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a University of Minnesota School of Public Health, Division of Health Services Research and Policy, Minneapolis
b University of Minnesota School of Social Work, St. Paul
Robert L. Kane, University of Minnesota School of Public Health, Division of Health Services Research and Policy, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN 55455 E-mail: kanex001{at}umn.edu.
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Abstract |
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Methods. We compared the functional status and satisfaction of WPP elderly enrollees with those of two sets of dually eligible controls drawn from the Medicaid waiver rosters. One set of controls came from persons in the same county who opted not to enroll in WPP. The second came from matched counties that did not have access to the WPP. Enrollees were interviewed in person. Family members were interviewed by telephone.
Results. The prevalence of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) dependency was lower for the WPP sample than that for the controls. The pattern of unmet needs was generally comparable. About half of each sample had a written advance directive. Overall, there were few areas of significant difference in beneficiaries' satisfaction. The WPP families were more satisfied than either control group that services were provided when needed and were better coordinated. There were no significant differences in the prevalence of any aspect of care burden.
Conclusions. The impact of WPP seems limited. There is some evidence that families perceive better coordinated care. A more complete evaluation will await the analysis of the differences in utilization patterns between WPP and the controls.
THE Health Care Financing Administration (HCFA) (now the Centers for Medicare and Medicaid Services [CMS]) has been encouraging efforts to better coordinate services provided to individuals eligible for both Medicare and Medicaid. These individuals are often frail elderly Medicare beneficiaries who have high medical costs and have spent down their income and assets to become Medicaid eligible, or they are low-income elderly persons who have aged into the Medicare program, but are not necessarily frail. Approximately 17% of individuals enrolled in Medicare were also covered by the Medicaid program and represented 28% of total Medicare expenditures during 1997. Dual eligibles represent approximately 19% of the Medicaid population and account for 35% of Medicaid expenditures (1). While these two programs potentially provide a comprehensive package of benefits, some observers note a lack of coordination in benefits and resultant fragmented care, which is both wasteful and inefficient. Medicare and Medicaid have different payment rules and provider qualifications, offer different benefit packages, and have little incentive for integration.
The dual-eligible demonstrations are designed to combine Medicare and Medicaid funding for dual-eligible populations in order to improve coordination and remove redundancies. Ideally, such a merger should improve efficiency and permit more service (and results) for the same expenditures, or reduce the overall expenditure. Placing such combined programs under the umbrella of managed care is a step designed to control costs. However, it is not clear if simply changing the nature of the funding, or even adding an overlay of case management, is sufficient to achieve the improvements in care and savings in costs being sought.
Several demonstration projects have been launched. The earliest was the Minnesota Senior Health Options (MSHO) program, which sought to use health plans as the vehicle to merge funding streams. In essence, the MSHO model relied heavily on funding incentives to change patterns of care, but the infrastructure was largely unchanged except for mandated case management. The early results of the evaluation of that effort suggest only modest impacts (2). In contrast, the Wisconsin Partnership Program (WPP) offers a model that has a more direct intervention.
The WPP is a managed care program to serve the dual-eligible population—those eligible for coverage under both Medicare and Medicaid. As with all dual-eligible managed care programs, its intention is to pool the resources of the two programs in order to gain better integration and avoid duplications and conflicts from different rules for eligibility and coverage. In addition, the flexibility afforded by a single-payment pool allows more creative uses of the money to cover whatever services are deemed necessary.
The WPP model is based on the Program for All-inclusive Care of the Elderly (PACE) approach, which uses a staff model of medical care built around day care. A major goal of PACE is to minimize the use of institutions (both hospitals and nursing homes). The PACE approach emphasizes teamwork with broad participation in regular care conferences by employees at all levels. PACE physicians are specifically hired by the programs and are the exclusive providers of primary care (3)(4)(5). The WPP variation attempts to address aspects of that approach that have made it difficult to market (i.e., the need to use a PACE physician and the heavy reliance on day care); namely, WPP allows enrollees to remain with their own primary care physician (PCP) and to make substantially less use of day care. In order to achieve the same level of teaming that has been a PACE hallmark, WPP created an interdisciplinary care management team composed of a nurse, social worker, and nurse practitioner (NP). A major part of the latter's responsibility is coordinating closely with the PCP in order to bring him or her into the care planning and implementation loop. The level of delegation from PCP to NP varies with the rapport developed.
The PACE model places strong emphasis on the importance of involving all of the care providers in a coordinated team effort. WPP has attempted to reproduce this value through its care management team, but the PCP is, at best, only a distant player. Much of the burden for coordination falls to the NP. This task is made more difficult because most of the participating PCPs have only small WPP patient caseloads.
WPP serves two client populations: frail elders and younger disabled adults. The frail elderly population is defined using basically the same criteria applied to PACE. Although most WPP enrollees are dually eligible for both Medicare and Medicaid, some with Medicaid only are eligible for WPP. The WPP enrollees must be eligible for admission to a nursing home but living in the community at the time of enrollment. Although there are no succinct criteria for nursing eligibility, the decision is based on three elements: activity of daily living (ADL) dependencies, medical complexity, and need for health-related services.
WPP operates at four sites. ElderCare in Madison (Dane County) and Community Care for the Elderly in Milwaukee sites serve only frail elderly clients and also operate PACE programs. Another site in Madison, Community Living Alliance, serves only disabled clients and is not included in this aspect of the evaluation. The fourth site, Community Health Partnership, serves both elderly and disabled clients in a three-county region in western Wisconsin; only the elderly enrollees are included in this part of the evaluation.
Because WPP is a CMS demonstration project operating under an 1115 waiver, an evaluation was mandated. This article describes the approach taken to that evaluation of the frail elderly group and presents preliminary findings from a survey of WPP enrollees and controls. In an effort to reduce the role of selection bias, the evaluation design uses two separate control groups: (a) comparable frail older persons in the same service area who could have joined WPP but did not and (b) comparable persons in matched areas outside those served by WPP who had no opportunity to enroll in WPP. The comparable samples were chosen from frail elders enrolled in the Wisconsin Community Options Program (COP), a Medicaid home- and community-based waiver program. COP enrollees received a variety of community services designed to meet their care needs, but got their medical care from fee-for-service Medicare providers (for which Medicaid paid the deductibles and covered those services not covered by Medicare).
The overall evaluation design calls for a comparison of utilization patterns based on administrative data sources and a cross-sectional survey to determine the differences in the nature of those enrolled in WPP and the COP controls. This article reports on the results of the survey that examined areas of functioning and satisfaction with the care received.
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Methods |
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In the cases where the enrollee could not be interviewed, a proxy respondent was sought. Based upon our previous experience, the following information was used in making a decision to use a proxy:
The first choice for a proxy was a responsible family member who had adequate contact with the beneficiary to provide valid answers. However, not all beneficiaries had family members who saw them regularly. For those who did not, a staff member was used as a proxy. Staff members were usually nurse practitioners, RNs, aides, case managers, or social workers. Staff members were not asked questions regarding patient satisfaction, quality of care, decision making, or unmet need.
The questionnaire was modeled after one used in a prior dual-eligible evaluation (2), but was modified to emphasize elements the WPP program staff felt were especially salient to their approach; namely, attention to team care and respect for client autonomy. The survey instruments included a description of the person, information regarding use of formal and informal care, satisfaction including issues of access to services, advance medical directives, general health, functional status (ADLs and instrumental ADLs [IADLs]), and informal caregiver burden (for family of community respondents). Wherever possible, previously tested measures were utilized. Items regarding ADLs were derived from instruments developed by Finch and colleagues (6). These questions focused on beneficiaries' ability to engage in basic daily activities, e.g., bathing, dressing, toileting, transferring, feeding, and walking. IADL items focused on the beneficiaries' ability to engage in a range of higher order daily activities from shopping to management of finances.
In addition to questions about ability to perform ADLs and IADLs, questions about unmet need for assistance with functional problems adapted from the work of Allen and Mor were used (7). For example, people who reported difficulties using the toilet were asked if they had needed help and did not receive it, if they were wet or soiled because they did not receive this help, and if they had to wait more than 20 minutes before receiving help. To get at unmet need with regard to transferring, patients were asked if they needed additional help getting in or out of a bed or chair and did not receive it and if they had fallen as a result of this lack of assistance. Satisfaction questions addressed receipt of services or the nature of the services they received (e.g., were services provided when needed, did personnel communicate effectively, did patients [or families] participate in decision making). The questions were posed as dichotomous agree/disagree statements. Parallel versions of the satisfaction items were used with both enrollees and family respondents. The measure of burden was based on the Caregiver Reaction Assessment instrument developed by Given and colleagues (8). Questions were asked about the extent to which advance directives were used and any pressures felt to adopt them.
As noted above, two sets of controls were used. For the in-area controls, COP clients living in the same counties as WPP enrollees were matched. For the out-of-area controls, each county participating in WPP was matched with a comparable nonparticipating county and a matched COP sample drawn from that county's registrants. (We had initially hoped to match on race as well, but the urban areas around Milwaukee had a much higher proportion of nonwhites, which precluded such a match with other counties.)
Of the 463 elderly WPP enrollees identified, we were unable to locate 18; four had moved out of the area; 13 could not understand English and no proxy was available; and another two had no proxy. Thus, of the 426 persons eligible to participate, interviews were completed for 400 (response rate 91%); 18 beneficiaries and six proxies refused interviews, and one interview was incomplete. Of these, 299 were beneficiaries, 95 were family proxies, and six were staff proxies. Among the 500 in-area controls targeted, 37 could not be located; five had moved out of the area; four could not understand English and no proxy was available; another four had no proxy; and 41 controls and three proxies refused interviews. Of the 406 interviews (response rate 86%), 253 were with beneficiaries, and 127 were with proxies. Of the 459 out-of-area controls originally targeted, 32 could not be located; eight moved; eight had no proxies; and four could not understand English and no proxy was available. The final sample of 355 included 224 beneficiaries, 105 family proxies, and 26 staff proxies (response rate 84%); 46 beneficiaries and six proxies refused.
Seventy percent of the families of WPP respondents (278 of 400) responded (including the 95 family proxies). The refusal rate was less than 5%. Among the controls, we obtained family interviews on 66%: 267 (out of 406) in-area and 247 (out of 355) out-of-area. The refusal rate was 1% for the in-area controls and 2% for the out-of-area controls.
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Results |
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Like the clients, WPP family members were less likely to be white than either control group. The caregivers were predominately female and adult children who lived nearby. Out-of-area controls were more likely to be spouses. In-area controls had less regular contact with the clients.
The pattern of family satisfaction with care also showed few differences across groups. Both control groups reported needing to spend more energy getting needed care and had less confidence in the ability of the care teams to communicate internally. Families were also asked about various aspects of caregiver burden. As seen in Table 7 , there were only a few significant differences in the prevalence of care burden. After adjusting for age, gender, race, marital status, education, number of dependent ADLs and IADLs, number of medical conditions, and whether beneficiary lives with caregiver, WPP families had fewer problems paying for caregiving and family activities were less likely to center around caregiving than out-of-area controls.
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Discussion |
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The scarce differences in satisfaction suggest that the WPP has not produced a noticeable improvement over the care regularly provided. WPP beneficiaries expressed more satisfaction about the frequency of preventive services and the frequency of physician contacts, but in some areas central to the goals of WPP, such as care coordination and teamwork, the control groups paradoxically showed significantly greater satisfaction. For example, controls expressed more satisfaction with having their needs taken seriously and the coordination of their care. However, given the large number of comparisons, it is not clear that these differences might not have occurred by chance, and probably should not be overinterpreted.
The rates of several unmet needs measures raise concerns about whether the care of the most vulnerable is adequate. Because the denominator for each of these rates was dependent persons, the rates are small and unstable. Nonetheless, some of the rates raise serious questions. Approximately 20% of WPP participants who needed help in toileting were wet or soiled because of inadequate help and had to wait at least 20 minutes for assistance. More than 25% of those who could not feed themselves said they did not get the help they needed.
The disability rates among the WPP sample are generally lower than those in the control groups. Although the cross-sectional design does not permit separating the effects of enrollment from the benefits of treatment, it seems unlikely that these differences in disability rates are due to the care received, especially in light of the modest differences in services reported. However, the apparent discrepancy between the reported prevalence of dementia and the rate of mental status questionnaire errors can be attributed to the differences in the rate of proxy respondents among the three groups. The proxy rate for the WPP was 25%, whereas the proxy rates for the controls were 31% for in-area and 37% for out-of-area.
One difference between the WPP sample and the controls is their tenure in their respective programs. On average the WPP clients had been in the program for a little over a year at the time of the survey, whereas the controls had been in COP for more than five and a half years. This difference in exposure could be associated with differences in satisfaction.
Why has the WPP failed to achieve a greater impact? Conceptually, this model appears to capture important elements of PACE, while making it more attractive by allowing patients to retain their usual primary physicians. However, this latter step may be the Achilles heel of the program. The participating physicians did not participate very much. In three of the four WPP sites, more than half the primary care providers cared for five or fewer patients. Only the site shared with the Milwaukee PACE program had a more concentrated physician pool. This modest level of participation makes it unlikely that physicians will change their practice styles to meet the needs of WPP clients. The burden then falls heavily on the interdisciplinary care management team to make the difference. The team must capture the spirit and commitment of the PACE care team and ensure access even when primary care is not as immediately available. The data available to date suggest that this effort may not be sufficient. The WPP staff have recognized the problem of inadequate physician participation and are taking steps to address it.
Indeed, although it has now been made a fixed alternative in the Medicare repertoire, the PACE model itself has not been shown to be as effective as some may believe. A limited evaluation of the initial demonstration sites showed that PACE did achieve its goal of reducing the use of institutions. Hospital days and hospital admissions for PACE clients were lower than those for fee-for-service Medicare beneficiaries in general for the first 18 months of the evaluation, an impressive statistic when one considers the frailty of PACE clients. Likewise, PACE clients had fewer nursing nights and admissions through the first year of the evaluation, but the difference dwindled over time. Perhaps commensurately, PACE clients had more ambulatory visits throughout the 24 months of the evaluation. Much less is known, however, about the clinical outcomes of this care. There were few differences between PACE clients and controls in terms of functional status over time, nor were there many patterns of differences in terms of self-rated health status, quality of life, or satisfaction (9). Thus, the expectations for WPP, which lacks some of the integrative vigor of the original PACE model, may be more modest. Subsequent analyses will explore differences in patterns between WPP and controls on service utilization.
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Acknowledgments |
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Note: HCFA is now the Centers for Medicare and Medicaid Services (CMS).
Received July 20, 2001
Accepted October 2, 2001
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This article has been cited by other articles:
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  J. H. Flaherty, B. Stalvey, and L. Rubenstein Guest Editorial: A Consensus Statement on Nonemergent Medical Transportation Services for Older Persons J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M826 - 831. [Full Text] [PDF]
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