Functional impairment levels in PACE enrollees.

Introduction

A variant of the Health Outcomes Survey, the Medicare Health Outcomes Survey-Modified (HOS-M) is a brief mixed mode annual survey (mail with telephone followup) specifically designed to collect functional status information from enrollees in the Program of All Inclusive Care for the Elderly (PACE) organizations or in the dually eligible beneficiaries demonstrations. CMS uses the HOS-M results to adjust Medicare capitation rates paid to these plans, taking the frailty of the enrollees into account. The frailty adjuster is applied in conjunction with the CMS-Hierarchical Coexisting Condition model and is based on activities of daily living (ADLs) limitations. After a brief description of the HOS-M and the PACE program, we present the results from the 2006 HOS-M to describe the health status of the PACE enrollees that participated in the survey.

Description

HOS-M

Previously called the PACE Health Survey, the HOS-M was fielded nationally for the first time in 2003. The protocol differs from that of the HOS in several ways. These differences are designed to lead to a high response rate despite the frailty of the target population, so that payment adjustments are as accurate as possible. The instrument has just 17 items, with ADLs as the core items used for calculating the frailty factor. Proxy respondents are encouraged and represent a substantial proportion of the respondents. Smaller plans provide detailed contact information for their enrollees and for family members to use in case a proxy is needed. The instrument is available in English, Spanish, and Chinese (Walsh et al., 2003). Each year, RTI International draws the sample, works with smaller plans to develop their contact data files, and analyzes the resulting data. DataStat, the National Committee for Quality Assurance-certified sole HOS-M vendor, fields the survey each year under contract to each of the participating plans.

To participate in the HOS-M, PACE plans have to be operational for 1 year. Because the HOS-M is used to adjust Medicare payments for specific categories of enrollees, PACE individual enrollees are included in the HOS-M sample if they are age 55 or over, reside in the community, and do not have end stage renal disease; they also have to be enrolled in their respective plans for at least 1 full month. Presented here are the results for PACE enrollees only, although the HOS-M is also fielded to enrollees in the dually eligible demonstrations.

Pace

PACE integrates long-term and chronic care with the standard Medicare acute care benefit package. Eligibility is based on State-by-State determinations of NHC status, i.e., whether the applicant meets his or her State's criteria for nursing home admission under Medicaid. Much of the care is provided through day centers operated by PACE staff comprised of physicians, nurses, social workers, rehabilitation therapists, and other ancillary providers, as well as inhome services. A small proportion of PACE enrollees become residents of nursing facilities when they can no longer be supported adequately in other settings (these enrollees are not included in the HOS-M). Most PACE enrollees are dually eligible Medicare/Medicaid beneficiaries for whom PACE organizations receive monthly capitation payments from both Medicare and Medicaid.

On January 1, 2006, there were 32 PACE organizations nationwide serving 10,867 Medicare beneficiaries.

Results

In 2006, 6,247 of the 8,649 PACE eligibles responded to the HOS-M, yielding an overall response rate of 72.2 percent for PACE plan enrollees. This response rate is similar to those for previous years. Thirty-two PACE plans participated in 2006 HOS-M. The entire eligible enrollment was included in the HOS-M sample for plans enrolling less than 1,400 beneficiaries (31 PACE plan) while we drew a sample of 1,000 eligible beneficiaries from the Medicare files for 1 PACE plan with larger enrollment.