A Paradigm Shift in the Golden Years The Transition from Federal Medicare to Managed Care Medicare by Mary Striegel Submitted in Partial Fulfillment ofthe Requirements for the Degree of Master in Health and Human Services III The Bitonte College ofHealth and Human Services The Youngstown State University May 25,1999 A Paradigm Shift in the Golden Years The Transition from Traditional Medicare to managed care Medicare Mary Striegel I hereby release this thesis to the public. I understand this thesis will be housed at the Circulation Desk ofthe University Library and will be available for public access. I also authorize the University or other individuals to make copies ofthis thesis, as needed, for scholarly research. Signature: I \. /.• / 61· L .:/ .. ' .'~. /..... ..~ _.(·ce.c~.-{.~... . Gordon Frissora, Ph.D., Committee Member r;- ;AS-/qq Date s/~"5-/77 Date ~. ~ _.(·ce.c~..~ s/~ ~. ~ _.(·ce.c~..~ Abstract Traditional federal Medicare, which provides health insurance coverage for approximately 13% ofthe national population, spent $213 billion in 1997. Due to medical advances, escalating healthcare costs and the rising senior population, the existing Medicare program is predicted to be bankrupt by the year 200 I. In an attempt to prevent this, the u.s. Department ofHealth and Human Services enacted legislation to allow commercial insurance plans to offer a managed care Medicare option. Because of low out-of-pocket costs and the extensive use ofprevention programs associated with managed care Medicare, senior citizens are rapidly converting to these plans. It is important, then, to examine the quality ofhealthcare offered by both managed care Medicare and the traditional Medicare plan. This observational study used a descriptive correlational research design composed ofa convenience sampling ofAllegheny County, PA senior citizens attending community based, congregate senior centers. An adaptation ofthe Consumer Assessment ofHealth Plan Survey was used to determine perceptions of quality ofcare and sociodemographic variables. Using a proportional odds model, it was revealed in the data that the overall quality rating for type ofinsurance plan was predicted by the rating ofphysicians' skills, the perception that the plan provided the services needed, the amount oftime the physician spent with the subject and education level. The overall plan rating for managed care Medicare was 4.22 (s.d=0.76) whereas federal Medicare was 2.95 (s.d.=1.39). This data supports the hypothesis that subjects insured by managed care Medicare believe that they are provided with a quality ofmedical care better than that provided by federal Medicare. 1Il TABLE OF CONTENTS Abstract iii List ofFigures vi List ofTables vi CHAPTER ONE: Introduction Preface 1 Problem Statement. 1 Hypothesis 2 Basic Assumptions 2 Delimitations 2 Limitations 3 Operational Definitions 3 Summary 5 CHAPTER TWO: Literature Review Introduction 7 History ofMedicare 7 Insurance Benefits ofTraditional Medicare 8 Expansion ofthe Medicare Program 9 Threats to the Traditional Medicare Program , 10 Medicare Reform 10 Regulation ofMedicare 11 Development ofa Managed Care Medicare Plan 11 The Managed Care Medicare HMO 12 Expansion ofManaged Care Medicare 13 Federal Regulation ofManaged Care Medicare 13 Private Regulation ofManaged Care Medicare 16 Quality ofCare Associated with Managed Care Medicare 16 Summary 18 CHAPTER THREE: Methods Introduction 20 Research Design 20 Setting , 20 Subjects 21 Sampling Plan 21 iv Instrumentation 22 Procedure 23 Data Analysis 24 Summary 25 CHAPTER FOUR: Analysis ofData Introduction 26 Demographic Profile ofthe Subjects 26 Descriptive Statistics 28 The Proportional Odds Model Analysis 29 Logistic Regression 37 Summary 38 CHAPTER FIVE: Summary, Conclusions and Research Recommendations Summary 41 Conclusions 42 Implications 43 Research Recommendations .43 Bibliography 44 Appendix A Center Identification and Permission 52 Appendix B Ethical Considerations and Human Subjects Protections........65 Appendix C Written Permission for Survey Administration 75 Appendix D Senior Health Plan Survey 77 v List ofFigures Figure 1: Distribution ofPlan Rating by Plan Type 30 Figure lA: Cumulative Distribution ofPlan by Site .,.,., ., .. 31 Figure 2: Individual Plan Rating by Site ., ., .. ., ., 32 Figure 3: Doctor Rating by Plan Type 33 Figure 4: Comparison ofPlan Type and Time Spent with Doctor. 34 Figure 5: Number ofChronic Diseases by Plan Type 35 Figure 6: Diet and Exercise Education Compared to Plan Type.., 36 Figure 7: Relationship ofVariables Impacting Plan Rating 39 List ofTables Table 1: Socioeconomic Data .26 Table 2: Statistical Results ofProportional Odds Model.. .. ., .., .., ., .,29 VI CHAPTER ONE Introduction Preface Medicare is the primary health insurance provider for American senior citizens, those people aged 65 and older. From national statistics complied in 1998, it is shown that Medicare covers 38.4 million people, which represents less than 13% ofthe total population (HCFA, 1998). This relatively small percentage ofthe population consumed $213 billion in health care costs, in 1997 (HCFA, 1998). Researchers postulate that if healthcare spending continues at its' current rate for its' current number ofparticipants, the Medicare program will be exhausted by the year 2001 (Schwartz, 1995). Due to the rise in life expectancy coincident with the maturation ofthe "baby boomers", the senior population will grow to 25% ofthe total population by 2050 (Vanderlann, 1995). In an attempt to curb Medicare spending, the federal government enacted legislation that enabled Medicare recipients to choose managed care Medicare as an option for their health insurance carrier. To ensure delivery ofquality care from these managed care Medicare plans, the Department ofHealth and Human Services created the Health Care Financing Agency (HCFA). HCFA's primary purpose is the regulation ofthe entire Medicare program, including traditional Medicare and the managed care Medicare options. (HCFA, 1997). Problem Statement Nationally, senior citizens comprise less than 13% ofthe total population. Comparatively, the senior population ofAllegheny County, PA has reached 18.1 %, making it the second largest senior citizen population in the United States. In the next ten year period, this geographical area is expected to have a senior population rise to 23% (Rotstein, 1998). Statistics compiled in 1998 show that 29% ofthe senior citizens living in Allegheny County, PA have elected managed care Medicare (Rotstein, 1999)). Due to this rapid and voluminous shift from traditional Medicare, it is important to examine the quality ofcare being offered to these residents. The purpose ofthis report, then, is to compare the perceptions ofquality ofcare associated with senior citizens who have chosen either traditional Medicare or the managed care Medicare plans. Hypothesis Senior Citizens who have chosen managed care Medicare believe that they are provided with a quality ofmedical care better than that provided by traditional Medicare. Basic Assumptions The first basic assumption ofthis study is that senior citizens who chose managed care Medicare will adhere to the guidelines set forth by that plan and use medical resources as directed by their primary care physician. The second assumption is that study participants will answer survey questions honestly and without fear ofretaliation. Delimitations There are two delimitations ofthis study. The first is plan design. Traditional Medicare coverage is available to senior citizens and persons with selected disabilities, regardless ofage. However, because ofthe high percentage ofsenior citizens living in Allegheny County, PA, this study will be limited to those persons aged 65 and older that are not considered disabled. The second delimitation is geographical composition. Since Allegheny County is an urban area with world-renowned medical systems, the health care in this area may differ from that offered in other metropolitan, suburban or rural areas of the country. 2 Limitations The questionnaire was quite lengthy (48 questions) which may have resulted in a lower response rate. The participants may have become distracted prior to the completion ofthe questionnaire. This was an observational study that measured perceptions ofquality ofcare. These perceptions can be linked to individual nebulous traits such as attitude, motivation and personality that were not measured by the questionnaire. While the senior centers and the subjects were chosen in a random manner, the collected data was not randomly distributed. Larger sample sizes may have yielded a more normalized distribution. Operational Definitions In this study, the following terms are defined. Average Adjusted Per Capita Cost (AAPCC)-a complicated formula that is used by the federal government for calculations ofpayments to managed care programs. Agency for Health Care Policy and Research (AHCPR)-a federal agency that is charged with supporting and conducting health care research related to insurance plans. Baby Boomers-those people born between the years of 1946 and 1965. Consumer Assessment ofHealth Plans (CAHPS)-a study devised to identify specific quality indicators associated with health insurance plans. Case Manager-A registered nurse, employed by managed care plans, who coordinates care for the plan members. 3 Consolidation Omnibus Budget Reconciliation Act (COBRA)-the legislation that allows managed care Medicare beneficiaries to disemoll from the plan every 30 days, if they so choose. Competitive Medical Plans (CMP)-managed care plans that provide limited access and do not meet federal requirements. Computerized Needs-Oriented Quality Measurement Evaluation System (CONQUEST)-an online resource that provides managed care Medicare plan information in an easy to read format. Department ofHealth and Human Services (DHHS)-a federal agency that has the overall responsibility for administration ofthe Medicare program. General Accounting Office (GAO)-the agency responsible for budgeting ofthe federal programs, including the Medicare program. Health Care Employer Data Information Set (HEDIS)-a mandatory set ofinformation that managed care plans are required to collect and annually report HCFA. Health Care Financing Administration (HCFA)-a federal agency that has the responsibility of oversight and regulatory control ofthe Medicare program. Health Maintenance Organization (HMO)-managed care plans that are federally qualified, and provide a wide variety ofservices within a selected network. Managed Care-health insurance plans that provide a wide variety ofservices within a select network. Managed Care Medicare-those managed care plans that have met requirements to provide health insurance coverage for the Medicare population. Medicare-a federally funded health insurance plan for the aged and disabled. 4 Medi-gap Policy-supplemental insurance coverage purchased to pay for services not covered by traditional Medicare. Office ofthe Inspector General (OIG)-the federal agency responsible for legislative compliance ofmanaged care Medicare plans. Preferred Provider Organizations (PPO)--managed care plans that, are mainly controlled by physician groups, and provide medical care within a select network. Peer Review Organization (PRO)--a panel ofexperts that review medical compliance issues ofmanaged care Medicare plans. Tax Equity and Fiscal Responsibility Act (TEFRA)-the legislation that allows HCFA to contract with managed care Medicare plans. Summary The current Medicare program facing financial insolvency. While both the percentage ofthe population entitled to federal Medicare and the cost ofhealthcare continue to rise, the available funds are dwindling. Measures must be adopted to ensure that adequate health insurance coverage continues to exist for the American senior citizen population. Managed care Medicare appears to be a reasonable remedy to the ailing federal Medicare system. In Chapter Two, a review ofthe literature is presented. In Chapter Three, the research methodology, the selected data analysis technique and the survey instrument is discussed. In Chapter Four, the results ofthe data analysis are presented with a discussion of the covariates and socioeconomic variables. 5 In Chapter Five, a summary ofthe study, the findings, and implications are reviewed. Recommendations for future research are proposed. 6 CHAPTER TWO Literature Review Introduction Ifchanges are not made to the current federal Medicare program, it is predicted it will be bankrupt by the year 2001, (Schwartz, 1995) leaving virtually no healthcare coverage for American senior citizens. Researchers postulate that managed care Medicare, ifregulated properly, is a feasible remedy to this situation. A review ofthe relevant literature was done and follows in the sections entitled: history ofMedicare, insurance benefits oftraditional Medicare, expansion ofthe Medicare program, threats to the traditional Medicare program, Medicare reform, regulation ofMedicare, development ofa managed care Medicare plan, the managed care Medicare HMO, expansion of managed care Medicare, federal regulation ofmanaged care Medicare, private regulation ofmanaged care Medicare, quality ofcare associated with managed care Medicare, and a chapter summary. History ofMedicare The concept of a national health insurance in the United States began in the late 1930's with the congressional assumption that the federal government would be a significant financial contributor. The basic concept and associated details were the subject of35 years ofCongressional debate (HCFA, 1996). Then, on July 30 1965, President Lyndon Johnson delivered this historical speech. No longer will older Americans be denied the Healing powers ofmodem medicine. No longer will illness crush and destroy The savings that they so carefully put away Over a lifetime, so that they might enjoy dignity In their later years (Kinney, 1995 p.1164). 7 With this speech, Title XVIII ofthe Social Security System, entitled "Health Insurance for the Aged and Disabled", became national law. Title XVIII is also known as Medicare. With the inception ofMedicare, the federal government recognized medical care as a basic right-along with food, clothing and shelter (HCFA, 1996). Congress used an 1881 German definition of"elderly" as those people aged 65 years ofage and greater (Rotstein, 1998). This age group became targeted for this national health insurance, as they were considered to be a "deserving and privileged population." (HCFA, 1996). Medicare was designed as "socially unifying legislation" that embraced all social classes, on equal terms, in one age group (HCFA, 1996). Insurance Benefits ofTraditional Medicare Medicare consists oftwo distinct parts. At the age of65, all Americans who have worked a minimum of 16 quarters (or four full time years), are entitled to Part A. Thus, it is considered universal health insurance, covering costs associated with acute care and rehabilitation hospitals, skilled nursing facilities, home care and hospice services. Part A is financed through employer and employee payroll taxes, presently at the rate of 1.45% ofgross income (Vladek and King, 1995a). Part B is a voluntary program covering physician fees, outpatient testing, laboratory services, and durable medical equipment (HCFA, 1997). Part B is financed through monthly premiums, presently at $43.80, that are paid by the beneficiary, which account for only 25% ofthe costs. The remaining 75% ofthe monies are provided by the federal reserve (Callahan, 1996; HCFA, 1997). Medicare does not cover all medical services and many Medicare recipients also elect supplemental coverage, commonly known as a Medigap policy. Medigap policies 8 are usually purchased through federally qualified commercial insurance corporations (Callahan, 1996), typically costing between $500 and $5,000 per year in premiums (Kinney, 1995). Examples of services not covered by Medicare are preventive health programs, eyeglasses, hearing aids, and prescription drugs (Vladek, 1995a). Expansion ofthe Medicare Program In its' first year, Medicare covered 19.1 million elderly (HCFA, 1996). By the end of 1996, that number rose to 38.4 million (HCFA, 1998). The elderly population is expected to continue to grow at a rapid rate due to advances ofmodem medicine, better working conditions and a cleaner environment (Rubenstein, 1997). As the American public ages, the incidence ofchronic diseases rises (Brown University, 1997). Due to the advances ofmodem medicine, some chronic diseases are no longer fatal (Vladek, 1995a), creating an older population with more illness and higher associated medical care costs (Brown University, 1997). Average life expectancy is rising. In 1996, when the national elderly population was 12%, the average life expectancy at birth was 79.7 years for males and 85.6 years for females (Vanderlann, 1995). By the year 2050, it is estimated that this will rise to 85.8 years for males and 89.0 years for females, making the elderly 25% ofthe total population (Vanderlann, 1995). A large part ofthis rise can be attributed to the maturation ofthe "baby boomers", those born between 1946 and 1965. All tolled, the potential number ofpeople eligible for Medicare is expected to reach 80 million by the year 2050 (Blanchette, 1997), representing a 132% rise in the national senior population (HCFA, 1996). 9 Threats to the Traditional Medicare Program Medicare is presently the largest payer for healthcare services (Schwartz, 1995). In 1996, Medicare paid $213 billion for 38.4 million beneficiaries (HCFA, 1998). This payment represented a 10.5% increase from 1995 and accounted for 10% ofthe federal budget (Vladek, 1995a). Since Medicare's inception, expenditures have risen 3-5% per year beyond general inflation (Callahan, 1996; Pawlson, 1997) and ifthese costs are not curtailed, the Medicare fund is expected to be depleted by the year 2001 (Schwartz, 1995). The increased number ofbeneficiaries and the rise in the incidence ofchronic illness will result in higher Medicare costs. Managed care Medicare is considered to be a feasible solution to assist with Medicare reform. Medicare Reform A primary goal ofMedicare reform is to move federal Medicare beneficiaries to managed care Medicare (Meng, Jatulis, McDonald and Legorreta, 1997; Roller and Allman, 1996) with an expected decrease in overall Medicare spending. (Aston, 1997; Besdine, 1997; Miller and Luft, 1997). The concept ofmanaged care Medicare is not new. In fact, a managed care Medicare option was offered in 1965, with the initial presentation ofthe traditional Medicare platform (Kinney, 1995). However, due to the initial low reimbursement rates to qualified insurance companies, there was no inherent incentive to market this insurance option. This lack ofaction led to public naivete and consequent low enrollment rates (Boult, Pacala and Boult, 1995). By 1982, the rising elderly population and their associated medical costs provided the impetus for Medicare to improve reimbursement rates to qualified health insurance plans, thereby increasing public awareness ofthis Medicare option (Wagner, 1996; Vanderlann, 1995). 10 Regulation ofMedicare The Department ofHealth and Human Services (DHHS) has the overall responsibility for the administration ofthe Medicare program. DHHS created the Health Care Financing Administration (HCFA) to ensure provision ofquality care in the Medicare system (HCFA, 1997). HCFA's responsibilities are the formation ofpolicy and procedures, contract oversight, operations and general financing (HCFA, 1997). As the managed care Medicare market was developed, HCFA's role was expanded to assume its' regulatory and administrative controls (HCFA, 1997). Development ofa Managed Care Medicare Plan In an effort to shift some ofits beneficiaries to managed care, HCFA examined three types ofmanaged care plans: Competitive Medical Plans (CMP), Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO). Competitive Medical Plans are plans that do not meet federal requirements and provide limited service. Most CMP's are located in rural areas. HCFA chose not to use these plans due to potential regulation problems and limited access (DeMichelle and Gottlich, 1996). Preferred Provider Organizations are plans that employ select physicians and contract with specific hospitals. Participants ofthis plan receive low cost care ifthey stay within the PPO network. Ifthey chose to go outside the network, they must pay a significant portion ofthe medical costs. In a three year (1992-1995) HFCA sponsored study, researchers found that the PPO programs were ofhigh cost with many administrative flaws (McIlrath, 1995). Health Maintenance Organizations are federally qualified plans that provide a select network ofphysicians and hospitals, yet provide a full range of services. HMOs are largely rooted in wellness programs and preventive medicine 11 (Aliberti and Deroulin, 1995). Ofthe three potential plans, HCFA chose HMO for managed care Medicare due to its extensive services and large coverage area. HCFA found that plans other than HMO's are controversial and may actually increase costs to the federal government, rather than generate savings. Other plans are also subject to fewer consumer protections and have more complex payment schedules (Feder and Moon, 1998). The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 authorized HCFA to contract with federally qualified HMOs (Kinney, 1995). To be federally qualified, a Medicare HMO must meet stringent criteria. 1. HMOs must meet federal statutory, regulatory and contract requirements. 2. HMOs must serve at least 5000 people. 3. HMOs must offer at least all services provided by federal Medicare. 4. HMOs must have member grievance and appeal procedures (Kinney, 1995 p. 1178). The Managed Care Medicare HMO Medicare HMO plans are commonly known as managed care Medicare (MCM), and will be herein referenced as such. To provide all services offered by federal Medicare, MCM bundles Part A and B into one benefit package. This creates low out-of-pocket costs, eliminates the need for a Medigap policy, and provides additional health benefits (DeMichelle, 1996). MCM are not permitted to retain savings through plan efficiencies, thereby enhancing benefits for the enrollees (White, 1997). MCM is required to collect information on its members and most plans use this as a data base to develop epidemiology based programs (Besdine, 1997). This allows MCM to offer preventive programs such as routine mammography, 12 prostate and colorectal screening and routine immunizations (Group Health Foundation, 1995; Vanderlann, 1995). HCFA pays MCM 95% ofthe amount that HCFA would have paid to care for that beneficiary under traditional Medicare (Buntin, 1998; Kinney, 1995). This amount is calculated using a complicated formula known as the adjusted average per capita cost (AAPCC) that is primarily based on age, sex, welfare status, institutionalization and geographic area. AAPCC is published annually in the federal register (Fox, 1996). Expansion ofManaged Care Medicare MCM plans are growing as rapidly as the individual number ofbeneficiaries. As ofSeptember 1997, there were 303 registered Medicare HMO plans, an increase of56% from the proceeding 10 month period (Sherman and Colenda, 1998). In 1985, there were 300,000 MCM beneficiaries. In 1995, the number rose to 3.1 million (DeMichelle, 1996) and another 1 million enrolled in MCM in 1996 (Fisher, 1996; Lamphere, 1997). With a total of5 million members, MCM experienced an unprecedented growth rate of 38% in a 15-month period between 1995-1996 (Brown University, 1997). The American Association ofHealth Plans (AAHP) report that 100,000 seniors continue to enroll in MCM each month (American Association ofHealth Plans, 1998). Researchers forecast that this trend will continue (Landers, 1999). Federal Regulation ofManaged Care Medicare Because ofthis explosive growth, the General Accounting Office (GAO) is questioning the ability ofHCFA to monitor this adaptation ofthe Medicare program (DeMichelle, 1996; Martin, 1998). To provide oversight, HCFA has employed a variety ofmeasures to regulate MCM. A panel ofexperts, referred to as a Peer Review 13 Organization (PRO), assists HCFA with review ofhospital medical records. This allows HCFA to target specific hospitals and physicians whose practice patterns differ from the norm. The PRO will then contact these providers and perform targeted compliance audits (Docteur, Colby and Gold 1996; Inglehart, 1992). HCFA requires MCM to collect their own statistics (Eli Research, 1996; Lohr, 1988). For internal validity and consistency, HCFA has developed a mandatory set ofitems known as the Health Care Data Information Set (HEDIS) (Docteur, 1996, Kang, 1997; George and Bearon, 1980). HEDIS requires plans to provide data on mammography, diabetic eye exams, smoking cessation programs, immunizations and a senior health survey (Kang, 1997). This senior health survey is a measure ofthe functioning and well being ofthe enrollees. By HCFA mandate, it must be administered on a voluntary basis, only after the person has submitted an application for plan enrollment. This mandate is designed to prevent plans from prohibiting enrollment to those who have chronic and severe health conditions (Kang, 1997; Stewart and Ware, 1992), and is to be used for screening purposes only (Besdine, 1997; Vladek, 1995b). Case mangers that are employed by the MCM use this screening information. (Wagner, 1996). The role ofthe case managers is dictated by the MCM (Group Health Foundation, 1995; Pacala, Boult, Hepburn, Kane, Kane, and Malone, 1997), but typically provide oversight for high-risk members (Pacala, 1997; Roggin, 1997; Rubenstein, 1997). The case manger can coordinate the members' care and direct them to appropriate use of MCM resources (Martin, 1998; Roller and Allman, 1996; Williams, Elder, Seidman and Mayer 1997). Case managers can also promote continuity ofcare through solicitation of appropriate community agencies (Boult, 1995; Pawlson, 1997; Reidel and Long, 1996). 14 HCFA also monitors MCM educational materials, application forms and marketing efforts. MCM must submit all proposed written materials for HCFA approval before they are issued to the public (Grimaldi, 1997; Neuman, Maibach, Dusenbury, Kitchman and Zupp, 1998). Further, in dealing with individual members with questionable mental status, MCM representatives must involve significant others or issue a mentation test before accepting any signed enrollment applications (Kinney, 1995). Because MCM plans can differ dramatically, (Butler, 1995), HCFA has imposed legislation, noted as the Consolidation Omnibus Budget Reconciliation Act (COBRA), stating that members can disenroll from a plan for any reason and as often as every 30 days (Kinney, 1995; Pretzer, 1998). MCM disenrollment rates are considered to be an objective measure ofquality ofcare (Riley, Ingber and Tudor, 1997). In 1997, the GAO found that disenrollment rates vary from 14.6% to 40%, depending on the MCM plan (Cleary and McNeil, 1998). In 1997, Riley, Ingber and Tudor studied disenrollment rates ofMCM and found that disenrollment was higher in the first three months and was mainly associated with members who switched from one plan to another. This suggests that members frequently shop around for best pricing and coverage. An important finding by Riley et al. (1997) was that people with chronic illness disenroll sooner, returning to the traditional Medicare plan. This implies that the chronically ill are a vulnerable population in the scope ofMCM (Archer, 1998; Besdine, 1997; Morgan, Virnig, DeVito and Perisly, 1997.). An article by Kane (1996), supported by Friedland and Feder (1998), suggests that there are higher disenrollment rates among African Americans, the severely ill and the very old, suggesting that there is decreased access to care for these subgroups (Kane, 1996). This information highlights the need for 15 longitudinal and population based studies focusing on the availability ofproviders, the appropriateness ofthe medical care being provided and the outcome ofthese services (Morgan, 1997; Wholey, Burns and Lavizzo-Mourey, 1998). Private Regulation ofManaged Care Medicare For any healthcare plan to succeed it must involve physicians. The GAO states that 77% ofpracticing physicians accept Medicare and managed care insurance plans (Besdine, 1997; Terry, 1997). The American Medical Association (AMA) is involved with HCFA to monitor physician involvement in the overall Medicare program. The AMA states that physicians have a moral and ethical responsibility to treat their patients appropriately and encourages physicians to identify and aggressively manage frail patients using prevention strategies and medical management regardless ofthe type of health care coverage (Kavesh, 1996; Sherman and Colenda, 1998). Further, the AMA states that physicians should encourage patients to utilize prevention programs and medical care routinely available in MCM plans (Watcher, Katz, Showstack, Bindman and Goldman, 1998). Quality ofCare Associated with Managed Care Medicare The Journal ofthe American Medical Association reports that quality problems exist throughout the entire U.S. healthcare system, regardless ofthe type ofinsurance coverage. Work needs to be done to achieve uniform quality throughout the entire healthcare system, focusing on quality assessment and quality improvement (Brook, 1997). Because it is a relatively new concept, managed care Medicare has been suspected ofproviding inferior care. This is an area ofconcern for consumers, providers and the 16 care plans, as compared to other forms ofhealth care coverage. To monitor this situation, HCFA instituted the Agency for Health Care Policy and Research (AHCPR). This is the lead federal agency charged with supporting and conducting health service research (AHCPR, 1997). The AHCPR sponsored a five year study, the Consumer Assessment of Health Plans (CAHPS) (CAHPS, 1996), to identify health insurance plans that consistently offer high quality care for MCM (CAHPS, 1996) and to provide this information to the general public (Kang, 1997). CAHPS preliminary findings show that consumers desire to remain under the care oftheir current physician and to have minimal out-of-pocket costs (AHCPR, 1997; Sofacer, 1998; Watcher, 1998). To improve availability ofthis information, AHCPR developed a Computerized Needs-Oriented Quality Measurement Evaluation System (CONQUEST), an on-line resource that provides information on accessible, effective and safe means ofcare for the elderly population (CONQUEST, 1998). Research findings by the American Association ofHealth Plans (AAHP) show that MCM plans "provide care comparable to or better than care provided by traditional Medicare" (AAHP, 1998). In 1997, Miller and Luft, found that quality of care provided in MCM was approximately equal to that in traditional Medicare, with similar prescribed treatment plans for patients with congestive heart failure, colorectal cancer, diabetes, hypertension and ambulatory care. The Center for Disease Control (CDC) concurs with Miller and Luft and state that for these diseases MCM provides equivalent or superior care than federal Medicare. The CDC elaborates that the coordinated and comprehensive nature ofMCM services is superior to the episodic and fragmented care offered by traditional Medicare (AAHP, 1998). In 1997, Meng et. al. conducted a study that showed 17 traditional Medicare (AAHP, 1998). In 1997, Meng et. al. conducted a study that showed that MCM enrollees highly rated plan satisfaction, quality ofcare provided and physician skills. Further, a study conducted by Mathematica Policy Research for the Physician Payment Review Commission showed that 96% ofthe MCM beneficiaries rate their care as very good or excellent (AAHP, 1997). Additionally, this study compared MCM with traditional Medicare in four vulnerable areas: overall healthcare, physician's exam, physician availability and office accessibility. More than 90% provided good to excellent ratings while 2% were dissatisfied (AAHP, 1997). The need for this type ofresearch will continue as the senior population continues to rise and the American healthcare system continues to change. Surnrnary In conclusion, the MCM program is showing expansive growth. While HCFA is encouraging senior citizens to enroll in MCM, they are monitoring access and quality of care provided. Many studies have been done to investigate quality ofcare associated with this new phase ofMedicare (Gourley and Duncan, 1998; Sherman, 1998). An article by Butler (1995), supported by Meng et. al. (1997), finds MCM are reporting high ratings for satisfaction, as well as, physician skills and prescribed plans ofcare (Cleary, and McNeil, 1988; Meng, 1997). Data collection and interpretation are important to ensure provision ofnecessary care and the quality associated with that care (Oberlander, 1997; Sherman, 1998). This research supports the assumption that MCM is a viable, feasible option for providing quality care for America's elderly population; and is the basis to investigate the hypothesis that similar findings will exist in the senior population living in Allegheny County, PA. 18 Chapter Three provides an outline ofthe methodologies used in the study. An explanation ofthe design, the sample population and measurement tool is discussed. Chapter Four illustrates the descriptive data and relevant findings from the collected questionnaires. The significance ofthese findings are reported and discussed. Chapter Five presents the conclusions and implications ofthe study. Recommendations for future research are proposed. 19 CHAPTER THREE Methodology Introduction Chapter three provides an outline ofthe research methodologies used in the study to compare the perceptions ofquality ofcare in a convenience sample ofsenior citizens living in Allegheny County, PA. It investigated the quality ofcare comparisons between a selected senior citizen population insured by managed care Medicare (MCM) and those participants enrolled in a federal Medicare (FM) plan. It also investigated the relationships between perceptions ofquality ofcare and selected variables that are significant correlations ofthese perceptions. An explanation ofthe design, sample, measurement tool and the statistical methods used are discussed. Research Design A descriptive correlation research design was used in this study. A self administered survey was conducted to determine the perceptions ofquality ofcare compared to MCM and the federal Medicare plan. Setting This study was conducted at four congregate senior centers in Allegheny County, PA. A random sampling was done to select two urban centers within the city limits of Pittsburgh, PA and two rural centers located on the outer perimeters ofAllegheny County, PA (The 1998 Bell Atlantic Telephone Directory). The participating rural centers were located in New Kensington, PA (the northeast corner ofAllegheny County) and Penn Hills, PA (the eastern border ofAllegheny County). Appendix A includes identification ofthe senior centers, their addresses and the directors' names. 20 Subjects To obtain a reasonable estimate ofpopulation parameters, 200 participants, aged 65 and older, were selected from a convenience sampling. Four groups, chosen from community based congregate senior centers, comprised the sampling. The participants were divided into three age categories, as described by Rotstein, (1998), the "young old" aged 65-74, the "middle old" aged 75- 84, and the "old old" aged 85 and older. Sampling Plan Because the method ofobtaining subjects for the study was a convenience sampling, the ability to detect significant relationships and differences would have increased as the sample size increased. To comply with requirements set forth by the authors ofthe commercial survey, a p value of .05 was used to determine statistical significance in this study (U.S. Department ofHealth and Human Services, 1997). The four groups were divided into an equal sampling to give better variance estimates and were grouped as follows: 50 urban based participants with traditional Medicare, 50 urban based participants with MCM, 50 rural based participants with traditional Medicare and 50 rural based participants with MCM. Ethical considerations and human subjects protection has been addressed during this research. Appendix B lists the precautions taken to ensure fair and just treatment of the participants and authorization from the Human Subjects committee. 21 Instrumentation To obtain a suitable commercial instrument for this study, the U.S. Department of Health and Human Services was contacted. Because of its' relationship to quality of care, the Consumer Assessment of Health Plan Survey (CAHPS) was chosen. Since the CAHPS survey is a publication ofthe U.S. Department ofHealth and Human Services, it is not subject to copyright protections. A standard cover letter by John Eisenberg, M.D. is enclosed in Appendix C. In exchange for permission to use the CAHPS survey instrument, the CAHPS committee requests a copy ofthe final research project (U.S. Department ofHealth and Human Services, 1997). The original version ofthe CAHPS survey consisted of88 questions. To emphasize the collection ofresponses related to quality ofcare, the survey was modified according to the specific guidelines listed in Appendix H ofthe CAHPS Reporting Kit (U.S. Department ofHealth and Human Services, 1997). The modified version, used in this study, consisted of48 questions with an anticipated completion time of20 minutes. Appendix D contains this survey instrument and the scoring legend. Questions were structured to fit three specific categories. Seven items (numbered 1,2,26,27,28,29,48) described the health plan. Twenty-four items (numbered 7,11,13,14,21 ,22,23,24,25,32,33,34,35,36,37,38,39,41 ,42,43,44,45,46,47) characterized the subject. Seventeen items (numbered 3,4,5,6,8,9,10,12,15,16,17,18,19,20,30,31,40) depicted quality. Each question was asked in a multiple choice format with 13 questions rated on an informal Likert scale with the lowest response, "a", equal to 1 and the highest response,"f', equal to 5. 22 Procedure The directors offour community based, congregate senior centers were contacted to obtain written consent to survey its' attendees. Using the random sampling method described above, the four centers were chosen. In a telephone conversation, the directors provided information on the hours of operation, characteristics ofthe population served and peak hours ofattendance. All centers operated on a Monday through Friday daytime, business-hour schedule. Specific days and times, over a one-week period, were arranged to administer the survey instrument. The data collection was scheduled to coincide with planned center activities, when requested by the administrative director. A detailed cover letter was provided to explain the purpose and nature ofthe study and the credentials ofthe researcher. The directors ofeach center provided individual written consent. These are enclosed in Appendix A. While in the center, the researcher observed each attendee. The attendees were approached individually and questioned about age, insurance type and interest in voluntary participation in the study. The senior attendees who consented to participate in the survey were escorted to a quiet area ofthe center and were given individual, written questionnaires and pens. They were told to keep the pen in appreciation for their participation. While written instructions are listed on the survey instrument, the following verbal instructions were also given. This is a study to examine ifyou believe that your insurance plan provides quality ofcare. This is an anonymous, confidential, voluntary survey. Ifyou choose not to finish it, you may leave and take your survey form with you. Please do not put your name on 23 the survey. Ifanyone needs help with any ofthe question or has trouble seeing the print, please raise your hand and you will be assisted by this researcher. This survey will take approximately 20 minutes to complete. When you are finished, please place it in the box on this table. No one will know your answers. Thank you for participating in this research project. When they were completed, the participants placed the surveys in a sealed, slotted box that was placed on a table in the front ofthe room. The researcher remained in the room until all surveys were collected. Before leaving, all research materials were gathered and the participants and staffwere verbally thanked. A follow up thank you letter was sent to the director of each participating center. (Appendix A). A total of200 (N=200) surveys were distributed. One hundred seventy seven surveys were successfully completed, for a return rate of88%. All surveys were administered and retrieved by the researcher at the time ofdata collection. Data Analysis The data sets were analyzed using the Statistical Analysis Systems (SAS) for Windows program. Variables were assigned. Across all testing, the dependent variable was perception ofquality ofcare (UQC and RQC). The independent sociodemographic variables were identified to be education level (EDI, ED2), race (AA, W), marital status (M, NM), age (AGEl, AGE2, AGE3) and sex (M, F). All variables were analyzed for relationships and differences using descriptive statistics, logistical regression and a proportional odds model developed using the SAS computer package. All equations and SAS commands are listed in Appendix E. Descriptive statistics were collected for survey question 48, where comments were solicited. 24 Summary In this chapter, research methodologies were used to compare the perceptions of quality ofcare associated with MCM and federal Medicare (FM) and its' relationships to the selected variables. Data obtained from this study provided a baseline for the insured, ambulatory, senior citizen population ofAllegheny County, PA. Chapter Four provides the statistical analysis and relevant findings ofthe collected data. The significance ofthese findings are reported and discussed. Chapter Five presents the conclusions and implications ofthe study. Recommendations for future research are proposed. 25 CHAPTER FOUR Analysis ofData Introduction Information from the completed senior health plan survey was used to determine perceptions ofquality ofcare associated with managed care Medicare and federal Medicare. The objective ofthis analysis is to determine the relationships among type of insurance plan, perceptions ofquality associated with that plan and covariates. Demographic Profile ofthe Subjects A total of200 (N=200) questionnaires were distributed to a convenience sampling ofsenior citizens attending four congregate senior citizen centers in Allegheny County, PA. One hundred seventy seven questionnaires were completed, for a response rate of 88%. The socioeconomic data collected are summarized in Table 1 that follows. 26 Table 1: The socioeconomic data for managed care Medicare (MCM) and federal Medicare (FM) by number, percentage and significance. Variable Number Percentage of Number Percentage of Percentage of Model MCM MCMsample FM FMsample total sample significance Age 65-74 years 44 45 34 43 44 NS* 75-84 years 47 47 32 42 45 NS* 85+ years 8 8 12 15 11 NS* Sex Male/M 40 41 41 52 46 NS* Female/F 59 59 37 47 54 NS* Race AA 18 18 22 28 23 NS* Caucasian 81 82 56 72 77 NS* Marital Status Married 42 42 31 40 41 NS* Not Married 57 58 47 60 59 NS* Income Class 20-29K 17 17 20 26 21 NS* 30-39K 36 36 30 38 37 NS* 40-49K 20 20 23 30 24 NS* 50-59K 10 10 11 14 12 NS* Education Level High School 74 75 65 83 78 Y** College 25 25 13 16 21 Y** *NS= not significant by proportional odds model. **y= significant by proportional odds model. 27 Descriptive Statistics Analysis The socioeconomic data reflected that 44% ofthe total subject population were in age range 1 (65-74 years), 45% were in age range 2 (75-84 years) and 11 % were in age range 3 (85 years and above). The ratio ofmen to women was 46% male to 54% female. Only two racial classes were identified in the sample population-23% ofthe respondents were African American and 77% ofthe respondents were Caucasian. Marital status was classified as either married (41 %) or not married (59%). Four income classes were identified where 82% ofthe respondents reported highest yearly lifetime earnings to be between $20-49,000 per year. Seventy eight percent ofthe respondents reported an 8 th to li h grade education and 21 % reported at least "some" college education. Rotstein (1999) reports that MCM accounts for 29% ofthe senior citizen population in Allegheny County, PA. The composition ofthis sample was 56% MCM and 44% FM. This is significantly higher than the senior population ofAllegheny County, PA, reported as a whole. Throughout the literature, there are perceived concerns that the transition to managed care Medicare requires changing existing physician relationships and reducing the access to specialty care. (AHCPR, 1997; Miller and Luft, 1997, Sofacer, 1998; Watcher, 1998.) These concerns are not reflected in this study sample. Ninety three percent ofthe sample stated that they were able to maintain the services oftheir current physician and 95% readily reported access to specialty care. 28 The Proportional Odds Model Analysis The response variable (RATEPLAN) is the reported experience with health insurance plan measured on a scale from one (worst) to five (best). A histogram, and follow up two sample t-testing, ofthis response was done and showed that the assumptions ofnormality were not met; thus usual regression methods (including ANOVA) are not appropriate statistical testing for these responses. Since the response is categorical and ordered, a proportional odds model could be used to analyze this data. Using SAS, a potential proportional odds model was identified. This model assumes a linear model for the log odds ofobserving a response> j given covariates Xl through Xk, I ( P(Y~j Ixi'K ,xk ) J fJ K P og = a· + IXI + + kXk • 1 - P(Y > .I K ) J - ] xi' 'X k The interpretation IS that the odds of observing response~j are exp~(Xj2-XjI)+K+ fJ/X k2 -X kl )) times higher at (XJ2, ...,xk2) than at (Xll, ..., Xkl). Using nuisance parameters, alphal-4, in this model, a goodness offit test showed adequate fit (p=O.08) ofthe assumption ofthe proportional odds model. Table 2, below, shows the results from fitting the proportional odds model using forward stepwise variable selection. Appendix E contains the SAS commands for this model. 29 ~ ~ exp~(Xj2 Table 2: Results from fitting the proportional odds model using forward stepwise variable selection. Parameter Estimate Standard Error P-value Alpha1 -10.13 1.06 0.0001 Alpha2 -7.99 0.96 0.0001 Alpha3 -6.28 0.87 0.0001 Alpha4 -4.19 0.80 0.0001 HPSERV 1.70 0.52 0.0011 RATEMD 0.72 0.17 0.0001 MDTIME 1.07 0.21 0.0001 EDUC 0.43 0.18 0.0162 The insurance plan quality rating (RATEPLAN) is predicted by the subjects rating ofthe care provided by their doctor (RATEMD), whether the plan provided help, equipment and services needed (HPSERV), the perception that the doctor spent sufficient time with the patient (MDTIME), and the education level (EDUC). Since the covariate coefficients are all positive, the odds ofobserving favorable service rating, higher doctor rating, higher rating oftime spent with the doctor and higher levels ofeducation yield a higher rating ofplan (RATEPLAN). The average plan rating for MCM was 4.22 (s.d.=O.76) while the average rating for FM was 2.95 (s.d=1.39). Histograms ofthis are shown in Figure I and Figure IA. 30 Figure 1: Histograms showing the distribution of plan rating by plan type where one is the worst possible plan and five is the best possible plan. Those covered by managed care Medicare appear to rate their plan more highly than those under federal Medicare. .----------------------------~--~- Federal Medicare ~ 2 0 N ;2 0 0 2 3 4 5 Plan Rating Managed Care Medicare ~ 2 ~ ;2 0 0 2 3 4 5 Plan Rating 31 ----------------------------~--~- ~ ~ ~ ----------------------------~--~- ~ Figure lA: Histogram showing the cumulative distribution of plan rating by site where one is the worst possible plan and five in the best possible plan. Site 1 and Site 3 are rural. Site 2 and Site 4 are urban. "--------~--~--~---------"~------~----------- Site 1 ~I Aan Rating Site 2 ~I Aan Rating Site 3 ~I Aan Rating Site 4 ~I Ran Rating 32 ~I ~ ~ ~ ~I ~ ~ ~ To determine if geographical differences affect perceptions of quality ofcare, two urban and two rural sites were analyzed. Fifty six percent ofthe urban subjects elected MCM while 44% remained with FM. Forty five percent ofthe rural subjects elected MCM while 55% remained with FM. Using the proportional odds model ofanalysis, there is no significant difference in the perceived quality ofcare among these geographical areas, thus Urban Quality ofCare (UQC)=Rural Quality ofCare (RQC). A representation ofthis is listed in Figure 2. Figure 2: Histograms showing the distribution of plan rating, where one is the worst possible plan and five is the best possible plan, for rural vs. urban locations supporting the conclusion of no significant effect of rural vs. urban setting. 33 To examine perceptions of quality ofmedical care provided by their physicians, subjects were asked to rate the skills oftheir physician on a Likert scale with the lowest response being one and the highest response being five. Eighty seven percent ofthe respondents rated their physician skills as good to excellent. Those subjects with MCM reported higher skill levels than those with FM. The proportional odds model showed that the effect ofplan type had a significant effect on the odds ofreporting a favorable doctor rating. Estimate 0.72, X 2 (1, N=177)=17.5, p=. 0001. Figure 3 demonstrates this in histogram form. Figure 3: Histograms showing the distribution ofdoctor rating by plan type where one is the worst possible medical care and five is the best possible medical care. Doctors appear to be more highly rated by subjects in managed care Medicare. Federal Medicare ~ ~ fiI g 0 0 2 3 4 5 Doctor Rating Managed Care Medicare ~ ~ fiI S2 0 0 2 3 4 5 Doctor Rating 34 ~ ~ ~ ~ An indicator, ofperceived quality ofcare referenced throughout the literature, is the amount oftime a physician spent with the patient while in the physician office. (Miller and Luft, 1998; Watcher, 1998.) This indicator was rated on a Likert scale with the lowest response being one and the highest response being four. Ninety six percent of MCM stated that their physician "usually or always" spends enough time with them, while 42% ofFM stated the same response. The proportional odds model showed that the effect ofplan type had a significant effect on the odds ofreporting an adequate amount oftime spent with their physician. Estimate 1.07, X 2 (1, N=177)=24.8, p=O.OOOl. This histogram is described in Figure 4. Figure 4: Histograms showing the relationship between plan type and rating of doctor time spent where one is the least amount of time spent and five is the most amount of time spent. Those in managed care Medicare show higher ratings of time spent with the doctor. ~~~~~~--------~~~~~~~~~-------------, Federal Medicare 0 '" 0 '" 0 ... 0 N 0 0 2 3 4 Doctor TIme Spent Rating Managed Care Medicare 0 '" 0 '" 0 ... 0 N 0 0 2 3 4 Doctor TIme Spent Rating 35 ~~~~~~--------~~~~~~~~~-------------, One ofthe criticisms ofMCM, listed in the literature, is that senior citizens who are chronically ill do not elect MCM coverage (Kane, 1996). To examine this possibility, five chronic diseases were chosen for analysis (U.S. Department of Health and Human Services, 1997). Each subject was asked ifa series ofquestions to indicate the following: heart disease (HRHD), cancer (HRCA), stroke (HRCVA), lung disease (HRLD) and/or diabetes mellitus (HRDM). Responses were rated as "no" or "yes" and scored zero and one respectively. These variables were summed and each ofthe subjects was scored from 0/5, the most healthy, to 5/5, the most sick. The resultant histogram (Figure 5) showed that there is no statistical significance between plan type and the summed number of existing chronic illnesses. Figure 5: Histogram showing the relationship between number of members with chronic diseases and plan type. There appears to be no significant difference between the two plans. ----_._-------- Federal Medicare ~ iii ~ !'" )-0 I J ,./'£ __ 'tj \ (t ,). I d = - I 59 l\Jtt~~~U41~ se~iorcitizen~~~end l\Jtt~~~U41~ Municipality of PENN HILLS A HOME RULE COMMUNITY MUNICIPAL BUILDING 12245 FRANKSTOWN ROAD· PENN HILLS, PA 15235-3494 April, 1999 I give Mary Striegel permission to enter the Penn Hills Senior Service Center to administer an anonymous, confidential survey. is;ncerel.Y,, '--'&'<'. ..,./(2. ?'2...., L{j "~) Corinne Puszko Penn Hills Senior Service Center 147 Jefferson Road Pittsburgh, PA 15235 (412) 244-3405 60 ~~ 404 East Main Street Evans City, PA 16033 (724) 538-4232 May 5,1999 Ms. Corrine Puszko Penn Hills Senior Citizen Center 147 Jefferson Road Pittsburgh, PA 15235 Dear Ms. Puszko, I want to take this opportunity to thank you for allowing me to enter this senior citizen center and survey your participants. I not only learned a great deal, but I met some wonderful people. It is my hope that the information that I collected will be ofvaluable importance as the face ofmodem healthcare changes. Ifmy research article is accepted for publication, I will share the information with your center. Ifthere is any additional information that you made need, in the future, please do not hesitate to call me. Thank You. 61 March 24, 1999 Dear Mr. Duffy, My name is Mary Striegel and I am a graduate student at the Youngstown State University majoring in Health and Human Services. As a partial requirement for a Master's degree, I am conducting a survey to determine the senior citizen's perception ofquality ofcare in both managed care Medicare and traditional Medicare. This study will enable me to complete thesis requirements, and more importantly, identify information that may have a significant impact on the health insurance offered in the western Pennsylvania area. I am asking for your permission to enter your senior center, perform a free blood pressure screening and administer a general questionnaire to your senior citizen attendees. The questionnaire will take approximately 15 minutes to complete. Your decision to allow me to collect this information is completely voluntary. This study is for research purposes only and all responses will be held strictly confidential. No one will be asked to identify him or herself in any way. The findings will be reported in aggregate form only, no individual responses will be used. A summary ofthe results ofthe study will be available upon request. You may obtain a copy by contacting me at the phone number listed below. Ifyou have any questions about this study, please contact me or my faculty advisor at the phone numbers listed below. Ifyou agree to allow me to conduct this survey at this senior citizen center, please sign one copy ofthis letter and return to me in the selfaddressed stamped envelope. Thank you, in advance, for you time and cooperation in this research study. Sincerely, ,r-, Cl ,\ ;1 .-::;.> '~~:~~~~ 404 East~nStreet Evans City, PA 16033 (724) 538-4232 Carolyn Mikanowicz, Ph.D. Faculty Advisor The Youngstown State University One University Plaza Youngstown, Ohio 44555 (330) 742-3658 62 I give my permission for Mary Striegel to administer an anonymous, confidential, voluntary survey to the;;enior citize s who attend this senior center. X 11 0. ' r', '~~:~~~~ ,enior National Steelworkers Oldtimers Foundation 500 Marka Street Mcf'eesport. Pennsvlvania 15132 Phone 412-678-0159 Fax 412-1)78-2684 April, 1999 To whom it may concern: This letter is to acknowledge that Mary Striegel has permission to perform blood pressure screenings and conduct a survey of National Steelworkers Old timers Foundation consumers concerning health care issues. The consumers will participate voluntarily and remain anonymous. Allegheny County Area Agency on Aging is aware of this agreement. Sincerely, ---- 1/~~ K":~.Duff~,Director Mon Yough Project 63 1/~~ ~.Duff~, 1/~~ ~.Duff~, 404 East Main Street Evans City, PA 16033 (724) 538-4232 May 5,1999 Mr. Kevin DuffY National Steelworkers Old-timers Fund 500Market Street McKeesport, PA 15132 Dear Mr. DuffY, I want to take this opportunity to thank you for allowing me to enter this senior citizen center and survey your participants. I not only learned a great deal, but I met some wonderful people. It is my hope that the information that I collected wiII be ofvaluable importance as the face ofmodem healthcare changes. Ifmy research article is accepted for publication, I wiII share the information with your center. Ifthere is any additional information that you made need, in the future, please do not hesitate to call me. Thank You. li1~~Jl IV/Lel~Uv~ MaryStrieg~tl~ 64 li1~~ IV/Lel~Uv~ Strieg~tl~ li1~~ IV/Lel~Uv~ Appendix B Ethical Consideration and Human Subjects' Protections and Consent Form Ethical Considerations To ensure that adequate safeguards were included and respected in this study, the following principles were applied to all participants. 1. Subjects legal rights were respected; their right to privacy, dignity and comfort were maintained during the investigation through the protection ofconfidentially. All participants were instructed not to place their names or any identifying marks on the questionnaire. 2. Participation in this investigation was voluntary and the right to withdraw at any time, without penalty, was permitted. 3. The results ofthis research study was made available upon request. 4. Instructions and disclosure, given to the directors ofthe senior centers, are listed in Appendix A. 66 Youngstown State University / One University Plaza / Youngstown, Ohio 44555-0001 April 20, 1999 Dr. Carolyn Mikanowicz, Associate Professor, for Ms. Mary Striegel, Student Department of Health Professions CAMPUS Dear Dr. Mikanowicz and Ms. Striegel: The Human Subjects Research Committee has reviewed your protocol, HSRC#55-99, "A Paradigm Shift in the Golden Years. The Transition from Federal Medicare to Managed Medicare," and determined that it is exempt from review based on a DHHS Category 2 exemption. Any changes in your research activity should be promptly reported to the Human Subjects Research Committee and may not be initiated without HSRC approval except where necessary to eliminate hazard to human subjects. Any unanticipated problems involving risks to subjects should also be promptly reported to the Human Subjects Research Committee. Best wishes in the conduct of your study. Sincerely, ~.- Eric Lewandowski Administrative Co-chair Human Subjects Research Committee c: Mr. Joseph Mistovich, Chair Department of Health Professions Exempt Protocol Submission Form File Number --;--:-:-=,---------- (camplelea by HSC) A Paradigm Shift in the Golden Years. The transition from Federal Medicare ritle ofResearch: _ to managed care Medicare. mcipa! Investigator(s): _Mu.s;j,a..l.r.;..y-...lSw.t.....r....li..s;e<...ligo.s;eL.Jl _ )ate Submitted: 4 / 5 / 99 -------- ~dvisor(if appropriate): Carolyn Mikanowicz! Ph. D lepartment(s): The College of Health and Human Ser':;...v:....l:::.·c:::;.e:::.::::.s _ .nticipated FundingSource:_....:s~e::.:l:::.f=.._;f=_u~n~d=e""-d_ rojected Duration of Research: 2 to 4 weeksmon~Projected Starting Date: 4 /----=..1=.5__/ 99 ther organizations and/or agencies. ifany. involved in the study: none -::empt under code (see definitions above - circle one): 3 5 6 unmary Abstract (BRIEF descriptIon of participants. measures. procedures used m the proposed research - 250 words or less. :tach COpY ofOConsent Fonn and U measures) Traditional Medicare, which provides health insurance coverage for approximately 13% ofthe national population, spent $203 billion dollars in associated health care costs in 1996. Due to the advances of modem medicine and the maturation ofthe "baby boomers", the senior population is predicted to swell to 25% in the next 50 years. Ifcurrent spending continues, the present Medicare program will be bankrupt by the year 200 l-leaviI1g virtually no health care coverage for American senior citizens. In an attempt to curb Medicare spending, the U.S. Department ofHealth and Human Services enacted legislation to allow commercial insurance plans to offer a managed care Medicare option. Because ofthe low out-of-pocket costs and the extensive use ofprevention programs associated with managed care Medicare, senior citizens are rapidly converting to these managed care plans. It is important, then, to examine to quality of care offered by both managed care Medicare and the traditional Medicare plan. This study will use a descriptive correlational research design composed of convenience sampling ofAllegheny County, PA senior citizens to compare perceptions ofquality ofcare in both types of insurance plans. The, 200 subject, sample will be obtained from urban and rural based senior citizens attending community based, aggregate senior centers. A survey instrument created by the U.S. Department ofHealth and Human Services, known as the Consumer Assessment of Health Plan Survey, will be adapted for this research. Participants will be asked to provide socioeconomic data to compare perceptions ofquality ofcare associated with these variables. Data will be analyzed using analysis ofvariance testing (ANOVA), independent t-tests and descriptive statistics. *5.=-ClQ Date Approved 0 Approved WIth Conditions o Full Comnuttee ReVIew HSC Cornnuttee Chau Date 68 ~dvisor Source:_....:s~e::.:l:::.f=.._;f=_u~n~d=e""-d e Received ._-..,..---:---- e compleled by Human SubjeclS Secretary) Protocol # ---------- To be completeu by Hwn:ll\ SubJeclS Secreury) YOUNGSTOWN STATE UNIVERSITY Human Subjects Protocol Review Fonn arllr1",nr 724 538 4232 742-3658 The College of Health and Human Services Department Name & Telephone # Department Name & Telephone II lcipal Investigator* Carolyn Mikanowicz, Ph.D student investigators. Typed Name & Title Ldvisor's name first) Investigator* Mary Stri egel Typed Name & Title Investigator* Typed Name & Title Department Name & Telephone II se Note: Do not list collaborators from other institutions here unless they hold approved Joint appoilHment(s) at YSU ~of Study A_p_a_r_a_d_l_'g_m_S_h_l_'_f_t_i_n_t_h_e_G_o_l_d_e_n_Y_e_a_r_s_._T_h_e_t_r_a_n_s_i_t_i_o_n_f_r_o_m_F_e_d_e_r_a_l_M_e_d_i_care to managed care Medicare. xternal Funding Involved? e check appropriate box) Kl NO o YES es, Type in Name of Funding AgencylProgram _ ivity Start Date End Date Anticipated Funding Date _ Collaborating Institutions Involved? e check appropriate box) ~ NO o YES ~,Type in the Following _ Institutiun :"lame Name & Title <)f Chief Collaborator Institution Name Name & Title <)f Chief Collaborator is Study Subject to Other tutional Human Subjects Review? lX) NO o YES ~,Type in the Following Institution .'iame Protocol Review Date/Determination tution with Primary Review Responsibility E9 0 YSU OTHER (Please IdentIfy) 69 ~ ~ ~, ~, ~ ~, INSTRUCTIONS TO INVESTIGATORS rhe purpose ofan institutional human subjects review is to foster academic inquiry through the study ofhuman )rocesses and behavior, while protecting subject rights and interests. The following questions are intended to )romote both ofthese ends. Please answer each question below accurately, completely and in language :omprehensible to an informed layperson. Attach additional pages as necessary. Requests for further '1formation or clarification ofissues or questions related to human subjects research or this protocol may be firected to the current co-chairs ofthe YSU Human SUbjects Committee via the Office of Grants and >ponsored Programs (Telephone 742-2377). Please type all responses on this form and any attachments. Briefly describe the nature of the activity you are proposing to conduct involving human subjects. Please try to limit your response to the space provided, and be sure to address the following: (A) the purpose of the research and the hypotheses to be tested; (B) short references to the pertinent scientific literature; (C) an overview of the research design, method and mode of analysis; (D) an appraisal of the anticipated value of the research to the investigator(s), the human subjects, YSU, the scientific community, and society-at-large; (E) the specific site(s) of the research; and (F) investigator access to them. Traditional Medicare, which provides health insurance coverage for approximately 13% of the national population, spent $203 illion dollars in associated health care costs in 1996 (Health Care Financing Administration, 1997). Due to the advances of modern ledicine and the maturation of the"baby boomers", the senior population is expected to rise to 25% of the total population in the next oyears (Vanderlann, 1995). If current spending continues, the current Medicare program will be bankrupt by the year 2001, leaving Ie elderly population with no form of health insurance coverage (Schwartz, 1995). In an attempt to curb Medicare spending, the U.S. 'epartment of Health and Human Services enacted legislation to allow commercial insurance plans to offer a managed care Medicare ption. Because of the low out-of-pocket costs and the extensive use of wellness programs associated with managed care Medicare, enior citizens are rapidly converting to these plans. The purpose of this research is to examine perceptions of quality of care of those senior citizens who have health insurance Jverage by either traditional Medicare or the managed care Medicare options. This research will test the hypothesis that senior citizens who have chosen managed care Medicare believe they are provided ith a quality of medical care better than that provided by traditional Medicare. This study will use a descriptive correlational research design composed of a convenience sampling of senior citizens to )mpare perceptions of quality of care in both types of insurance plans. The, 200 subject, sample will be obtained from senior citizens ho participate in community based, congregate senior centers. A survey instrument created by the U.S. Department of Health and uman Services, known as the Consumer Assessment of Health Plans Survey, was adapted for this research. Participants will be ;ked to provide socioeconomic data to compare perceptions of quality of care associated with these variables. Data will be analyzed ;ing analysis of variance testing (ANOVA), independent t-tests and descriptive statistics. This study will provide beneficial baseline data on the individual perceptions of quality of care for a select population of senior lizens. This data can be used by the local health departments, local departments of aging, governmental agencies, such as the U.S. epartment of Health and Human Services, and the individual managed care Medicare plans offered in this geographical area. By mducting this type of research, the Youngstown State University will be seen as a leader in this field as this type of insurance is lrrently becoming available to the senior citizen population of Mahoning and Trumbull Counties. Nationally, senior citizens comprise less than 13% of the total population. Comparatively, the senior citizen population of legheny County, PA has reached 18.1 %, making it the second largest senior citizen population in the United States. In the next ten ~ars,this geographical area is expected to have a senior population rise to 23% (Allegheny County Health Department, 1997). ~causeof the large percentage of senior citizens living in Allegheny County, Pennsylvania, it has been chosen as a site for this udy. The administrators of four community based, congregate senior citizen centers will be contacted to obtain written permission to Irvey its' attendees. To compare data across geographical regions, two urban based and two rural based areas within Allegheny )unty, Pennsylvania will be chosen for participation. Mary Striegel, graduate student, will do all research. The faculty advisor for this study is Carolyn Mikanowicz, Ph.D. Others I the thesis panel include Joseph Waldron, Ph.D. and Gordon Frissora, Ph.D. No other persons will have access to the specific search data. All data will be reported in aggregate form. Once completed, the research will be provided, by the researcher, upon quest as outlined by the school of graduate studies. 70 ~ars, ~cause ~ars, ~cause 2. Please describe the target population in specific terms. Be sure to provide detail about numbers of subjects, age, gender, physical condition or any other information that establishes the parameters of the population of your study. A total of 200 subjects will be surveyed. The subjects must be aged 65 or older and be insured by either traditional Medicare or managed care Medicare. The participant must be able to answer basic questions about their health status and their insurance plans. The researcher will assist, as individually requested, those willing participants whom are observed to have low literacy levels or cognitive impairments. t Briefly describe each of the different conditions or manipulations to be conducted in the stUdy. A self-administered survey will be conducted. See specifics listed in question 5. ~.Briefly describe the nature of the measures or observations that will be taken in the study. To determine individual perceptions of quality of care associated with traditional Medicare and managed care Medicare, a 'oluntary, anonymous and confidential survey will be administered. Participants will be asked to provide socioeconomic variables to Issess variance in perceptions of quality of care associated with both types of insurance plans. •. If any questionnaires, tests, or other instruments are to be used, please provide a brief description and either a copy or an indication of when a copy will be submitted to the Committee for review. The survey instrument was modified according to guidelines listed in Appendix H of the Consumer Assessment of Health Plans .urvey Reporting Kit that was developed by the U.S. Department of Health and Human Services. This modified version consists of 48 uestions and will take approximately 15 to 20 minutes to complete. Please see the attached survey instrument. Questions were instructed to fit three specific categories. Seven items (numbered 1,2,26,27,28,29,48) describe the health plan. 'wenty-four items (numbered 7,11,13,14,21,22,23,24,25,32,33,34,35,36,37,38,39,41 ,42,43,44,45,46,47) characterize the subject. ;eventeen items (numbered 3,4,5,6,8,9,10,12,15,16,17,18,19,20,30,31,40) depict quality. Each question is asked in a multiple-choice )rmat rated on an informal Likert scale with the lowest response, "a", equal to one and increasing accordingly by one point. Will the subjects encounter the possibility of psychological, social, physical or legal risk, that is, the probability of harm or injury occurring as a result of participation in this research study? o Yes X No If so, please describe. Will the study involve any stress, that is, any physical, chemical or emotional factors that may cause bodily or mental tension and may be a factor in causing disease? 0 Yes X No If so, please describe. Will the subjects be deceived or misled in any way? 0 Yes X No If so, please describe and include a statement regarding the nature of their debriefing. 71 ~.~. 9. Will there be any probing for information that an individual might consider to be personal or sensitive? 0 Yes X No If so, please describe. 10. Will subjects be presented with materials that they might regard to be offensive, threatening, or degrading? 0 Yes X No If so, please describe. 11. Approximately how much time will be required of each subject? The survey will take approximately 15 to 20 minutes to complete. 12. How will subjects for this study be solicited or contacted? The administrators of four community based, congregate senior citizen centers will be contacted to obtain written permission to >Urvey its' attendees. In a telephone conversation, the administrators will be asked to provide information on the hours of operation, :haracteristics of the population served and the peak hours of attendance. A written, detailed cover letter will be sent to the :Idministrators asking for permission to conduct this survey. While in the center, the researcher will visually observe the senior citizens. ::ach will be individually asked questions related to age, insurance type and willingness to participate in a voluntary, anonymous and :onfidential survey. Those willing to participate will be escorted to a quiet area of the senior center where the survey will be self ldministered. The researcher will remain in the room at all times for observation, questions and required assistance. 13. What steps will be taken to insure that subjects' participation is voluntary? What inducements will be offered to subjects for their participation? What is the source of those inducements? Voluntary participation will be stressed to the senior center administrators as well as to the individual subjects. Verbal and i1ritten directions will be given stating that this is a voluntary survey, that the subject may refuse to participate and opt to withdraw from 'Ie survey process at any time, without any penalty. All survey forms are to be placed in a slotted, sealed box by the participant. In appreciation for participating, the subjects will be offered a complimentary pen that will be provided by the researcher. 4. It is important that subjects be informed regarding the general nature of the proposed human subject activity, especially including a description of anything they may consider unpleasant or risky. Please provide a statement regarding the nature of the information, which will be stated orally or otherwise made available to potential subjects prior to their volunteering. This is a survey to determine if you believe that your insurance plan provides quality of care. This study is specifically designed ) compare traditional Medicare to managed care Medicare. If you are aged 65 or older and are insured by either of these plans and re willing to participate in a voluntary, anonymous and confidential survey, please follow me to this corner of the lunchroom. If you hose not to finish the survey, you may leave and take your survey with you. This is anonymous. Please do not put your name or any lentifying marks on the survey form. If anyone needs help with any of the questions or has trouble seeing the print, please raise your and and I will assist you. This survey will take approximately 15 to 20 minutes to complete. When you are finished, please place it in Ie box on the table. No one will know your answers. Please keep the pens in thanks of your participation. Thank you for articipating in this research project. 5. What steps are being taken to insure that subjects give their consent prior to participating? Will a written consent form be used? 0 Yes X No If so, please attach it to this form. If not, state why not. If subjects are minors, how will parental/guardian consent be obtained? The written consent of the senior citizen center administrators will be collected. Each subject will be asked individually and lliectively for verbal consent to participate. Each subject will be permitted to stop participating at any point, ifthey so chose, without ly form of penalty. Completion of the written survey instrument indicates consent. 6. Will any aspect of the data be made part of a permanent record that can be identified, directly or indirectly, with a sUbject? 0 Yes X No 72 17. Will the fact that a subject did or did not participate in a specific experiment or study be made part of any permanent record available to a supervisor, teacher or employer? 0 Yes X No 18. What steps will be taken to insure the anonymity of subjects' identities or the confidentiality of the data they provide? The subjects will be instructed, in written and verbal direction, to refrain from putting their names or any identifying marks on the survey instrument. The individual participants will place all completed survey forms in a sealed, slotted box. The researcher will only open the box after leaving the premises. All data will be reported in aggregate form so no individual responses can be identified. 19. Will any data from files or other archival data be used? 0 Yes X No ZOo If there are any risks involved in the study, please describe any offsetting benefits that may accrue to the SUbject or to society. There are no risks involved in this study. 73 Protocol # ~:--""'"7'~- (To be completed by Human Subjects Secretary) INVESTIGATOR STATEMENT OF ASSURANCES A. I/we hereby state that I/we will follow and conform to all applicable laws, regulations and policies affecting human subjects in research established by Youngstown State University and/or other cognizant oversight authorities, including but not limited to those cited in the handbook, Human Subjects Research: Regulations and Procedures. B. I/we hereby recognize the right of legally-authorized access by members or representatives of the Youngstown State University Human Subjects Committee to any pertinent records associated with the above study, and further agree to provide the Committee, upon request, with documentation of any and all procedures undertaken as part of this study. c. IIwe hereby agree to notify the Committee in advance of any changes in project scope that would materially affect the conduct of the study, or any aspect of the study, relative to human subjects activity or involvement. ). I/we affirm that the project as described above is a true, accurate, and complete representation of the study to be conducted under Youngstown State University auspices and with Youngstown State University approval. _. I/we affirm that all individuals associated with the conceptualization, organization and conduct of the study described above possess the requisite qualifications to undertake it. (All student investigators must attach a copy of their curriculum vitae and/or a letter from their approved academic advisor attesting to the students' qualifications to conduct faculty-supervised research). (For studies conducted off-campus) I/we affirm that all appropriate authorizations, clearances and approvals have been obtained to allow the above activity to occur at the above designated site(s), and that documentation to this effect is, or is being, provided to the Human SUbjects Committee in support of this protocol. /'\,j. .' (8-<.I;rr. lbJ..w.""" < 'rincipa Investigator Signature ;arolyn Mikanowicz, Ph.D ~o-InvestigatorSignature V /'\ /