Details

Autor(en) / Beteiligte

• Kerwin, Joanne P

Titel

The Allocation of Rehabilitation Therapies for Stroke Patients in Medicare's Home Health Benefit

Ort / Verlag

ProQuest Dissertations Publishing

Erscheinungsjahr

2011

Link zum Volltext

• ProQuest

Quelle

ProQuest Dissertations & Theses A&I

Beschreibungen/Notizen

• Allocation of Rehabilitation Therapies for Stroke Patients In Medicare's Home Health Benefit In 1997, Congress passed the Balanced Budget Act (BBA), which reformed Medicare's home health benefit in an effort to reduce expenditures and target use. This legislation mandated replacement of Medicare's cost-based, fee-for-service reimbursement system with a Prospective Payment System (PPS). In accordance with the congressional mandate, Medicare implemented the Interim Payment System (IPS) as a temporary stop-gap measure as it developed PPS, which was not enacted until 2000. In 2005, Schlenker and colleagues analyzed IPS and PPS visit data and risk-adjusted outcomes and found that modest improvements in some functional outcomes correlated with increased therapy use across medical conditions. As Schlenker and colleagues acknowledged, further analysis of therapy use, which is health condition-specific, is required. Stroke is a leading cause of long-term disability in the United States. The rehabilitation treatment of stroke provides a good paradigm for examining the allocation and impact of therapy services in home health. Several theoretical frameworks guide this study and provide a comprehensive rationale for variable selection in the research models chosen. The economic concepts of Principal-Agent and Theory of the Firm will be considered as criteria to evaluate the provider response to a payment policy change. Best practice guidelines encourage use of the Disablement Model as a conceptual framework for thinking about patients' physical impairment, functional loss, and disability, with the goals of restoring health and improving quality of life. The first aim of this study is to compare therapy delivery patterns between the two payment systems. The second aim of this study is to compare functional outcomes of stroke beneficiaries seen during the IPS and PPS periods. Data from the Chronic Care Data Warehouse (CCW) formed the basis of this analysis. This data set represents a 5% sample of Medicare beneficiaries with a stroke diagnosis who received home health services. The analysis compares patient-level characteristics as measured on the Outcome and Assessment Information Set (OASIS) and actual visit data for the years 2000 (n = 5,904), pre-PPS, and 2004 (n=5,927), post-PPS. A second level of analysis considers profit status from the Provider of Services file (POS) and geographic factors from the Area Resource File (ARF) to adjust for market influences. Logistic regression analysis identifies how the allocation and intensity of therapy differed between IPS and PPS. The first model estimates receipt of therapy. The second model estimates the number of visits above or below the ten-visit payment threshold. The third model uses a change score method and multiple regression analysis to identify functional outcomes in bathing, speech, transfers, and ambulation or locomotion. The fourth model employs logistic regression to predict adverse events within each payment system. Results demonstrated that the growth rate in new users of therapy between the IPS and PPS periods was 42%. In fact, stroke beneficiaries were 37% more likely to receive 10 or more visits of therapy during the PPS period compared to beneficiaries in the IPS period. The analysis supports the hypothesis that functional outcomes were different for beneficiaries seen during the IPS versus PPS periods. Beneficiary outcomes in speech, bathing, transfer ability, ambulation, and adverse events were better during the PPS period, compared the IPS period. Indicators point toward improvement in allocative efficiency during PPS with improved functional outcomes for stroke beneficiaries in home health care. Payment policy has long been recognized as an important lever controlling expenditures and use of health care services. Accordingly, this dissertation sheds light on the relationship between payment policy and rehabilitation therapies, informing refinement and study of the payment system. In addition, if this study influences policies that maintain access to rehabilitative services, we have an opportunity for Medicare savings and improvements in quality of life for stroke beneficiaries.