State-Level Health Care Expenditures Associated With Disability.

OBJECTIVE: Given the growth in national disability-associated health care expenditures (DAHE) and the changes in health insurance-specific DAHE distribution, updated estimates of state-level DAHE are needed. The objective of this study was to update state-level estimates of DAHE. METHODS: We combined data from the 2013-2015 Medical Expenditure Panel Survey, 2013-2015 Behavioral Risk Factor Surveillance System, and 2014 National Health Expenditure Accounts to calculate state-level DAHE for US adults in total, per adult, and per (adult) person with disability (PWD). We adjusted expenditures to 2017 prices and assessed changes in DAHE from 2003 to 2015. RESULTS: In 2015, DAHE were $868 billion nationally (range, $1.4 billion in Wyoming to $102.8 billion in California) accounting for 36% of total health care expenditures (range, 29%-41%). From 2003 to 2015, total DAHE increased by 65% (range, 35%-125%). In 2015, DAHE per PWD were highest in the District of Columbia ($27 839) and lowest in Alabama ($12 603). From 2003 to 2015, per-PWD DAHE increased by 13% (range, -20% to 61%) and per-capita DAHE increased by 28% (range, 7%-84%). In 2015, Medicare DAHE per PWD ranged from $10 067 in Alaska to $18 768 in New Jersey. Medicaid DAHE per PWD ranged from $9825 in Nevada to $43 365 in the District of Columbia. Nonpublic-health insurer per-PWD DAHE ranged from $7641 in Arkansas to $18 796 in Alaska. CONCLUSION: DAHE are substantial and vary by state. The public sector largely supports the health care costs of people with disabilities. State policy makers and other stakeholders can use these results to inform the development of public health programs that support and provide ongoing health care to people with disabilities.

National Health Care Expenditures Associated With Disability.

BACKGROUND: In 2003, national disability-associated health care expenditures (DAHE) were $398 billion. Updated estimates will improve our understanding of current DAHE. OBJECTIVE: The objective of this study was to estimate national DAHE for the US adult population and analyze spending by insurance and service categories and to assess changes in spending over the past decade. RESEARCH DESIGN: Data from the 2013-2015 Medical Expenditure Panel Survey were used to estimate DAHE for noninstitutionalized adults. These estimates were reconciled with National Health Expenditure Accounts (NHEA) data and adjusted to 2017 medical prices. Expenditures for institutionalized adults were added from NHEA data. MEASURES: National DAHE in total, by insurance and service categories, and percentage of total expenditures associated with disability. RESULTS: DAHE in 2015 were $868 billion (at 2017 prices), representing 36% of total national health care spending (up from 27% in 2003). DAHE per person with disability increased from $13,395 in 2003 to $17,431 in 2015, whereas nondisability per-person spending remained constant (about $6700). Public insurers paid 69% of DAHE. Medicare paid the largest portion ($324.7 billion), and Medicaid DAHE were $277.2 billion. More than half (54%) of all Medicare expenditures and 72% of all Medicaid expenditures were associated with disability. CONCLUSIONS: The share of health care expenditures associated with disability has increased substantially over the past decade. The high proportion of DAHE paid by public insurers reinforces the importance of public programs designed to improve health care for people with disabilities and emphasizes the need for evaluating programs and health services available to this vulnerable population.

Risk adjustment in Home Health Care CAHPS.

The authors disagree with previous research concluding that the Home Health Care Consumer Assessment of Healthcare Providers and Services (CAHPS) publicly reported data are insufficiently adjusted for patient comorbidities.

Effects of Integrating Care for Medicare-Medicaid Dually Eligible Seniors in Minnesota.

Individuals dually eligible for Medicare and Medicaid often receive fragmented and inefficient care. Using Minnesota fee-for-service claims, managed care encounters, and enrollment data for 2010-2012, we estimated the likely impact of Minnesota Senior Health Option (MSHO)-seen as the first statewide fully integrated Medicare-Medicaid model-on health care and long-term services and supports use, relative to Minnesota Senior Care Plus (MSC+), a Medicaid-only managed care plan with Medicare fee for service. Estimates suggest that MSHO enrollees had significantly higher use of primary care and, potentially, of community-based services, combined with lower use of hospital-based care than similar MSC+ enrollees. Adopting fully integrated care models like MSHO may have merit in other states.

Qualitative analysis and conceptual mapping of patient experiences in home health care.

This study explored patient experiences in home health care through a literature review, focus groups, and interviews. Our goal was to develop a conceptual map of home health care patient experience domains. The conceptual map identifies technical and personal spheres of care, relating prior studies to new focus group and interview findings and identifying the most important domains of care. Study participants (n = 35) most frequently reported the most important domain as staff who are caring, supportive, patient, empathetic, respectful, and considerate (endorsed by 29% of participants). The conceptual map includes 114 discrete domains.

Patient experience and process measures of quality of care at home health agencies: Factors associated with high performance.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

Racial and Ethnic Disparities in Patients' Experience With Skilled Home Health Care Services.

Racial and ethnic disparities are found in many health care settings; however, there is little prior research on such disparities among patients receiving home health care services. This study used 2012 Home Health Care CAHPS(®) data to identify any overall patient-level disparities in self-reported experience of care and to decompose these disparities according to whether they result from within-agency versus between-agency differences. Although patient experience of care ratings were high across all groups, the study identified consistently lower ratings for all minority groups on two of three Home Health Care CAHPS measures, with Asians reporting the greatest disparities. Three quarters of disparities were found to be within-agency disparities, which were primarily related to care processes and provider/patient communications rather than to specific health care services received. Despite high ratings in general, home health agencies may need to focus on cultural competency initiatives to address racial and ethnic disparities within their agencies.

Disability status, mortality, and leading causes of death in the United States community population.

OBJECTIVE: We examined the effect of functional disability on all-cause mortality and cause-specific deaths among community-dwelling US adults. METHODS: We used data from 142,636 adults who participated in the 1994-1995 National Health Interview Survey-Disability Supplement eligible for linkage to National Death Index records from 1994 to 2006 to estimate the effects of disability on mortality and leading causes of death. RESULTS: Adults with any disability were more likely to die than adults without disability (19.92% vs. 10.94%; hazard ratio=1.51, 95% confidence interval, 1.45-1.57). This association was statistically significant for most causes of death and for most types of disability studied. The leading cause of death for adults with and without disability differed (heart disease and malignant neoplasms, respectively). CONCLUSIONS: Our results suggest that all-cause mortality rates are higher among adults with disabilities than among adults without disabilities and that significant associations exist between several types of disability and cause-specific mortality. Interventions are needed that effectively address the poorer health status of people with disabilities and reduce the risk of death.

The impact of assistive technologies on formal and informal home care.

PURPOSE OF THE STUDY: Assistive technologies help people with disabilities compensate for their impairments. This study assessed which of 5 categories of assistive technologies-indoor/outdoor mobility, bed transfer, bathing, toileting, and telephone assistance-were substitutes or complements for human personal assistance by differentiating between total and formal personal assistance service (PAS) hours. DESIGN AND METHODS: The study analyzed 2004 National Long-Term Care Survey community-dwelling respondents receiving assistance with activities of daily living. Ordinary least squares (OLS) on total PAS hours was estimated on the entire sample, and logit and OLS models were estimated on the likelihood and hours of formal PAS, respectively. RESULTS: Assistive technology for indoor/outdoor mobility, bed transfer, and bathing was found to be substitutes for total PAS, whereas assistive technology for bed transfer and toileting was found to be complements for the use of formal PAS. Telephone assistance was not significant for either total or formal PAS hours. IMPLICATIONS: The use of some assistive technologies by older people with disabilities appears to reduce the amount of informal care provided, but not the amount of paid PAS. Thus, this study does not provide support for the hypothesis that the use of assistive technologies will reduce use of paid care and, therefore, spending for long-term care.

Systematic review: Effective characteristics of nursing homes and other residential long-term care settings for people with dementia.

OBJECTIVES: In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. DESIGN: Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. RESULTS: Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials (RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. CONCLUSION: Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia.

Obesity and people with disabilities: the implications for health care expenditures.

OBJECTIVE: This study estimates additional average health care expenditures for overweight and obesity for adults with disabilities vs. without. DESIGN AND METHODS: Descriptive and multivariate methods were used to estimate additional health expenditures by service type, age group, and payer using 2004-2007 Medical Expenditure Panel Survey data. RESULTS: In 2007, 37% of community-dwelling Americans with disabilities were obese vs. 27% of the total population. People with disabilities had almost three times ($2,459) the additional average obesity cost of people without disabilities ($889). Prescription drug expenditures for obese people with disabilities were three times as high and outpatient expenditures were 74% higher. People with disabilities in the 45- to 64-year age group had the highest obesity expenditures. Medicare had the highest additional average obesity expenditures among payers. Among people with prescription drug expenditures, obese people with disabilities had nine times the prevalence of diabetes as normal weight people with disabilities. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. CONCLUSIONS: Obesity results in substantial additional health care expenditures for people with disabilities. These additional expenditures pose a serious current and future problem, given the potential for higher obesity prevalence in the coming decade.

Immigrant and non-immigrant certified nursing assistants in nursing homes: how do they differ?

This study analyzes the 2004 National Nursing Assistant Survey and other survey data to examine the characteristics and experiences of immigrant and non-immigrant certified nursing assistants (CNAs) in nursing facilities. Descriptive results focus on differences in personal characteristics, working conditions, extrinsic rewards, work experiences, job satisfaction, and workplace discrimination. The findings indicate that immigrant CNAs are older, better educated, and somewhat more highly paid than their non-immigrant counterparts but also experience substantial levels of discrimination and language-related communication barriers at work. The paper discusses major policy issues that arise from the increase in immigrant labor in long-term care.

Estimates of state-level health-care expenditures associated with disability.

OBJECTIVES: We estimated state-level disability-associated health-care expenditures (DAHE) for the U.S. adult population. METHODS: We used a two-part model to estimate DAHE for the noninstitutionalized U.S. civilian adult population using data from the 2002-2003 Medical Expenditure Panel Survey and state-level data from the Behavioral Risk Factor Surveillance System. Administrative data for people in institutions were added to generate estimates for the total adult noninstitutionalized population. Individual-level data on total health-care expenditures along with demographic, socioeconomic, geographic, and payer characteristics were used in the models. RESULTS: The DAHE for all U.S. adults totaled $397.8 billion in 2006, with state expenditures ranging from $598 million in Wyoming to $40.1 billion in New York. Of the national total, the DAHE were $118.9 billion for the Medicare population, $161.1 billion for Medicaid recipients, and $117.8 billion for the privately insured and uninsured populations. For the total U.S. adult population, 26.7% of health-care expenditures were associated with disability, with proportions by state ranging from 16.9% in Hawaii to 32.8% in New York. This proportion varied greatly by payer, with 38.1% for Medicare expenditures, 68.7% for Medicaid expenditures, and 12.5% for nonpublic health-care expenditures associated with disability. CONCLUSIONS: DAHE vary greatly by state and are borne largely by the public sector, and particularly by Medicaid. Policy makers need to consider initiatives that will help reduce the prevalence of disabilities and disability-related health disparities, as well as improve the lives of people with disabilities.

Nursing home work practices and nursing assistants' job satisfaction.

PURPOSE: To estimate the impact of nursing home work practices, specifically compensation and working conditions, on job satisfaction of nursing assistants employed in nursing homes. DESIGN AND METHODS: Data are from the 2004 National Nursing Assistant Survey, responses by the nursing assistants' employers to the 2004 National Nursing Home Survey, and county-level data from the Area Resource File. Multinomial logistic regression was used to estimate effects of compensation and working conditions on nursing assistants' overall job satisfaction, controlling for personal characteristics and local labor market characteristics. RESULTS: Wages, benefits, and job demands, measured by the ratio of nursing assistant hours per resident day, were associated with job satisfaction. Consistent with previous studies, job satisfaction was greater when nursing assistants felt respected and valued by their employers and had good relationships with supervisors. Nursing assistants were more satisfied when they had enough time to complete their work, when their work was challenging, when they were not subject to mandatory overtime, and where food was not delivered to residents on trays. IMPLICATIONS: This is the first investigation of nursing assistant job satisfaction using a nationally representative sample of nursing assistants matched to information about their employing nursing homes. The findings corroborate results of previous studies in showing that compensation and working conditions that provide respect, good relationships with supervisors, and better staffing levels are important to nursing assistant job satisfaction.

Why do they stay? Job tenure among certified nursing assistants in nursing homes.

PURPOSE: This study identifies factors related to job tenure among certified nursing assistants (CNAs) working in nursing homes. DESIGN AND METHODS: The study uses 2004 data from the National Nursing Home Survey, the National Nursing Assistant Survey, and the Area Resource File. Ordinary least squares regression analyses were conducted with length of job tenure as the dependent variable. Tenure of CNAs was hypothesized to be motivated by the extrinsic rewards of their job, initial training and mentoring, reasons for being a CNA, organizational culture, and personal, facility, and market characteristics. Separate analyses were conducted for the overall sample and for CNAs who worked for the facility for more than 1 year. RESULTS: Among policy-relevant domains, extrinsic rewards had the largest number of significant variables (4). Only 1 training and 1 organizational culture variable significantly affected CNA job tenure. Significant variables in domains not readily influenced by policy (e.g., personal characteristics and characteristics of the facility and surrounding market area) were often significant in both regressions. IMPLICATIONS: This study underscores the importance of the basic economics of job choice by low-income workers. Wages, fringe benefits, job security, and alternative choices of employment are important determinants of job tenure that should be addressed, in addition to training and organizational culture.

Making the system work for home care quality.

The post-acute and long-term care systems are changing rapidly, with an increasingly important role being played by home care. Under the current system, home care does not consistently meet the needs of older people living in the community. This problem is caused, in large part, by the existing system of financing and regulating home care. This paper examines how the current system funded by Medicare, Medicaid, state programs, private insurance, and out-of-pocket spending affects the delivery and quality of home care services. Specifically, this paper analyzes how financing, coverage of services, reimbursement, quality regulation and assurance, and information coordination affects the quality of home care. The paper concludes by drawing implications for policy.

Are consumer-directed home care beneficiaries satisfied? Evidence from Washington state.

PURPOSE: This study analyzed the effect of consumer-directed versus agency-directed home care on satisfaction with paid personal assistance services among Medicaid beneficiaries in Washington State. DESIGN AND METHODS: The study analyzed a survey of 513 Medicaid beneficiaries receiving home- and community-based services. As part of a larger study, we developed an 8-item Satisfaction With Paid Personal Assistance Scale as the measure of satisfaction. In predicting satisfaction with personal assistance services, we estimated an ordinary least squares regression model that was right-censored to account for the large percentage of respondents who were highly satisfied with their care. RESULTS: Among the older population, but not younger people with disabilities, beneficiaries receiving consumer-directed services were more satisfied than individuals receiving agency-directed care. There was no evidence that quality of care was less with consumer-directed services. In addition, overall satisfaction levels with paid home care were very high. IMPLICATIONS: This study supports the premise that consumer satisfaction, an important measure of quality, in consumer-directed home care is not inferior to that in agency-directed care. The positive effect of consumer direction for older people underlines the fact that this service option is relevant for this population. In addition, this research provides evidence that home- and community-based services are of high quality, at least on one dimension.

Cost-effectiveness of hospital vaccination programs in North Carolina.

Although influenza and pneumonia are largely vaccine-preventable, vaccination coverage rates are well below Healthy People 2010 goals. The aim of this study was to examine the costs and cost-effectiveness of three provider-based vaccination interventions in the hospital setting: standing orders programs (SOPs), physician reminders (PRs), and pre-printed orders (PPOs). Data on program operating costs and the numbers of patients who received influenza or pneumococcal vaccinations were collected from nine North Carolina hospitals. Results demonstrated that the additional cost per patient vaccinated in 2004 was US dollars 58 for SOPs, US dollars 90 for PRs, and US dollars 412 for PPOs. These findings suggest that SOPs are a cost-effective approach for increasing adult vaccination coverage rates in hospital settings.

Personal care satisfaction among aged and physically disabled Medicaid beneficiaries.

We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.

Workforce issues and consumer satisfaction in Medicaid personal assistance services.

This study used a survey of older people and younger persons with disabilities who were receiving Medicaid-financed home and community-based services (HCBS) to assess the effect of workforce issues on consumer satisfaction. We found that recruitment problems had very strong negative and significant effects on consumer satisfaction. An interruption in service was a more important and significant indicator of consumer dissatisfaction than not having the same worker over time. We also found that problems with worker training and respect and treatment of consumers strongly and significantly affected satisfaction with paid care. Efforts to improve workforce issues are needed to improve the quality of care of these services.