The following is a summary of home-care-related government research projects. The information was taken from the most current Active Projects Report: Research and Demonstrations in Health Care Financing prepared by the Center for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration. This publication describes CMS's research and demonstration (R&D) projects that were active as of January 1, 2001. It includes intramural CMS research projects as well as those that are operated under contracts, grants or waivers. There are indices by topic, project title, awardee, principal investigator, State and project officer/director. The large number and diverse nature of the projects described in this publication show that CMS has a well-considered, broadly-defined and aggressive R&D program.
The Office of Strategic Planning prepares this report annually, with input from project officers throughout CMS. We are sending a copy to each CMS manager and to all the project officers.
The material is available on www.hcfa.gov as a PDF (Portable Document Format) file. It can be found by selecting "Research and Demonstrations," "Research Reports and Publications" and "2001 Active Projects Report."
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY DEMONSTRATION
Description: HCFA is mandated to conduct a demonstration that replicates the model of care developed by On Lok Senior Health Services in San Francisco, California. The Program of All-inclusive Care for the Elderly (PACE) Demonstration replicates this model of managed care service delivery for very frail community-dwelling elderly persons. Most of the beneficiaries are dually eligible for Medicare and Medicaid coverage and all are assessed as being eligible for nursing home placement according to the standards established by participating States. The model of care includes, as core services, the provision of adult day health care and multidisciplinary case management through which access to and allocation of all health and long-term care services are arranged. Physician, therapeutic, ancillary, and social support services are provided on site at the adult day health center, whenever possible. Hospital, nursing home, home health, and other specialized services are provided off site. Transportation is provided for all enrolled members who require it. This model is financed through prospective capitation of both Medicare and Medicaid payments to the provider. Initially demonstration sites assumed financial risk progressively over 3 years; the later sites assumed such risk from day one. The sites listed below, and their State Medicaid agencies, have been granted waiver approval to provide services under this demonstration.
Status: In response to changes in Title XVIII of the Social Security Act made by the Balanced Budget Act of 1997, PACE is being established as a permanent part of the Medicare program and as a State option under Medicaid. It is expected that the demonstration sites will transition from a demonstration to a permanent entity once regulations implementing this public law become effective. California, Colorado, Maryland, Massachusetts, Michigan, New York, Ohio, Oregon, South Carolina, Tennessee, Texas, Washington, Wisconsin
96-056 Program of All-Inclusive Care for the Elderly (PACE) Quality Assurance
Description: The purpose of this task order is to develop a core data set that will be the foundation for an outcome-based quality improvement (OBQI) system for the Program of All-Inclusive Care for the Elderly (PACE) program. The OBQI system, developed by the Center for Health Services Policy and Research, contains items for outcome measurement and risk adjustment at specific time intervals. Using the data collected with this instrument, site-level reports are produced summarizing the outcome measures. By comparing site-level case-mix adjusted outcome reports to other PACE site outcome reports, and to the site's previous outcome reports from earlier time periods, the site, HCFA, and the State Medicaid agencies will be able to identify areas that require further examination due to inferior (or perhaps superior) outcomes. In the second phase, the sites take a closer look at why and how the specific outcomes are achieved and make recommendations for improvements in the case of poor outcomes.
Significant progress has been made in the development of outcome indicators for PACE. The efforts of two clinical panels resulted in a composite list of outcome indicators to be considered for inclusion in the OBQI data set. This list is being used to determine the key outcome indicators for focusing outcome measurement and data item specification activities. Feasibility testing of the proposed data items and data collection protocols began in April 1999 and continued through June 1999. In September 1999, the data set was submitted to the Office of Management and Budget (OMB) for clearance.
Status: The OBQI contract was modified in October 1999, which expanded the period of performance and increased the level of effort to support the development of a Core Comprehensive Assessment (COCOA) instrument for PACE providers. The COCOA instrument will enhance the uniformity of data collection and assist PACE sites in responding to multiple requests for information. The timeline for the OBQI component will be combined with the timeline of the COCOA component of the project. Although this change in the timeline will delay the OBQI component for 18 months, the burden of data collection on the PACE sites will be decreased. This change in the timeline will ensure that the data items will be tested in the manner in which they will be used. Although HCFA received OMB approval on the OBQI data set, the COCOA data set (which will contain elements of the OBQI) will be submitted to OMB for clearance prior to a full field test of the data set.
00-112 Actuarial Assessment of PACE Enrollment Characteristics in Developing Capitated Payments
Description: Payments for medical services furnished by Program of All-Inclusive Care for the Elderly (PACE) organizations are fully capitated by Medicare and Medicaid. A variant of this capitated approach is used by Medicare to pay Medicare+Choice organizations, which generally have much larger numbers of Medicare participants than PACE organizations. Because of their unique niche, total reliance on capitated payments (Medicare and Medicaid), lower enrollee levels, and higher mortality rates, PACE organizations may have a higher level of financial risk than Medicare+Choice plans. In order to assess the potential risk elements as well as to help determine implications for policy purposes, an actuarial evaluation and assessment of payment rates for PACE will be performed under this contract.
Available studies suggest that PACE enrollees are sicker, frailer, and more costly than the average Medicare beneficiary. It is not clear whether these higher costs are driven by enrollment into PACE after a precipitating event, or if these costs are ongoing as a result of enrolling patients with chronic/persistent illnesses. Either bias would likely act to increase the financial risk assumed by PACE organizations particularly in light of the assumption of a random draw in Medicare+Choice, where payment is based on the average.
This contract assesses the financial risk that PACE organizations incur as a result of their smaller enrollment numbers, biased populations, and higher mortality. Risk will be characterized in enrollment level tiers and compared and contrasted to the risk characteristics of larger health delivery organizations. Simulations and the actuarial theory of ruin will be used in this assessment. The impact of joint capitated funding streams (Medicare and Medicaid) also will be modeled. Available claims data and data sets from other studies will be analyzed under this contract.
Status: The project is in the data collection phase.
COMMUNITY NURSING ORGANIZATION DEMONSTRATION
Description: HCFA was directed to conduct demonstration projects at four or more sites to test a capitated, nurse-managed system of care. The two fundamental elements of the Community Nursing Organization (CNO) Demonstration are capitated payment and nurse-case management. These two elements are designed to promote timely and appropriate use of community health services and to reduce the use of costly acute-care services. The legislation mandates a CNO service package that includes home health care, durable medical equipment, and certain ambulatory care services. Four applicants were awarded site demonstration contracts on September 30,1992. The selected sites represented a mix of urban and rural sites and different types of health providers including a home health agency, a hospital-based system, and a large multispecialty clinic.
Status: All four CNO demonstration sites underwent a 1-year development period and began a 3-year operational period in January 1994. The Balanced Budget Act of 1997 extended the demonstration period through December 31, 1999. HCFA competitively selected an evaluator for the project who also provided technical assistance to the four CNO sites. HCFA also competitively awarded an external quality assurance contract. Two sites have ceased to participate, two remain. The analysis of the evaluator's data continues as does the Phase II evaluation.
99-068 Aging in Place: A New Model for Long-Term Care
Description: The goal of the "Aging in Place" model of care for frail elderly is to allow elders to remain in their homes as they age, rather than requiring frequent moves to allow for more intensive care if and when it becomes necessary. The University of Missouri's Sinclair School of Nursing is in the process of implementing such a model. Although a planned element of the program is a new senior housing development, the program currently targets elderly residents of existing congregate housing. The University has received a grant in support of the evaluation of this model of care.
Status: A first-year award was made to the applicant subject to revision of the study design and work plan according to terms and conditions established by the review panel. HCFA staff met with the Principal Investigator and other members of the research team at a kick-off meeting on September 1, 1999, at which time a revised work plan and budget were submitted. As a result of changes to the study plan, the applicant requested an increase in the first-year award with a corresponding reduction in the Years 2-4 awards and no change in the total budget. This change was approved.
96-079 Medicare Competitive Bidding Demonstration for Durable Medical Equipment
Description: This demonstration project is being implemented to test the feasibility of obtaining lower prices through competitive bidding for selected lines of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Demonstrations are being implemented in two metropolitan areas. Section 4319 of the Balanced Budget Act of 1997 permits the selection of a sufficient number of suppliers in each product category to meet the projected demand at the demonstration site. Those suppliers selected as demonstration suppliers are the only ones eligible to receive Medicare payments for supplying the products covered by the demonstration to Medicare enrollees residing in Polk County, Florida and the San Antonio, Texas Metropolitan Statistical Area (MSA). The supply lines that were offered for competitive bidding at the first site are:
The supply lines that were offered for competitive bidding at the second site are:
Special transitional arrangements were made for beneficiaries who had a relationship with an oxygen supplier prior to the beginning of the demonstration in both sites and a nebulizer inhalation drug supplier in the San Antonio site. In addition, current rental contracts for hospital beds in both sites, manual wheelchairs in the San Antonio site and enteral pumps in the Polk County site are allowed to complete their terms. Payments for DMEPOS products not covered by the demonstration will continue to be made at the prevailing Medicare fee schedule.
Status: The first demonstration site became operational on October 1, 1999 in Polk County. There were 73 bids from 30 suppliers for the product categories covered by the demonstration. The bids were reviewed for price and quality. Sixteen suppliers were selected as "Demonstration Suppliers" for one or more of the covered product categories. The average price reductions from the Medicare standard prevailing fee schedules are:
The new rates took effect on October 1, 1999 and remain in effect for 2 years. A second round of bidding will take place in Polk County in 2001 to determine the prices for the final a year of the project.
The second demonstration site will become operational on February 1, 2001 in the San Antonio, Texas MSA. This area consists of Bexar, Comal and Guadalupe counties. There were 179 bids from 77 suppliers for the product categories covered by the demonstration. The bids were reviewed for price and quality. It is anticipated that 52 suppliers will participate in the demonstration. The average price reductions from the Medicare statewide fee schedules are:
The new rates will take effect on February 1, 2001 and will remain in effect through 2001.
98-239 Evaluation of Competitive Bidding Demonstration for DME and POS
Description: HCFA has mounted a demonstration to test the feasibility and effectiveness of establishing Medicare fees for durable medical equipment (DME) and prosthetics, prosthetic devices, orthotics and supplies (POS) through a competitive bidding process. The fundamental objective of competitive bidding is to use marketplace competition to establish market-based prices and to select DME suppliers. The Balanced Budget Act of 1997 (BBA) authorized competitive bidding demonstrations for Part B services (except physician services), and the current project is being conducted under that authority. The initial site of the demonstration is Polk County, Florida. A second site, San Antonio, Texas, was selected in 2000. Competitively bid product categories in Polk are oxygen supplies and equipment, hospital beds, enteral nutrition, surgical dressings, and urological supplies. Product categories in Texas are oxygen supplies and equipment, hospital beds, manual wheelchairs, nebulizer drugs, and non-customized orthotics. Medicare contracts with winning suppliers in Polk County commenced in October 1999, and San Antonio contracts were scheduled to commence February 2001.
Section 4319 of the BBA specifically mandates evaluation studies addressing competitive bidding impacts on expenditures, quality, access, and diversity of product selection. This task order will study these and other outcomes of the demonstration. The evaluation will use several types of research designs, such as multiple time series analysis and pre-test/post-test comparisons. The results of the evaluation will help HCFA decide how to conduct any future competitive bidding activities.
Status: Data collection activities and analysis have begun. A pre-demonstration survey of oxygen users and users of other medical supplies was fielded in two Florida counties (Polk and Brevard) in March 1999. The results suggested beneficiaries were highly satisfied with the services and survey, fielded in CY 2000, will provide data for the pre-test/post-test comparison design analyzing the impact of the demonstration in Polk County. The evaluation team conducted five site visits to Polk County. The evaluation team conducted five site visits to Polk County in 1999 and 2000 as part of the project's case study activities addressing access, quality, administrative and market outcomes. A baseline survey in two Texas areas, San Antonio and Austin-San Marcos, was fielded in 2000, and an initial site visit to Texas was conducted in late 2000. Other evaluation activities now in the planning stages include claims analyses, focus groups, fee-schedule analyses, and additional surveys. The first annual evaluation report to Congress is scheduled for release in early CY 2001. A paper analyzing the responses to the Polk County baseline survey has been submitted for publication.
CONSUMER DIRECTED DURABLE MEDICAL EQUIPMENT DEMONSTRATION
Description: This demonstration project is designed to help Medicare beneficiaries who have disabilities exercise greater choice and control in meeting their personal needs for wheelchairs and related equipment. The project sites are Centers for Independent Living. The centers, which are funded by the U.S. Department of Education, are local consumer-led organizations devoted to helping people with disabilities live and work in their communities. HCFA's funding supports efforts to help individual beneficiaries choose and obtain wheelchairs and ongoing maintenance, as well as special features such as removable tires, carrying packs, extra padding, and desktops that otherwise might cost them more money. The centers provide information, referrals and assistance to increase consumers' direct involvement in choosing and negotiating the best price for wheelchairs and special features. Beneficiaries submit requests for prior authorization and negotiate with suppliers. Any savings are used to purchase additional features or equipment that Medicare otherwise would not cover. Medicare will pre-approve payment for a beneficiary's wheelchair based on their individual medical needs. These projects represent a step toward giving individuals with disabilities the tools to live and work more independently with dignity, and it is hoped that efforts like these will assist people with disabilities in achieving greater employment outcomes.
Status: As of the fall of 2000, these projects were in their early stages. Initially the funding supports the development of plans. HCFA expects to begin paying for claims submitted under the demonstrations in the future.
99-057 Evaluation of Issues Related to Prospective Payment System under Consolidated Bidding for Skilled Nursing Facilities and Home Health Agencies
Description: This project provides analytical support for HCFA on operating issues (claims processing, medical review (MR) and data processing) for providers and HCFA contractors (intermediaries, carriers, and Durable Medical Equipment Regional Carriers (DMERC) related to the implementation of skilled nursing facility (SNF) Part A prospective payment system (PPS), consolidated billing under Parts A and B, and implementation of the new SNF Part B fee schedule.
The primary issues are:
Rate setting is not included.
Status: A report was submitted on home health consolidated billing recommending that DME claims continue to be processed by the DMERC. Congress subsequently enacted legislation to this effect also.
A report was submitted defining issues in consolidated billing for SNFs under Part B suggesting that a preferable approach would be implementation of adequate edits to detect duplicate billing. Congress subsequently enacted legislation to this effect also.
Recommended Common Working File and standard systems edits were identified for HCFA. HCFA is in the process of implementing these edits.
A description of recommended procedures was furnished to HCFA in the form of a draft Part A Program Memo and a draft SNF Manual Transmittal. The program memo has been published, and the draft SNF manual is in the final stages of HCFA clearance.
Remaining activities include:
96-057 Case-Mix Adjustment for a National Home Health Prospective Payment System
Description: The primary focus of this study is to understand existing variation in home health resource patterns and to use this information to develop a case-mix adjustment system for a national home health prospective payment system (PPS). In this study elements from the Outcomes and Assessment Information Set (OASIS), which has been developed for outcome-based quality assurance and improvement for Medicare home health agencies, are analyzed for their usefulness as measures within a case mix adjustment model. Detailed information, including information on resource utilization and additional items needed for case-mix adjustment not included on OASIS, has been collected from participating agencies. Under modifications to the original contract, the project assumed additional tasks to (1) develop and test home health PPS grouper software, (2) provide technical assistance for setting PPS rates, (3) design and assist HCFA in implementing an OASIS verification protocol for use by regional home health fiscal intermediaries, and (4) develop data and conduct further analyses to refine the initial case mix model.
Status: Ninety agencies were recruited and trained from eight states (Arkansas, California, Florida, Illinois, Massachusetts, Pennsylvania, Texas, Wisconsin) in the spring and summer of 1997. All agencies began data collection on a 6-month cohort of new admissions to home care beginning in October 1997. Data collection ended in the spring of 1999. Analysis to date has resulted in a viable, clinically coherent system of 80 case-mix groups that explains more than 30 percent of the variation in resource use on a development sample drawn from the cohort members. Resource use is measured for 60-day periods of care, to conform to the unit of payment under the national PPS. Selected OASIS assessment items, collected at the start of care, are used in the grouping system. The case-mix items fall into three major domains: clinical factors, functional-status factors, and utilization factors. Within each domain, a parsimonious set of items is summarized into a score for the patient. In two of the domains, scores are partitioned into four levels corresponding to high, moderate, low, and minimal impact, based on the relationship of the score to resource utilization. In the third domain, scores are partitioned into five impact levels. A patient's combination of levels on all three domains identifies the group into which the patient is classified for purposes of case-mix adjusting the prospective payment amount. Under this system the patient's case mix classification may be updated at the end of the payment period to reflect the actual amount of home therapy services received during the 60-day payment period. Results of the study to date are described in two reports:
Additional reports on model validation results, refinement-related analyses, and OASIS data verification are expected in 2001.
00-023 Direct and Indirect Effects of the Changes in Home Health Policy and an Analysis of the Skill Mix of Medicare Home Health Services Before and After the Balanced Budget Act of 1997
Description: This project provides partial support for a project primarily funded by the Robert Wood Johnson Foundation (RWJ). As part of this larger project, HCFA supplies needed data and receives the results of a special study. The Major (RWJ) project examines three areas where impact of the Balanced Budget Act of 1997 (BBA) might fail the Medicare beneficiary, home health care agencies, and the overall medical and long-term care system. Analysis based on the data HCFA supplies under this award, taken together, will help understand the overall pattern of impacts and be useful in formation of future reimbursement policy. The special study for HCFA looks at beneficiary access. This will analyze pattern of Medicare home health use before and after the implementation of the BBA. There is a focus on assessing whether changes occurred in the skill mix of types of visits received by home health users. It will examine whether differential effects have occurred for different categories of home health users and in different geographic areas.
Status: The data are being accessed after considerable delay at HCFA. They are being prepared for analysis as of December 2000. Because of this delay in access to the information, the project has been extended through March 2002.
94-087 Maximizing the Cost Effectiveness of Home Health Care: The Influence of Service Volume and Integration with Other Care Settings on Patient Outcomes
Description: Home health care (HHC) is the most rapidly growing component of the Medicare budget in recent years. The rapid growth in home health use has occurred despite limited evidence about the necessary volume of HHC to achieve optimal patient outcomes and whether it substitutes for more costly institutional care. Little is known about integrating HHC with care in other settings to reduce overall health care costs. The central hypotheses of this study were that volume-outcome relationships are present in HHC for common patient conditions, that upper and lower volume thresholds exist that define the range of services most beneficial to patients, and that a strengthened physician role and better integration of HHC with other services during an episode of care can optimize patient outcomes while controlling costs. To test these hypotheses, a sample of 3,600 patient records were analyzed from agencies in 20 states stratified into high, medium, and low-volume categories based on annual visits per beneficiary. Trained data collectors at each agency recorded patient health status and service information between HHC admission and discharge to assess patient outcomes and costs within the HHC episode. Long-term, self-reported outcomes were measured from telephone interview data at HHC admission and from 6-month follow ups. These primary data concerning patient status and outcomes were combined with Medicare claims data over the episode of care to study the relationship between service volume in HHC and both patient outcomes and costs.
Status: Study Paper 1, Research Design Update, which summarized the research design and its evolution from the original proposal, was finalized in September 1998. Primary data collection ended in late 1998. An interim report on a subsample of 1,000 patients (February 1999) described case mix and volume relationships, and selected findings were presented at the November 1999 meeting of the American Public Health Association. Separately for the four common conditions (congestive heart failure, stroke, surgical hip procedures, and open wounds) a high-and low-volume group was selected by taking the highest and lowest 45% of the arrayed cases within each condition. The median volume (defined as number of visits until discharge or first inpatient admission) differed by a factor of about four to nine, depending on the condition. For home health aide services mea volume differed by a factor of between 30 and 47. Many case mix indicators were measured at the start of care. Of these, few demographic indicators differed between the volume groups within condition. But limitations in activities of daily living (ADLs) were significantly greater for the high-volume groups, these patients had a greater prevalence of chronic conditions, and their institutional utilization within the 14 days prior to admission was less likely to be an acute-care hospital, indicating the more pos-acute nature of the low-volume groups. This general case mix difference is consistent with the greater use of aide services for high-volume patients. Preliminary analyses of outcomes suggested relatively few differences in outcomes by volume, after controlling for condition. This result may mean that the additional services delivered to the high-volume group helped equalize outcomes between more severely ill and less severely ill patients. Risk-adjusted analyses are planned to explore this possibility.
95-094 Quality Assurance for Phase II of the Home Health Agency Prospective Payment Demonstration
Description: This demonstration project was designed to test the effect of per-episode home health prospective payment on the quality of care provided to Medicare patients receiving home care. Home health agencies (HHAs) receive an agency-specific episode payment based on 120 days of care and outlier payments, reimbursed at per-visit prospective rates, for episodes that extend beyond 120 days. A new episode of care is identified when there has been a gap in home health services for 45 or more days after the initial 120 days. Agencies receiving per-episode payments are subject to stop-loss and profit-sharing provisions, as well as case-mix adjustments. Ninety volunteer HHAs from five states (California, Florida, Illinois, Massachusetts, and Texas) were randomly assigned to either the control group (cost-based payment) or the treatment group (per-episode payment). All HHAs had entered the demonstration by January 1996. Since there is an incentive to underserve patients with per-episode prospective payment, data collection using a scaled-down version of the outcome-based quality improvement system was initiated about a year into Phase II of the demonstration. The period from May 1996 to July 1997 indicated s small difference in the end-results outcomes between treatment (per-episode payment) and control agencies (cost-based payment): treatment-agency patients displayed slightly less favorable outcomes than control-agency patients did. As of December 31, 1998, all participating agencies ended participation in the quality assurance component of the home health prospective payment system demonstration. All data collection was completed in January 1999. The final report will summarize the project and its major findings with regard to quality of care and outcomes under the prospective payment demonstration.
00-067 Medicare Post-Acute Care: Evaluation of BBA Payment Policies and Related Changes
Description: The purpose of this project is to study the impact of the Balanced Budget Act of 1997 (BBA) and other policy changes on Medicare utilization and delivery patterns of post-acute care. Post-acute care is generally defined to include the Medicare covered services provided by skilled nursing facilities (SNFs), home health agencies, rehabilitation hospitals and distinct part units, long-term care hospitals, and outpatient rehabilitation providers. The changes in post-acute care payment policy enacted in the late 1990's (mostly in the BBA with some subsequent modifications) were made one-by-one to most types of post-acute care. However, a beneficiary's post-acute care needs can often be met in alternative provider settings. Hence policy changes for one post-acute care modality may have ramifications for other post-acute and acute care services. Understanding the interrelationships among post-acute care delivery systems is critical to the development of policies that encourage appropriate and cost-effective use of the entire range of care setting. The results of this work may be useful in refining policies for individual types of post-acute care, as well as in developing a more coordinated approach across all settings.
Medicare utilization and expenditures for post-acute care increased dramatically in the 1990's prior to the passage of the BBA. Many of the changes enacted in the BBA were in reaction to the experience of the early 1990's and were aimed at controlling the decade's fiscally disturbing expenditure trends. Even before passage of the BBA, administrative actions (such as Operation Restore Trust) were taken to tighten the enforcement of coverage guidelines and reduce abuses that were perceived to be significant contributory factors to the runaway growth of the early 1990's. Chief among the BBA changes was the mandate for implementation of prospective payment systems to replace retrospective cost-based payment for all the major post-acute care providers. Among the BBA policies whose impacts are to be considered in this project are the following:
In general, the appropriate evaluation design is a "differences in differences" model that estimated differential effects over time as a function of differential degrees of impact. In this initial project, analyses will compare changes between the pre-BBA period of the 1990's and a post-BBA year, such as 1999. For the most part, the studies should focus on the interrelationships among the various post-acute care settings. However, in some cases, changes affecting a single type of post-acute care may warrant special analysis. The model needs to be applied flexibly to include a variety of beneficiary, provider, and market area analyses. In addition, analyses may involve data for individual years, as well as changes between years. Since the impacts of policy changes not yet implemented will continue to be of interest for many years, the analyses developed under this project are expected to use and refine methods that can be applied in future evaluation research. Analytically, this is a challenging project due to the numbers of provider types and policy changes involved. The staggered and overlapping temporal implementation of the changes further complicates the effort. The proposed analyses are not necessarily expected to be able to attribute causality to effects detected, nor are they expected to disentangle the effects of one policy change from the effects of another. In general, it will only be possible to determine net effects of all changes relevant to a specific analysis. However, in choosing time periods, attention will be paid to the policies that could be expected to impact behavior during the period of analysis. The project will utilize secondary data sources, primarily HCFA claims data. Claims for all relevant types of services will need to be linked with beneficiary enrollment information to create "episodes" of care by beneficiary. At least two such episode files will be required, one for a pre-BBA year such as 1995 or 1996 and another for a post-BBA year such as 1999. In addition, the project will design a strategy for monitoring and evaluation of impacts across post-acute care settings. We are interested in distinguishing between the needs for regular monitoring of impacts across post-acute care settings and more detailed evaluation studies. We are especially interested in defining data requirements for monitoring sentinel events that would serve as alerts for more in-depth evaluation.
The strategy will define data requirements for monitoring and evaluation activities, taking into consideration the data available for individual care modalities and the need to integrate data across modalities in as timely and efficient a manner as possible.
Status: The project is in the developmental stage.
97-215 Design of an Integrated Post-Acute Care System
Description: HCFA intends to create an infrastructure of post-acute and long-term care delivery and payment systems that are better integrated and more flexible in meeting the needs of beneficiaries with chronic illnesses and disabilities. The transition from our current benefit and provider-based system to a beneficiary-centered system requires several elements:
Additional work that incorporates beneficiary preferences into outcome measures, as well as further attempts to differentiate outcomes by post-acute-care modality for different patient conditions, is also needed. The purpose of this project is to design several elements needed in a more integrated system“an assessment tool, potential care management models, appropriate payment systems, and outcome measures that cross settings and incorporate beneficiary preferences, with the ultimate intent of pilot testing and refining these elements in a demonstration. A second purpose of this project is to design an optional demonstration that tests the feasibility and effectiveness of creating a more integrated post-acute-care system.
94-74
99-049 Expansion of Telehealth Services for Homebound Medicare Beneficiaries
Description: This project prepared a report that examines the possibility of making payments for medical services provided to Medicare beneficiaries who are "homebound or nursing homebound and for whom being transferred to health care services imposes a serious hardship. The report examined several possible payment models and includes detailed cost and savings estimates of providing home telecare to eligible Medicare beneficiaries using various payment models. The Balanced Budget Act of 1997 required HCFA to report on the possibility of making payments for a professional consultation that is delivered via telecommunications systems with a physician or practitioner (who is thus furnishing a service for which payment may currently be made). Eligible beneficiaries include Medicare beneficiaries who do not reside in a rural health provider scarcity area. HCFA already had acquired a report (Home Telecare in the US) which focused primarily on how telemedicine was being used in the home care setting. This earlier study found no indication that professional consultations, via telecommunications systems, are being provided in the home where there is a practitioner on each end of an interactive audio video telecommunications system.
The research indicates that three existing service models are in use:
Further analysis revealed that home telecare may be better suited for certain diagnoses. For instance, most programs that were contacted targeted congestive heart failure, chronic obstructive pulmonary disease and asthma. Diabetes, wound care, and mild dementia were also included in several programs. Many programs provided home telecare in addition to regular home care so that volume of enounters with homebound patients appears to rise for programs using telemedicine in the home. Additionally, this earlier report indicates that most home telecare is provided to patients who are homebound, while very little home telecare is being provided to patients who reside in nursing homes.
In addressing payment models, HCFA sought recommendations regarding the construction of model visit(s), diagnoses most suitable for home telecare, and appropriate time frames defining episodes of care. Additionally, the feasibility of each payment model would be assessed as it relates to the cost/savings analysis section of the report. To that end, HCFA sought recommendations regarding the preceding payment models.
Status: The final report is being reviewed.
94-074 Design and Implementation of Medicare Home Health Quality Assurance Demonstration
Description: Currently Medicare's home health survey and certification process is primarily focused on structural measures of quality. Although this process provides important information about home health care, an approach based on patient outcome measures would substantially increase the Medicare program's capacity to assess and improve patient well-being. To address this need, the Medicare Home Health Quality Assurance Demonstration will test an approach to develop outcome-oriented quality assurance and promote continuous quality improvement in home health agencies (HHAs).
The demonstration was implemented through a contract with the Center for Health Policy Research (CHPR), University of Colorado, to determine the feasibility of and establish the methodology for a national approach for outcome-based quality improvement (OBQI). Outcome measures are computed using the Outcomes and Assessment Information Set (OASIS), a set of valid, reliable measures, developed through research efforts conducted for HCFA by CHPR (1988-1994) to assess patient outcomes of care provided in the home.
Under the demonstration, staff of 50 regionally-dispersed HHAs complete the OASIS data collection instrument for each patient at the start of care and at 60-day intervals (up to and including discharge). The OAISIS data re submitted monthly to CHPR for validation and storage. There are three rounds of data analysis and outcome report generation, each based on 12 months of data.
The general framework for OBQI is a two-stage process of continuous quality improvement. Data are collected at regular time intervals for all adult patients. Risk adjustment is undertaken and outcome reports are produced for specific patient conditions ("focused reports") and for all adult patients ("global reports"). These reports are provided to the participating HHAs and are used to determine which outcomes are inferior, thereby providing a focus for agency staff to target problematic care. Exemplary care is also investigated in order to reinforce positive care behaviors. A plan of action allows the agency to monitor the changes in care behavior and through the next round of data collection, determine if targeted outcomes have improved and if reinforcement activities have maintained exemplary outcomes.
The contract was modified substantially to provide consultation and assistance to HCFA and its components in the nationwide implementation of the OASIS instrument. Most of these activities involve the development of software for OASIS data collection and transmission to the states and the OASIS national repository at HCFA, the continuing evaluation and development of the instrument, the generation of educational and training materials and their presentation to State agencies for dissemination to the nation's HHAs, and the development and presentation of similar material about the techiques of OBQI for use by HHAs. This contract modification also provides support to the Home Health OBQI System Pilot Project to develop a quality improvement support system for HHAs through the HCFA Peer Review Organizations. Finally, the contract provides for extensive general support to HCFA in the preparation of background material and expert technical consultation on a variety of policy issues related to OASIS.
Status: Fifty agencies in 26 states were phased into the demonstration beginning in January 1996. In January 1997, the demonstration agencies received their first outcome reports and developed plans of actions to improve care for two patient outcomes during 1997. Agencies received their second annual reports in May 1998, which contained baseline comparisons from 1997, and received their third and final reports in May 1999. A final report on the evaluation of the demonstration effort is expected in the beginning of 2001. The original contract was modified extensively to provide assistance in the nationwide implementation of OASIS collection and reporting, and the dissemination of information for the effective use of OASIS outcome reports. Funding was increased to a total of $5,185,000 and the project was extended 3 years to December 31, 2003.
99-088 BBA Studies of Home Oxygen Equipment
Description: After a fair amount of public discussion concerning overpayment for home oxygen equipment, the Balanced Budget Act of 1997 reduced the payment allowance by 25 percent (effective 1/1/98) and by an additional 5 percent (effective 1/1/99). With these significant payment reductions, the act required that the Government Account Office study issues related to oxygen equipment. It also required that HCFA arrange with peer review organizations (PROs) to evaluate access to and quality of home oxygen equipment. This evaluation was done in two phases. In Phase 1, a lead PRO designed the evaluation with the assistance of an organization that has expertise in such evaluations. In Phase II, the national evaluation was carried out.
Status: The study was completed.
99-059 Development and Testing of an Outcome Assessment Information Set (OASIS) Accuracy Verification Protocol
Description: This project will develop cost-effective methods for verifying and ultimately improving the accuracy of the Outcomes and Assessment Information Set (OASIS) data submitted by home health agencies (HHAs) to State agencies and HCFA. A major task under this project is to assess the current system for electronic editing and rejection of OASIS records that have fatal errors, as well as analysis of patterns within OASIS records transmitted by HHAs to the State and OASIS records maintained at HCFA in a national data base. The contractor will provide recommendations for HCFA concerning what cost-effective enhancements are needed to those components of the electronic OASIS data base system that affect data accuracy, including the electronic edits, testing of additional enhancements, and setting of error tolerances for the system. Another major task of this project is the development, testing, and analysis of a set of prototype accuracy protocols with differing levels of intensity of review and, thus, costs. It is expected that these protocols will include both electronic data analysis (offsite) and onsite verification components.
Status: The project has completed the development and pilot testing of clinical audit protocols. It was preparing for field testing in January. In the edit protocols segment of the project, work has been completed on two of the four protocols needed.
98-224 Evaluation of the Home and Community-Based Services Waiver Program
Description: The Home and Community-Based Services (HCBS) Waiver Program has been operating since 1981 and has experienced tremendous growth in recent years. The percent of Medicaid long-term care spending devoted to HCBS has increased from 10 percent to 19 percent (between the financial and beneficiary-level impacts of the program) in over a decade. The aim of this task order is to gain a better understanding of the broader HCBS waiver program and determine what programmatic mechanisms have been successful.
Status: The project is ongoing.
99-125 Provision of EPSDT Services in State Medicaid Plans and Medicaid Managed Care Contracts
Description: The Office of Strategic Planning is currently conducting intramural research of Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit for a study and report to Congress mandated by the Balanced Budget Act of 1997. An analysis of the EPSDT benefit requires sufficient data on State Medicaid programs to estimate the use and cost of EPSDT services, including medically necessary services (e.g., section 1905(r)). In support of HCFA's intramural research efforts, HCFA has contracted with the Center for Health Services Research and Policy at George Washington University to address the issue of medical necessity and obtain information on health services included in Medicaid managed care contracts and Medicaid State Plans. This information will be used to identify services that may be considered over and above what Medicaid costs would have been in the absence of the enhanced EPSDT service benefit (Omnibus Budget Reconciliation Act of 1989). The work to be performed will include a series of five tables with accompanying memoranda that summarize the research findings.
Status: The project is expected to be completed by 1/30/2001.
99-015 Transitioning Persons from Nursing Homes to the Community on a 'Date Certain'/Fostering the Use of Home and Community-Based Services: Attendant Care — Colorado
Description: This program was designed to assist the State in developing mechanisms that transition individuals, currently in nursing homes into the community (if that is their choice); identify and eliminate barriers to community living; and work with individuals and their families prior to admission to a nursing home to consider community-based alternatives.
Colorado's program sought to reduce barriers to community-based care by appropriately placing persons in the community (or nursing facility (NF)) when being discharged from the hospital. Colorado asserts that hospital discharge is the "single most important access point" for admission to the NF and estimated that about one third of these admissions could be diverted to the community if policies for preventing unnecessary placement in an NF were in place. Colorado identified barriers to community-based care, such as protracted time to process financial eligibility for Medicaid and financial risk with placement prior to determination, lack of awareness of community-based options, lack of facilities that provide a level of care between assisted living and skilled nursing facility, and a lack of personal resources to move into the community. Colorado's program has six objectives for eliminating these barriers which are based upon two pilot projects in the State that were aimed at reducing the number of clients going from hospitals to NFs and deinstitutionalizing persons inappropriately residing in NFs.
Specifically, Colorado developed and tested a screening instrument to quickly identify individuals who are likely to be discharged from hospital to an NF, but could be placed in alternate settings. This included the provision of short-term intensive case management in the hospital and following discharge to individuals identified in the screening procedure.
The State contracted with the Colorado Cross Disability Coalition to survey hospital discharge units, consumers, Single Entry Point case-management agencies, and advocacy organizations to determine what transitional services were needed by persons leaving hospitals to reside in community settings. The development of a resource network for at-risk disabled people resulted from these surveys.
Other objectives under Colorado's project were to:
Status: The funding for this program has ended and the State has provided HCFA with its final report.
99-069 Evaluation of the Child Health Insurance Program
Description: The State Children's Health Insurance Program (SCHIP) was established by the Balanced Budget Act of 1997. This program provides $24 billion to participating States over a 5-year period to provide health insurance to low-income uninsured children. Participating States may extend coverage to these children by:
States choosing to expand Medicaid are required to provide at least the same set of benefits offered in their traditional Medicaid program. Participating States electing to establish a separate program may base benefits on:
Children under age 19 who are not eligible for Medicaid with family incomes below 200 percent of the Federal poverty level of 50 percentage points above the current State Medicaid limit are eligible. To examine and track the impact of SCHIP in reducing the numbers of low-income uninsured children, States are required to report and assess the operation of their children's health insurance programs. The Secretary is required to report on the impact of SCHIP by the end of 2001.
The project will involve:
Status: In progress.
99-106 Home Care Services: The Effect of Unmet Need on Health Care Utilization
Description: The main objective of this study was to examine how the need for home care services and the service delivery mechanism itself affect the use of health care services among a population of Medicare-eligible elderly and disabled persons receiving home care. Home care is one of the fastest growing components of personal health expenditures. However, among persons receiving home care, there is still a considerable amount of unmet need — either a lack of, or insufficient help with, activities of daily living and instrumental activities of daily living. Moreover, different models of service delivery have been developed to provide home care. Both of these factors, unmet need and service delivery mechanism, can have significant impacts on costs of home care, as well as quality of life for home care recipients. However, the effect of these factors on the utilization of health services has not been included in past studies of home care programs. This research addressed the following:
Data came from two sources which were linked together: a survey of individuals receiving home care services through the California In-Home Supportive Services program, and Medicare claims data. Multiple regression analysis was utilized to examine the effects of service delivery mechanism and unmet personal assistance needs on use of health services. In addition, a stratified analysis based on level of disability was done in order to determine if the effects vary by degree of disability.
Status: Grant completed. The final dissertation report has been received.
99-111 Post Acute Care Use and Early Hospital Readmission of Hospitalized Elderly Medicare Patients
Description: The objective of this project was to investigate the variation in hospital discharge location and subsequent early hospital readmission attributable to patient, hospital, and market are characteristics for Elderly Medicare patients. The Balanced Budget Act of 1997 (BBA) expanded the prospective payment system to post-acute care. The BBA also expanded the definition of transfer cases by treating discharge to post-acute care as hospital transfers (for selected Diagnostic Reimbursement Groups.) These expansions are likely to result in new patterns of post-acute care choice and utilization. Understanding the attributable variations provides information for reforming post-acute care services and policy options for bundling post-acute care payments in the future. The specific aims for this study were to:
Status: Grant completed. The final dissertation report has been received.
00-004 Access to Medicare Home Health Care in the Wake of the Balanced Budget Act
Description: Recent changes to the Medicare home health benefit have altered the way that home health care agencies will be reimbursed. It has been estimated that the new reimbursement system, referred to as the Interim Payment System (IPS), will reduce agency revenues by 15-22 percent. Such reductions may encourage agencies to alter the amount, duration, or type of benefits provided to certain types of home health care patients. This study will investigate whether certain types of patients are experiencing reductions in access to care or in service receipt including: 1) not being admitted to home health services; 2) being discharged early; 3) receiving less services; or 4) receiving less expensive services. This study consists of a secondary analysis of data from the Medicare Current Beneficiary Survey (MCBS) Access to Care, Public Use File and HCFA claims files for the years 1996 and 1998. These comprise the primary data sources for this study. The researcher also obtained the Provider of Services Extract File from the OSCAR data base. She also conducted qualitative interviews with home health agency staff in an attempt to enhance the depth of understanding of these issues. Statistical analyses will allow her to: determine whether this particular policy change is affecting access to care; to test hypotheses regarding utilization patterns; to understand which factor (such as patient characteristics, agency characteristics, and supply-side factors) are more predictive of specific utilization patterns; and to understand the explanatory power of sets of independent variables. Qualitative interview data will allow the researcher to understand agency practices post-IPS, providing greater sensitivity to contextual elements and provider perspectives. These interviews will also be used to check for validity in the interpretation of quantitative data and to identify provider practices that may not be reflected in the claims files. Information from this study will be shared with policy makers and home health agency providers and may be utilized to improve the design of the prospective payment system or to design necessary clinical criteria for reimbursement limit exemptions in home health care.
Status: In progress.