS)ofdemographic,socioeconomic,andhealth-outcomesmeasuresthat
wouldbecommontoallprojects. However,theMDSprovidedonlyapartialsolutiontothe
heterogeneitywithintheCOBRAdemonstrationprojects. Therefore,thisreportpresentsboth
pooledandproject-specificfindings.
EnrolleeSampling.TheCOBRAprojectsrandomlyassignedenrolleestoexperimental
and control groups to assure that the two groups were as similar as possible before the
demonstration. Eachprojectsetcertainlimitsonitstargetpopulation(all,forexample,excluded
institutionalizedandhomeboundelderly). Generally,randomassignmentseemstohaveachieved
thegoalofminimizinginter-groupdifferenceswithineachproject.
Spill-OverEffects. In recruiting from the targetpopulations, each projectdealt
differentlywiththepossibilitythatcontrolgroupmembersmighthavereceivedsomeofthe
informationalcontentoftheinterventionsthatshouldhavebeenprovidedonlytoexperimental
subjects.Thiskindofcontaminationcanreducethesizeofestimateddemonstrationeffectsby
causingbehaviorchangesinthecontrolgroupsimilartothosethatareexpectedtooccurinthe
experimental group. For example, Johns Hopkins carefully limited publicity about the
demonstration. Conversely,Pittsburgh,facedwithadifficultrecruitmenttaskinruralwestern
Pennsylvania,widelypublicizedthedemonstration. Nodatawereavailabletotestforspill-over
effects. However,itisreasonabletoassumethatsomespill-overmayhaveoccurred;therefore,
statisticaltestswillprobablyunder-estimatethesizeofdemonstrationeffects.
AttritionBias. Attrition,throughfailuretoparticipateinfollowupinterviews,death,
or disenrollment from aparticipatinghealth maintenance organization (HMO), couldhave
threatenedtestsfordemonstrationeffectsbychangingthedistributionofdemographicandother
characteristicsbetweentheexperimentalandcontrolgroups. Overhalfofallenrolleescompleted
theprojects'finalfollowupsurveys. Attheprojectlevel,therateofparticipationinthefinal
surveysdidnotdifferbetweentheexperimentalandcontrolgroups. Forthemostp*art,the
characteristicsoftheexperimentalandcontrolgroupsbetweenthebaselineandfinalsurveyswere
notsignificantlyaffectedbyattrition.
TheDemonstrationIntervention.TheCOBRAdemonstrations facilitatetestsofhow
accesstofreepreventionservicesaffectsexpenditures,utilization,healthoutcomes,andhealth
1-4
behaviors. Therefore, an "intent-to-treat" model that compares all experimental subjects
(regardlessofwhetherornottheyactuallyuseddemonstrationservices)toallcontrolsubjects
producestheappropriatetestsfordemonstrationeffects. Sincethoseexperimentalsubjectswho
actuallyuseddemonstrationservicesdidsovoluntarily,anyestimatesofhowserviceuseaffects
outcomeswillbebiased. Randomization,whichminimizesbiasduetoself-selection,wasused
incomparisonsofexperimentalstocontrolsbutnotincomparisonsofusers(ofdemonstration
services)tonon-users.
The Representativeness of Demonstration Enrollees. COBRA demonstration
enrolleesdifferedinmanywaysamongthefiveprojects,astheydifferedfromthe"average"
Medicarebeneficiary. Minorityparticipationwasalmostnon-existentinallprojectsexceptJohns
HopkinsandUCLA. EducationandincomewerelowerintheJohnsHopkinsandPittsburgh
projectsthaninthethreeWestCoastprojects. Measuresofbaselinehealthstatusandriskfactors
alsovariedamongtheprojects. ComparedtotheaverageMedicarebeneficiary,however,the
averageCOBRAdemonstrationenrolleewashospitalizedlessofteninthefirstyearofthe
demonstration(with1989hospitaladmissionratesrangingamongprojectsfrom7,000to26,000
per100,000,comparedto33,000per100,000forallMedicarebeneficiaries). COBRAenrollees
werealsosubjecttolowerannualdeathrates,averaging2,556deathsper 100,000in 1989,
comparedto4,700per100,000inthelargerMedicarepopulation. Therefore,findingsfromthe
demonstrationmaynotapplytolesshealthyMedicareenrollees,buttheyprobablydodescribe
thebehaviorofthekindsofbeneficiariesmostlikelytouseaMedicarepreventionservices
benefit.
1.4 EffectsoftheDemonstrationsonPreventionandAcuteCareServiceExpenditures
andUtilization
The cross-cutting evaluation addressed two questions related to health services
utilization: Didexperimentalsubjectswhowereofferedfreepreventionservicesusethem,and
wastheavailabilityoffreepreventionservicesassociatedwitheffectsonnon-demonstration
services, includinghospitalization rates, utilizationofnon-hospital acutecare services, and
Medicareexpenditures? TheevaluatorusedMedicareclaimstoassessutilizationofdemonstration
1-5
services. TheevaluatoralsouseddatafromMedicareclaimsandenrollmentfilestoestimate
effectsofthedemonstrationonnon-demonstrationserviceutilizationforthefee-for-service
projects. EstimatesforthemanagedcareprojectswerebasedonHMOinternaldatafiles.
BecauseexpendituredatafromMedicareclaimscannotbecomparedtocostdatageneratedby
HMOs,andbecausethemanagedcareprojectsprovidedlimiteddataonskillednursingfacility
(SNF)andhomehealthagency(HHA)utilization,theonlymeasuresofutilizationcommontoall
5projectswerenumbersandlengthsofhospitalstaysandnumbersofoffice-basedphysician
visits.
UtilizationofDemonstrationServices
Mostexperimentalsubjectsuseddemonstrationservices(83percent),butparticipation
ratesvariedfromalowof63percentinJohnsHopkinsto97percentinSanDiego. Usersof
servicesgenerallyresemblednon-users. However,beingfemale,havinglessthanacollege
education,ornotreportingoneselftobeingoodhealthwerecharacteristicsmoreprevalentamong
non-usersthanusers.
Mostexperimentalsubjectswhousedsomedemonstrationservicesreceivedclinical
screeningservices,inpartbecausemostprojectsprovidedtheseinterventionsbeforecounseling
services. However,90percentormoreexperimentalsubjectsinthe3WestCoastprojects
receivedbothclinicalandcounselingservices,comparedtojustover50percentintheJohns
Hopkinsproject. On average, experimental subjectsparticipated in four visitsduringthe
demonstration,withprojectaveragesrangingfrom2.1visitsinUCLAto7.6visitsinSanDiego.
Placeofservicereflectedeachproject'sinitialdemonstrationdesign. Forexample,intheJohns
Hopkinsproject, physiciansprovided98percentofdemonstration servicesintheiroffices,
whereasphysiciansandhospitalswerenearlyequallyrepresentedinPittsburgh. Experimental
subjectsdeterminedtobeatriskbasedonresultsoftheHRAswereoftenreferredforspecific
interventions;patientcompliancewiththesereferralsvariedwidely,bothamongprojectsand
amonginterventions. Forexample,althoughWashingtonsubjectsreportedhighratesofinfluenza
immunization, only 6 percent received their immunizations through the demonstration;
comparablerateswere27and34percentinthefirst2yearsoftheSanDiegodemonstration,and
66and35percentinthefirst2yearsofthePittsburghdemonstration.
1-6
HCFAspentslightlyover$1.9millionprovidingHRAsandscreeningandhealth
promotionservicesduringthedemonstration. Averageexpendituresperexperimentalsubject3in
eachprojectreflectedthenumberofsubjects,serviceutilizationrates,andreimbursementrates,
rangingfrom$159inPittsburghto$306inWashington.
EffectsoftheDemonstrationonMedicareExpendituresandUtilization
Estimates ofdemonstration effects on non-demonstration service utilization and
expenditureswerebasedoncomparisonsofsimpleaveragesbetweenexperimentalandcontrol
subjects,aprocedurethatisappropriatewhenrandomassignmenthasbeensuccessfulinbalancing
characteristicsbetweenthesegroups. Attwoofthesites(JohnsHopkinsandSanDiego),
however,significantdifferencesintheincidenceofmortalitybetweenexperimentalsubjectsand
controlsubjectswereobserved. AttheJohnsHopkinssite,themortalityrateamongthecontrol
subjectswas2.8percentagepointsgreaterthantherateamongtheexperimentalsubjects(p<.05).
AtSanDiego,theexperimentalsubjectshadagreaterincidenceofmortality,withadifference
of2.6percentagepoints(p<.05). Althoughitwasthoughtthatdifferentialmortalityinthe
experimentalandcontrolgroupsmightthreatenthevalidityofestimatedeffects,analysisshowed
thedifferencestobesmallandnotassociatedwithexperimentalstatuswhendatawerepooled
acrossallprojects.
UtilizationoftotalPartAandhospitalinpatientservices. FrequencyofPartA
utilization, totalannualreimbursements,andreimbursementsperdayaliveincreasedamong
controlsubjectsinthefee-for-serviceprojectsoverthedemonstration. However,despitethe
occurrenceofsomestatisticallysignificantdifferentials,therewasnoevidencetosupportthe
predicteddemonstrationeffectsofrelativereductionsinhospitaluse inexpenditureamong
experimentalsubjects. InYear4,analysisofpooleddatashowedthatexperimentalsubjectswere
lesslikelytousePartAservices(adifferenceof1.9percentagepoints,p<.05),butdifferences
inthefinalyearinreimbursementmeasures,thoughnegative,werenotstatisticallysignificant.
Whendatafrombothfee-for-serviceandmanagedcareprojectswerepooled, theonlydifferences
thatapproachedsignificance(p<.10)showedthatexperimentalsubjectsweremorelikelytobe
3Expendituresperbeneficiarywerecalculatedbasedonailexperimentalparticipants,regardlessofutilizationof
services.
1-7