Nelda McCall

Utilization of home health services before and after the Balanced Budget Act of 1997: what were the initial effects?

OBJECTIVE To estimate the impact of the Balanced Budget Act of 1997 (BBA), which changed the way Medicare reimbursed for home health services, on a range of home health utilization measures, and to examine whether particular subgroups of beneficiaries were differentially impacted in the post-BBA period. DATA SOURCES Secondary data from the Centers for Medicare and Medicaid Services (CMS) Standard Analytic Files for the 1 percent sample of Medicare beneficiaries for fiscal years 1997 and 1999, linked with information from CMS eligibility, provider, and cost report files as well as the Area Resources File. STUDY DESIGN Logistic regression was used to estimate the effects of being in the post-BBA period on the incidence of home health service use and ordinary least squares (OLS) regression was used to estimate the effects of being in the post-BBA period on the amount and type of use by home health service users. Interaction terms we reincluded for all the independent variables to assess whether the effect was disproportionate among particular beneficiary subgroups. PRINCIPAL FINDINGS Results show a 22 percent decrease in the percentage using home health services post-BBA and a 39 percent decrease in the number of visits per user. Stronger reductions, though not very large, were found in the incidence of use for beneficiaries aged 85 and older, those in states with high historical Medicare home health use, and those with Medicaid buy-in. More intensive reductions in the number of services were found for those aged 85 and older, in high historical Medicare use states, nonwhites, females, those using for-profit agencies, and those treated for certain diagnoses. Less intensive reductions were associated with hospital-based agencies. CONCLUSIONS This research demonstrates that public program expenditures can be sharply curtailed with financial incentives. As reimbursement shifts to a prospective payment system legislated by the BBA, utilization should be closely monitored, especially for vulnerable subgroups.

Decreased Home Health Use: Does It Decrease Satisfaction?

This study investigates differences in satisfaction and quality of life for Medicare beneficiaries using home health care services before and after implementation of the Interim Payment System (IPS) as part of the Balanced Budget Act (BBA) of 1997. Data are from surveys conducted pre- and post-BBA. Multivariate analyses estimate the effect of being in the post-BBA period controlling for beneficiary, agency, and community characteristics. Sixteen dependent variables measure satisfaction with the agency, and two measure life quality. Despite dramatic utilization decreases, differences were not found for overall agency satisfaction, satisfaction with discharge, or with the nursing and therapist care received. Decreases in satisfaction were found for some interpersonal aspects of staff interaction and, for the group of respondents who received services in the agencies that participated in both the pre- and postperiods, with the decreasedprovision of personal care services. A large increase was found in staff encouraging independence.

The Effect of State Regulations on the Quality and Sale of Insurance Policies to Medicare Beneficiaries

This paper examines the effects of state regulations on the quality of insurance policies sold to Medicare beneficiaries and on the amount of sales abuse reported in the sale of such policies. State regulations regarding such policies relate to policy content and format, minimum rates of return, sale of these policies related to disclosure requirements, consumer information activities, and penalties for agent and company abuse. This paper examines the impact of specific regulations on the ratio of the expected policy benefits per premium dollars and on the number and kind of abusive sales practices reported by purchasers and nonpurchasers in agent and mail sales. The study finds that loss ratio floors, minimum benefit standards, and the development of states of consumer information guides for prospective policyholders have a positive impact on the quality of the policies purchased. In addition, the study finds that the amount of abuse reported is less when insurance companies routinely issue press releases concerning agent or company misrepresentation and when consumer guides are developed and available from the state.