The Medicare Prospective Payment System (PPS) could adversely impact vulnerable populations. This study investigated the potential impact of PPS on the dually eligible. Episodes of care from January to June 1999 were identified (n=27,724). Complete Outcome Assessment Information Set (OASIS) records were available for 17,688 (64%) episodes, of which 15,087 (85%) would receive a prospective payment under PPS. Individuals were classified as dually eligible (had both Medicaid and Medicare) (n=4,243) or not dually eligible (n=10,844), sorted into 60-day episodes, and assigned to Home Health Resource Groups (HHRGs). Results showed that the dually eligible were more likely to be female, live alone, have sanitation hazards in the home, not receive daily informal care, have pressure ulcers, and require more nursing visits. Shared characteristics were found between the dually eligible and those who would be prohibitively expensive under PPS including being Black; living alone; having sanitation hazards at home; lack of adequate informal care; presence of surgical wounds, pressure or status ulcers, a catheter, and 4+ co-morbidities; difficulty with speech, and needing help taking medications. The dually eligible are a vulnerable population at risk of not receiving adequate services under PPS given their mix of acute and chronic needs. We recommend that the proposed case-mix adjuster be re-evaluated for these characteristics using a large, nationally-representative sample.
Learning Objectives: At the conclusion of this session, participants will be able to: 1. List characteristics of dually eligible populations in home care. 2. Articulate why the dually eligible may be at-risk for receiving inadequate home health services. 3. Recognize the need to re-evaluate the proposed case-mix adjuster under the Medicare Prospective Payment System
Keywords: Home Care, Medicare/Medicaid
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.