The effect of HMO status on the outcomes of home-care after hospitalization in a Medicare population

Medicare Advantage and Home Health Care: A Systematic Review

OBJECTIVES

Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees.

METHODS

A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist.

RESULTS

Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits.

CONCLUSIONS

Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.

Health Effects of Managed Care Among the Near-Elderly

Objectives: The authors evaluate whether enrolling in a health maintenance organization (HMO) or preferred provider organization (PPO) affects the health of adults ages 55 to 64, relative to fee-for-service plans. Methods: A nationwide random sample of 4,044 adults with employer-sponsored health insurance is drawn from the 1994 to 2000 waves of the Health and Retirement Study. Multinomial logit regressions are estimated for self-reported general health status, first using a sample of all near-elders, then using subsamples of near-elders with and without longstanding chronic health conditions. The possibility of selection bias into managed care plans is considered and explicitly addressed in model estimation. Results: We find no ill effects of HMOs on health status, and older adults with a history of chronic health conditions actually fare better upon enrolling in these plans. Discussion: More research is needed to understand the reasons for the observed beneficial effects of managed care.

Measurement of activities of daily living in patients with COPD: a systematic review

BACKGROUND

The objectives of this systematic review were to synthesize the literature on measures of activities of daily living (ADLs) that have been used in individuals with COPD and to provide an overview of the psychometric properties of the identified measures and describe the relationship of the disease-specific instruments with other relevant outcome measures for individuals with COPD and health-care use.

METHODS

Studies that included a measure of ADLs in individuals with COPD were identified using electronic and hand searches. Two investigators performed the literature search. One investigator reviewed the study title, abstract, and full text of the articles to determine study eligibility and performed the data extraction and tabulation. In cases of uncertainty, a second reviewer was consulted.

RESULTS

A total of 679 articles were identified. Of those, 116 met the inclusion criteria. Twenty-seven ADLs instruments were identified, of which 11 instruments were respiratory disease-specific, whereas 16 were generic. Most instruments combined instrumental ADLs (IADLs) with basic ADLs (BADLs). The majority of the instruments were self-reported; only three instruments were performance based. Twenty-one studies assessed psychometric properties of 16 ADLs instruments in patients with COPD.

CONCLUSIONS

Although several ADLs instruments were identified, psychometric properties have only been reported in a few. Selection of the most appropriate measure should focus on the target construct (BADLs or IADLs or both), type of test (disease-specific vs generic and self-reported vs performance-based), depth of information obtained, and psychometric properties of the instruments. Given the relevance of ADLs to the lives of patients with COPD, its assessment should be more frequently incorporated as a clinical outcome in their management.

PACE: has it changed the chronic care paradigm?

The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

Socioeconomic disparities in the use of home health services in a medicare managed care population

OBJECTIVE

To investigate socioeconomic disparities in access to home health visits and durable medical equipment by persons enrolled in two Medicare managed care health plans.

DATA SOURCES

A telephone survey of 4,613 Medicare managed care enrollees conducted between April and October of 2000 and linked to administrative claims for a subsequent 12-month period.

STUDY DESIGN

We estimated a series of logistic regression models to determine which socioeconomic factors were related to home health visits and the use of durable medical equipment (DME) among Medicare managed care enrollees.

PRINCIPAL FINDINGS

Controlling for health and demographic differences, Medicare managed care enrollees in the lowest tertile for nonhousing assets had 50 percent greater odds than those in the highest tertile of having one or more home health visits. All else equal, enrollees with less than a high school education had 30 percent lower odds than those who had graduated from high school of using durable medical equipment.

CONCLUSIONS

Medicare managed care enrollees of low socioeconomic status do not appear to have reduced access to home health visits; however, use of durable medical equipment is considerably lower for enrollees with less than a high school education. Physicians and therapists working with Medicare managed care enrollees may want to actively target DME prescriptions to those with educational disadvantages.

Ethical conflicts over access to services: patient effects and worker influence in home health

A survey of home health social workers (N = 51) explored the effects on patients of ethical conflicts over access to services. The findings suggest that patients were as likely to be discharged or not receive services as they were to receive the services without paying a fee. Social workers rated themselves as moderately influential in the resolution of the conflict. Their influence was significantly correlated with patients more often receiving services and less often being discharged. Social work influence was enhanced by recognition of professional expertise and/or through informal networking within the agency. Implications for practice and education are discussed.

Evaluation methods for social intervention

Experimental design is the method of choice for establishing whether social interventions have the intended effects on the populations they are presumed to benefit. Experience with field experiments, however, has revealed significant limitations relating chiefly to (a) practical problems implementing random assignment, (b) important uncontrolled sources of variability occurring after assignment, and (c) a low yield of information for explaining why certain effects were or were not found. In response, it is increasingly common for outcome evaluation to draw on some form of program theory and extend data collection to include descriptive information about program implementation, client characteristics, and patterns of change. These supplements often cannot be readily incorporated into standard experimental design, especially statistical analysis. An important advance in outcome evaluation is the recent development of statistical models that are able to represent individual-level change, correlates of change, and program effects in an integrated and informative manner.

Physician perceptions of HMO care for older persons. Health Maintenance Organization

OBJECTIVE

Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients.

DESIGN

A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans.

PARTICIPANTS

The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts.

RESULTS

Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies.

CONCLUSIONS

The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.

Promises and perils of managed care for older patients with cardiac disease

Managed care for elderly patients with cardiovascular disease will likely become more widespread because it has the propensity to provide comprehensive care while controlling costs. The issues of comorbidity and the changes of aging per se become increasingly important with increasing age and emphasize the need to use the basic principles of clinical decision making in the management of elderly patients, rather than focusing exclusively on a specific acute problem. Currently, there is great turmoil in the managed care market for the elderly with multiple models being tried with highly variable degrees of success from both the financial and patient satisfaction perspective. Physician leadership can be a critical element in resolving many of the dilemmas.