The impacts of per-episode prospective payment for Medicare home health care on the quality of care : less is not necessarily worse

229 Pages·2000·7.8 MB·English

by  Chen, Arnold

ContractNo.: 500-94-0062 MATHEMATICA
MPRReferenceNo.: 8246-123
PolicyResearch,Inc.
TheImpactsofPer-Episode
ProspectivePaymentfor
MedicareHomeHealth
CareontheQualityof
Care: LessIsNot
NecessarilyWorse
May9,2000
ArnoldChen
Programmers:
HelaineNoveck
ElizabethStuart
WillBlack
AmyZambrowski
SurveyDirector:
RhodaCohen
Submittedto: Submittedby:
HealthCareFinancingAdministration MathematicaPolicyResearch,Inc.
7500SecurityBlvd,(C-3-21-06) P.O.Box2393
Baltimore,MD 21244-1850 Princeton,NJ 08543-2393
[phone]
ProjectOfficer: ProjectDirector:
AnnMeadow ValerieCheh
PrincipalInvestigators:
RandallBrown
ValerieCheh
BarbaraPhillips

ACKNOWLEDGMENTS
Iamgratefulforhelpfrommanycolleaguesinpreparingthisreport. ValerieCheh,Barbara
Phillips,andRandallBrowncarefullyreadearlierdraftsandmadeinsightfulandcriticalcomments.
RandallBrownpatientlyprovidedguidanceintheanalysisandstatisticalmethodology. Chris
Trenholmalsomadevaluablesuggestionsfortheanalysis. BarbaraPhillips,JenniferSchore,and
ChrisTrenholmcontributedtothebackgroundchaptersthroughpreviouswork. BarbaraPhillips
authoredAppendixAonthedesign,sampling,andfieldingofthepatientsurveys. HelaineNoveck,
Elizabeth Stuart, and Amy Zambrowski provided outstanding programming support. Laura
BerensonmeticulouslyandskillfullyeditedthereportwithhelpfromPatriciaCiaccio. Jennifer
Baskwelltirelesslytyped,formatted,andproducedthedraftreportwithhelpfromJillMillerand
StephanieCollins,andCindyMcCluremadetherevisionstoandproducedthefinalreport.
IalsothankAnnMeadow,ourprojectofficeratHCFAforongoingadviceandassistance,and
theCenterforHealthPolicyResearchattheUniversityofColoradoforprovidingtheQuality
Assuranceanddocumentation. Errorsoromissionsare,ofcourse,myresponsibility.
iii

CONTENTS
Chapter Page
EXECUTIVESUMMARY xv
THEPER-EPISODEHOMEHEALTHDEMONSTRATIONAND
I
EVALUATION 1
A. QUALITYOFHOMEHEALTHCAREUNDERTHE
DEMONSTRATION
1
B. THEMEDICAREHOMEHEALTHBENEFIT 3
C. THEPER-EPISODEDEMONSTRATION 6
1. DemonstrationPaymentandIncentives 7
2. OtherDemonstrationProcedures 10
II DATA 15
A. MEDICARECLAIMSDATA 16
1. ClaimsOutcomeVariables 18
2. ClaimsSample 20
B. QUALITYASSURANCEDATA 22
21.. QQuuaalliittyyAAssssuurraanncceeOSaumtpcloemeVariables 2225
C. FOUR-MONTHPATIENTSURVEYDATA 26
1. Four-MonthSurveyOutcomeVariables 27
2. Four-MonthSurveySample 28
D. EIGHT-MONTHSURVEY 30
E. CONTROLANDSUBGROUPVARIABLES 31
21.. SSttaannddaarrddCCoonnttrroollVVaarriiaabblleessffoorrAPagteinenctyCChhaarraacctteerriissttiiccss 3314
3. StandardControlVariablesforAreaCharacteristics 35
4. Patient-LevelControlVariables,byDataSource 36
5. Subgroups 39
v
CONTENTS(continued)
Chapter Page
II F. SUMMARYSTATISTICSFORCONTROLVARIABLES 40
(continued)
1. OverviewofDataSources 40
2. PatientCharacteristics 46
3. AgencyandAreaCharacteristics 47
4. ImplicationsfortheAnalysisofProgramImpacts 48
III METHODS 49
A. LOGISTICREGRESSIONMODELSFORESTIMATING
IMPACTS 49
1. EstimatingMainEffects 49
2. EstimatingSubgroupImpacts 50
B. ISSUESINWEIGHTINGOBSERVATIONS 53
21.. WRoebiugshttniensgstoofRReepsruelstesnttoAAgletnecrineatsiEvequWaelilgyhtingSchemes 5535
C. STATISTICALHYPOTHESISTESTING 56
1. DesignEffects 56
2. SignificanceLevels 57
IV DEMONSTRATIONIMPACTSONPATIENTOUTCOMES 61
A. POTENTIALEFFECTSONPATIENTOUTCOMES 61
B. IMPACTSONHEALTHANDFUNCTIONALSTATUS 65
1. Self-ReportedGeneralHealthandBasicActivitiesofDailyLiving ...65
2. InstrumentalActivitiesofDailyLiving 70
3. MedicalSymptomsandOutcomes 70
C. IMPACTSONUSEOFHEALTHSERVICES 72
1. Same-Body-SystemDiagnosisHospitalizationsandUseof
EmergencyHealthServices 72
2. Same-Body-SystemDiagnosisAdmissionstoHomeHealth
AgenciesandSkilledNursingFacilities 81
vi
CONTENTS(continued)
Chapter Page
IV D. IMPACTSONPATIENTSATISFACTION 82
(continued)
1. GeneralSatisfactionandSatisfactionwithTechnicalCare 82
2. InterpersonalCare 83
E. SENSITIVITYTESTS 90
1. WeightingObservationsProportionaltoAgencySize 91
2. IncludingPatientswithMorethanOneDemonstration
HomeHealthAdmission 98
F. SUMMARY 98
V SUBGROUPIMPACTS 101
A. DEFININGAGENCYANDPATIENTSUBGROUPS 101
B. POTENTIALSUBGROUPEFFECTSONPATIENT
OUTCOMES 103
C. IMPACTSFORAGENCYSUBGROUPS 105
1. High-UseorLow-UseAgencies 106
2. For-ProfitorNonprofitAgencies Ill
3. SmallorLargeAgencies 116
4. Hospital-BasedorFreestandingAgencies 120
5. BeloworAboveCostLimitsAgencies 120
D. IMPACTSFORPATIENTSUBGROUPS 127
E. SUMMARY 137
VI CONCLUSIONS 139
A. SUMMARYOFRESULTS 139
B. LIMITATIONS 141
C. POLICYIMPLICATIONS 143
REFERENCES 145
vii
CONTENTS(continued)
Chapter Page
APPENDIXA: DESIGNANDFIELDINGOFTHE
PATIENTSURVEY 149
APPENDIXB: SENSITIVITYANALYSES 159
APPENDIXC: COEFFICIENTESTIMATESFROMSELECTED
REPRESENTATIVEREGRESSIONS 183
viii
TABLES
Table Pa8e
ANALYSISSAMPLESFORTHEEVALUATIONOFIMPACTSOF
II.1 PROSPECTIVEPAYMENTONTHEQUALITYOFCARE 17
11.2 OUTCOMEVARIABLESFROMTHECLAIMSDATA 19
OUTCOMEVARIABLESFROMTHEQUALITYASSURANCE
11.3
DATA 23
11.4 OUTCOMESFROMTHEFOUR-MONTHSURVEY 29
STANDARDCONTROLVARIABLESFORTHEMAIN
11.5
MULTIVARIATEANALYSIS,BYSOURCE 32
11.6 ADDITIONALCONTROLVARIABLESFROMTHEQUALITY
ASSURANCEDATA 37
IL7 WEIGHTEDTREATMENTANDCONTROLGROUPMEANS
FORPATIENT-LEVELINDEPENDENTVARIABLESUSEDINTHE
ANALYSISOFCLAIMS,QUALITYASSURANCE,FOUR-MONTH
SURVEY,ANDEIGHT-MONTHSURVEYSAMPLES 41
II.8 WEIGHTEDTREATMENTANDCONTROLGROUPMEANS
FORAGENCY-ANDAREA-LEVELINDEPENDENTVARIABLES
USEDINTHEANALYSISOFCLAIMS,QUALITYASSURANCE,
FOUR-MONTHSURVEY,ANDEIGHT-MONTHSURVEYSAMPLES 45
MINIMUMDETECTABLEEFFECTSFORDIFFERENTDATA
III.1
SOURCES,INCLUSIVEOFDESIGNEFFECTS 59
IV.1 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINPATIENTS'
SELF-REPORTSOFGENERALHEALTH 66
IV.2 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINIMPROVEMENT
ANDSTABILIZATIONINBASICACTIVITIESOFDAILYLIVING
FROMQUALITYASSURANCEDATA 67
ix
TABLES(continued)
Table Page
IV.3 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINBASIC
ACTIVITIESOFDAILYLIVINGFROMFOUR-ANDEIGHT-MONTH
SURVEYDATA 68
IV.4 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESIN
INSTRUMENTALACTIVITIESOFDAILYLIVINGFROM
QUALITYASSURANCEANDSURVEYDATA 71
IV.5 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINMEDICAL
SYMPTOMSANDOUTCOMES 73
IV.6 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINHEALTH
SERVICESUSE 75
IV.7 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESIN
GENERALSATISFACTIONWITHCAREPROVIDEDBYTHEAGENCY...84
IV.8 ESTIMATEDDIFFERENCESBETWEENPROSPECTIVELYPAID
AGENCIESANDCOST-REIMBURSEDAGENCIESINSATISFACTION
WITHAGENCYSTAFF 85
IV.9 SUMMARYOFDIFFERENTWEIGHTINGSCHEMESONESTIMATED
EFFECTSOFPROSPECTIVEPAYMENTONBASICAND
INSTRUMENTALACTIVITIESOFDAILYLIVINGFROMFOUR-
ANDEIGHT-MONTHSURVEYS 92
IV.1 SUMMARYOFDIFFERENTWEIGHTINGSCHEMESONESTIMATED
EFFECTSOFPROSPECTIVEPAYMENTONOUTCOMESFROM
QUALITYASSURANCEANDCLAIMSDATA 93
IV.11 SUMMARYOFDIFFERENTWEIGHTINGSCHEMESONESTIMATED
EFFECTSOFPROSPECTIVEPAYMENTONSATISFACTION
OUTCOMESFROMTHEFOUR-MONTHSURVEY 96
x