The effects of a variant of the program for all-inclusive care of the elderly on hospital utilization and outcomes.

OBJECTIVES: To compare the effects of the Wisconsin Partnership Program (WPP) on hospital, emergency department (ED), and nursing home utilization with those of traditional care. DESIGN: Quasi-experimental longitudinal cohort design. SETTING: Selected counties in Wisconsin. PARTICIPANTS: WPP elderly enrollees and two matched control groups consisting of frail older people enrolled in fee-for-service insurance plans, Medicare, and Medicaid and receiving home- and community-based waiver services, one from the same geographic area as the WPP and another from a location in the state where the WPP was not offered. MEASUREMENTS: Data came from administrative records. Regression and survival analyses were adjusted for case-mix variables. RESULTS: No significant differences in hospital utilization, ED visits, preventable hospitalizations, risk of entry into nursing homes, or mortality were found. WPP enrollees had more contact with care providers than did controls. CONCLUSION: WPP did not dramatically alter the pattern of care. Part of the weak effect may be attributable to the small numbers of WPP cases per participating physician.

Variations on a theme called PACE.

BACKGROUND: The Program for All-inclusive Care of the Elderly (PACE) has been hailed as successful but of limited appeal. This study contrasts the effects on hospital utilization of PACE and a more liberal variant, the Wisconsin Partnership Program (WPP). METHODS: Hospital and emergency room (ER) utilization data from two sites that used both PACE and WPP to serve elderly clients were compared. The analysis of utilization was conducted using a cross-sectional longitudinal approach. The statistical significance of the difference between WPP and PACE groups was calculated by using regressions that adjusted for gender, race (white/nonwhite), age, original reason for entitlement in Medicare (elderly/disabled), dual eligibility, diagnoses during the previous 6 months, and county of residence. RESULTS: The PACE enrollees had fewer hospital admissions, preventable hospital admissions, hospital days, ER visits, and preventable ER visits than the WPP enrollees had. There was no difference in the length of hospital stays. CONCLUSIONS: PACE is more effective in controlling hospital and ER utilization than is the more flexible variant (WPP).

The quality of care under a managed-care program for dual eligibles.

PURPOSE: Our objective in this study was to compare the quality of care provided under the Minnesota Senior Health Options (MSHO), a special program designed to serve dually eligible older persons, to care provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN AND METHODS: Two control groups were used; one was drawn from nonenrollees living in the same area (Control-In) and another from comparable individuals living in another urban area where the program was not available (Control-Out). Cohorts living in the community and in nursing homes were included. Quality measures for both groups included mortality rates, preventable hospital admissions, and preventable emergency room (ER) visits. For the community group, nursing home admission rates were also tracked. For nursing home residents, quality measures included quality indicators derived from the Minimum Data Set. RESULTS: There were no differences in mortality rates for either cohort. MSHO had fewer short-stay nursing home admissions but no difference for stays 90 days or longer. MSHO community and nursing home residents had fewer preventable hospital and ER visits compared to Control-In. There were no major differences in nursing home quality indicator rates. IMPLICATIONS: The cost of changing the model of care for dual eligibles from a mixture of fee-for-service and managed care to a merged managed-care approach cannot be readily justified by the improvements in quality observed.

Patterns of utilization for the Minnesota senior health options program.

OBJECTIVES: To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN: Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences. SETTING: Urban Minnesota community and nursing home long-term care. PARTICIPANTS: Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included. MEASUREMENTS: Use of hospitals and emergency rooms, physician visits. RESULTS: In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group. CONCLUSION: In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents.

Consumer responses to the Wisconsin Partnership Program for Elderly Persons: a variation on the PACE Model.

BACKGROUND: The Wisconsin Partnership Program (WPP) is a variation on the Program for All-inclusive Care of the Elderly (PACE) model that is designed to be more flexible by allowing frail elderly dual-eligible (for both Medicare and Medicaid) clients to use their regular primary care physicians instead of relying on the physician hired by PACE. Case management is provided by a team of nurse, social worker, and nurse practitioner. The latter is charged with communicating with the client's primary physician. 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.

Outcomes of managed care of dually eligible older persons.

PURPOSE: To assess changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options (MSHO), a managed care program for older persons eligible for both Medicare and Medicaid. DESIGN AND METHODS: We used two sets of matched controls for MSHO enrollees and their families and matched controls living in the community and in nursing homes: Persons in the same county who were eligible to enroll but did not enroll in MSHO and persons in other metropolitan areas where MSHO is not available. For the community sample, we used questionnaires to measure functional status (activities of daily living), pain, unmet care needs, satisfaction, and caregiver burden. Approximately 2 years after the first survey, we resurveyed respondents who lived in the community at the time of the first survey. For the nursing home residents, we used annual assessments to calculate case mix to compare changes in functional levels over time. RESULTS: There were few significant differences in change over time between the MSHO sample and the two control groups. Out-of-area controls showed greater increases in pain but in-area controls showed less interference from pain. Compared with out-of-area controls, MSHO clients showed greater increase in homemaker use, meals on wheels, and outpatient rehabilitation. Compared with in-area controls, they showed more use of meals on wheels and less help from family with household tasks. There were few differences in satisfaction, but the MSHO families showed significantly lower burden than controls on five items. IMPLICATIONS: The analyses show only modest evidence of benefit from MSHO compared with the two control groups. The model represented by MSHO does not appear to generate substantial differences in outcomes across function, satisfaction, and caregiver burden.

Diagnosed prevalence and health care expenditures of mental health disorders among dual eligible older people.

PURPOSE: Little is known about mental health disorders (MHDs) and their associated health care expenditures for the dual eligible elders across long-term care (LTC) settings. We estimated the 12-month diagnosed prevalence of MHDs among dual eligible older adults in LTC and non-LTC settings and calculated the average incremental effect of MHDs on medical care, LTC, and prescription drug expenditures across LTC settings. METHODS: Participants were fee-for-service dual eligible elderly beneficiaries from 7 states. We obtained their 2005 Medicare and Medicaid claims data and LTC program participation data from federal and state governments. We grouped beneficiaries into non-LTC, community LTC, and institutional LTC groups and identified enrollees with any of 5 MHDs (anxiety, bipolar, major depression, mild depression, and schizophrenia) using the International Classification of Diseases Ninth Revision codes associated with Medicare and Medicaid claims. We obtained medical care, LTC, and prescription drug expenditures from related claims. RESULTS: Thirteen percent of all dual eligible elderly beneficiaries had at least 1 MHD diagnosis in 2005. Beneficiaries in non-LTC group had the lowest 12-month prevalence rates but highest percentage increase in health care expenditures associated with MHDs. Institutional LTC residents had the highest prevalence rates but lowest percentage increase in expenditures. LTC expenditures were less affected by MHDs than medical and prescription drug expenditures. IMPLICATIONS: MHDs are prevalent among dual eligible older persons and are costly to the health care system. Policy makers need to focus on better MHD diagnosis among community-living elders and better understanding in treatment of MHDs in LTC settings.