1 2003 Edition Report Active Projects Research and Demonstrations in Health Care Financing Contents 1 Theme 1: Monitoring and Evaluating CMS Programs 1 Theme 2: Improving Managed Care Payment and Delivery 23 Theme 3: Improving Fee-for-Service Payment and Delivery 47 Theme 4: Future Trends Influencing Our Programs 51 Theme 5: Strengthening Medicaid, State Children's Health Insurance Program (SCHIP), and State Programs 99 Theme 6: Meeting the Needs ofVulnerable Populations 107 Theme 7: Outcomes, Quality and Performance 123 Theme 8: Building Research Capacity 157 Mandate and Authority 173 Indices: • TopicalIndex • AlphabeticalIndex ofResearch andDemonstration Projects • Awardee Organizations • PrincipalInvestigators • State Index ofResearch andDemonstration Projects • CMSProject Officers andProjectDirectors & • FactsAbout the CentersforMedicare MedicaidServices & Centers for Medicare Medicaid Services U.S. Department ofHealth and Human Services Tommy G. Thompson, Secretary & Centers for Medicare Medicaid Services Thomas A. Scully, Administrator Leslie V. Norwalk, Acting Deputy Administrator and ChiefOperating Officer Office ofResearch, Development, and Information Stuart Guterman, Director William D. Saunders, Deputy Director This report was produced by: Systems, Technical and Analytic Resources Group Eric Katz, Director David Gibson, Deputy Director Production Coordinator Linda R. Lebovic ftA Active Projects Report Research and Demonstrations in Health Care Financing 2003 Edition Centers for Medicare & Medicaid Services . FOREWORD The Centers for Medicare & Medicaid Services (CMS) isresponsible foradministeringthe Medicareprogram and programs administeredby States such as Medicaid andthe State Children's Health Insurance Program (SCHIP). CMS oversees insurance regulation, the survey and certification ofhealth care facilities, and the Clinical Laboratory Improvements Amendments. We serve one in fourseniors, children,people withend stage renal disease, andpeople with disabilities. We also provide beneficiaries with informationaboutourprograms, Medigap options, consumer research, and grievanceandappeals processes. CMS directs roughly 600 individual research, demonstration, and evaluationprojects. Ourresearchhelps us to identify future trends thatmay influence ourprograms, meetthe needs ofvulnerable populations, andexamine the cost effectiveness ofourpolicies. Demonstrationprojects test, forexample, how anewpayment system, preventive service orhealthpromotioncampaign actually affects ourprograms, beneficiaries, States, andproviders. Evaluationprojects validate ourresearch and demonstration findings and helpus monitorthe effectiveness ofMedicare, Medicaid, and SCHIP. One ofthe Agency's challenges is to develop and implement newhealthcarepayment approaches andfinancing policies andto evaluate the impactofourprograms. Anotherishow to modernize Medicare from a medical acute care model to a comprehensive healthcare modelthat encourages healthy aging. CMS strives to meet the challenges of short-term health policyneeds witha long-termperspective toprovide meaningful information andanalyses responsive totheneeds ofourprograms andcustomers. CMS, togetherwith States, contractors, grantees, andotherFederal agencies, is committedto research anddemonstrations aimedat improving ourprograms, ensuring the quality ofcare andprovidingmodernhealth care services. Congress created Medicare and Medicaid in 1965. Medicare originallyprovidedhealthcare coverage to Americans overthe age of65. In 1972, the programwas expandedto Americans living withdisabilities and people with end stage renal disease. Medicaidis ajoint Federal-Stateprogramthatprovideshealthcare coveragetotheaged, blind, people with disabilities, and low-income familieswith childrenunder21 CMS research bothanticipates the future ofourprograms, andreflects the Agency's legislative and operational responsibilities. More recent legislation includes: • The Health Insurance Portability andAccountabilityActof1996 (HIPAA) provided forimprovedcontinuityor "portability" ofgroup health plan coverage and forgroup health insurance providedthrough employment or through the individual insurance market. CMS regulatesthe small and individual private health insurance markets andnational administrative simplification standards forall electronic health care transactions. • The Balanced Budget Act of 1997 (BBA) establishedMedicare+Choice as PartC ofthe Medicareprogram, creatingan array ofnew managedcare andotherhealth plan choices forbeneficiaries, in addition to a coordinated open enrollmentprocess. The BBA also createdthe State Children's Health Insurance Program(SCHIP) which is designedto assistthose working families with incomestoohigh for Medicaidbuttoo lowto be able to affordprivate health insurance. The BalancedBudget RefinementAct of1999made numerous changestothe Medicareprogram aimedatreducing the impact ofthepaymentreductions to providers in the BBA, stabilizedthe SCHIP allotment formula and modifiedthe Medicaid Disportionate Share Hospital program. • The Ticket to Work and Work Incentives ImprovementActof1999 expandedthe availabilityofMedicare and Medicaid forcertain beneficiaries with disabilities who return to work. The New Freedom Initiative announcedby President Bush on February 1, 2001 ispartofanationwideeffortto remove barriers to community living for people with disabilities. • In 2000, the Benefits ImprovementandProtection Actmade numerous changes to the Medicare, Medicaid and SCHIP programs. The Office ofResearch, Development, and Information prepares the annualActiveProjectsReport: Researchand Demonstrations inHealth CareFinancingto informCMS customers ofourresearch. It inventoriesboth intramural projects conductedby CMS staffandextramuralprojects conductedby contractors, grantees, andotherawardeeswith CMS support. While most ofthe extramuralprojects are funded from CMS' research, demonstration, and evaluation budget, some ofthe quality-related studies conductedbyQuality Improvement (formerly PeerReview) Organizations are supportedbyotherCMS budgets. The 2003 edition oftheActiveProjectsReportprovidesbasic informationon CMS research, demonstrationand evaluation projects active fromJanuary 1 through December31, 2002. It is organizedbytheme: Theme 1 Monitoring and Evaluating CMS Programs; Theme 2 Improving ManagedCare Paymentand Delivery; Theme 3 Improving Fee-For-Service Payment and Delivery; Theme4 Future Trends InfluencingOurPrograms; Theme 5 Strengthening Medicaid, State Children's Health Insurance Program (SCHIP), and State Programs; Theme 6 Meetingthe Needs ofVulnerable Populations; Theme 7 Outcomes, Qualityand Performance; and Theme 8 Building Research Capacity. TheActiveProjectsReportpresents abriefdescription ofeach projectand its status as ofDecember31, 2002. The abstractsprovidean identificationnumber, the projecttitle,the CMS project officername, the awardee, funding, and theperiod ofperformance. Several indices are providedattheback ofthis book to help readers locate information regarding specificprojects - organizedbyprojecttitle, project officer, principal investigator, awardee organization, Stateand legislative mandate summary. More detailedinformation regarding specificprojects may be obtainedfrom CMS projectofficers directly. This is thetwenty-thirdedition ofTheActiveProjectsReport. Formore information, please visitthe CMS website at www.cms.hhs.gov. Stuart Guterman Director OfficeofResearch, Development, andInformation OfficeofResearch,Development,andInformation CENTERS FORMEDICARE & MEDICAIDSERVICES Organization Chart OFFICEOP OPERATIONS ADMINISTRATOR MANAGEMENT OFFICEOFEQUAL DEPUTYADMINISTRATOR OPPORTUNITYAND OFFICEOFHIPAA andChiefOperatingOfficer CIVILRIGHTS STANDARDS " 1 1 1 1 OFFIC1EOF CENTERFOR CENTERFOR CENTERFOR RESEARCH. BENEFICIARY MEDICARE MEDICAIDAND OFFICEOF DEVELOPMENT. OFFICEOFTHE CHOICES MANAGEMENT STATE LEGISLATION AND ACTUARY OPERATIONS INFORMATION _L 1 1 OFFICEOF PUBLIC OFFICEOF STRATEGIC OFFICEOF OFFICEOF OFFICEOF AFFAIRS CLINICAL OPERATIONSAND FINANCIAL INFORMATION INTERNAL OFFICE STANDARDSAND REGULATORY MANAGEMENT SERVICES CUSTOMER QUALITY AFFAIRS SUPPORT 1 1 | NORTHEASTERN SOUTHERN MIDWESTERN WESTERN CONSORTIUM CONSORTIUM CONSORTIUM CONSORTIUM 1 1 1 REGIONAL*FIELD REGIONAL&FIELD REGIONAL*FIELD REGIONAL&FIELD OFFICES OFFICES OFFICES OFFICES — Active Projects Report 2003 Edition Theme Monitoring and I : Evaluating CHS Programs As the United States health care system continues to change, there is an ongoing need to monitor and evaluate the performance of the programs CMS administers. Beyond traditional measures of performance, like cost containment, quality, health outcomes, and access to care, we attempt to measure various beneficiary-focused attributes, such as knowledge of health behaviors. In our monitoring, we track how well Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP) meet the needs of specific groups of beneficiaries, including vulnerable populations. Our research also examines more specific policy issues. For example, as Medicare and Medicaid continue to pursue managed care options, we examine the cost-effectiveness and qualityofmanaged care, aswell as beneficiary satisfaction. CMS monitors and evaluates the impact of Medicaid, welfare reform, SCHIP, and our beneficiary information program on beneficiaries. CMS is committed to evaluating our programs to gain new insights into how they can perform better. These insights inform our regulatory, administrative, and legislative policymaking. CMSBeneficiariesandProgramSpending rehabilitationtherapyservices. These policies include perbeneficiary therapy limits applicable to certain Beneficiaries- FederalEntitlementOutlays- 79.3Millionor $417.8Billionor outpatient settings, skilled nursing facility prospective 1 in4oftheNation'sPeople in3oftheNation'sHealthDollars payment system, home health agency prospective paymentsystem, inpatient rehabilitation facility Medicare prospective payment system, long term care hospital pnly Medicaid 44% prospective paymentsystem, andoutpatient therapy S158.7JB 38% prospectivepayment system. This project will study the period 2000-2003, and will study changes in Medicaid beneficiary access andutilization oftherapy services Only MedicareSMI Medicare 43% DuallyEligible $108.9B $254.8B across all these settings with special attention to forMedicare 26% 61% changes inone ormore settings that follow apayment andMedicaid change in anothersetting. 8% Source: FY2003President'sBudget. Status: This is a continuation and extension of previous work, "Medicare Post-Acute Care: Evaluation ofBBA Payment Policies andRelated Changes" 01-114 Evaluation ofBalanced Budget Amendment (BBA) Impacts on Medicare (contract 500-96-0006/04), which coveredthe period 1996-1999. Deliveryand Utilization ofInpatientand Outpatient Rehabilitation TherapyServices ProjectOfficer: PhilipCotterill 02-079 Design and Implementation ofa Period: September200 -December Targeted BeneficiarySurveyonAccess to 2004 1 Physician Services Among Medicare Awardee: Health Economics Research Beneficiaries Funding: $998,540 ProjectOfficer: Renee Mentnech Period: September2002-September Description: This project studies the impact ofthe 2003 Balanced Budget Act of 1997 (BBA) on the delivery Awardee: Mathematica Policy Research and utilization ofinpatient and outpatient rehabilitation (DC) therapy services to Medicarebeneficiaries. Manyofthe Funding: $0 BBA changes, some already implemented and others still underdevelopment, directly affectpayment for Theme Monitoring and Evaluating CMS Programs I: y- , — Active Projects Report 2003 Edition Description:Thepurpose ofthisproject is to design 01-116 Evaluation ofthe Impact on Beneficiaries andimplement atargeted, short, beneficiary surveyon ofthe Medicare+Choice Lock-in Provision access tophysician services among Medicare beneficiaries. The intent ofthis targeted survey is to ProjectOfficer: Mary Kapp enhancethe ability ofCMSto determine, on as close to Period: September200l-September areal time basis as possible, whetherMedicare 2004 beneficiaries are experiencing access problems in Awardee: Barents Group specific geographic areas. Funding: $380,298 Description:This project will explore the impact on 1-144 Evaluation ofPrivate Fee-for-Service Medicare beneficiaries ofthe lock-inprovision ofthe Plans in the Medicare+Choice Program BalancedBudgetActof1997 (BBA). The lock-in ProjectOfficer: Nancy Zhang provision places limits onthe frequency, timing and Period: September2001-September circumstancesunderwhichMedicare+Choice (M+C) 2004 enrollmentelections canbemade. These changesare Awardee: AbtAssociates phasedinovera 2-yearperiodbeginningJanuary 1 Funding: $1,407,867 2002. Thepurpose ofthisprojectisto: 1) examinethe current (pre-lock-in) patterns ofenrollment and M+C CMS Description: The purpose ofthis project isto evaluate disenrollment in using existing thenewprivate fee-for-service (PFFS) optionavailable administrative data; 2) design amethodologyto underthe Medicare+Choice (M+C)program. The quantifythe impact on Medicare beneficiaries ofthe evaluation will use a combination ofprimary and lock-inprovision; and 3) analyze the impacton secondary data sourcesto evaluate the effects ofthe beneficiaries ofthe first yearofthe lock-inprovision. option onbeneficiaries andprogramcosts. Primary datawill be collected through site visits to participating Status: Theproject is in its developmental stage. plans andbeneficiary surveys. The PFFS plan option is one ofthenewtypes oforganizationsprovided for underthe M+C provisions. Theproject involvesthe 00-052 Evaluation ofthe Qualified Medicare Beneficiary (QMB) and the Specified Low- Sterling Plan, whichhas been available tobeneficiaries Income Medicare Beneficiary (SLMB) since July, 2000 andcapturesmanybeneficiaries who werepreviously enrolled in an M+C planthatwithdrew Programs fromthe program andforwhomthis plan isthe only ProjectOfficer: Noemi Rudolph M+C optionavailable. Analytic issuestobe addressed Period: September 999-November 1 inthe evaluation can be grouped into threebroad 2002 categories: 1) beneficiary analyses (enrollment, Awardee: Health Economics Research beneficiary experiences withthe plan, utilization); Funding: $1,466,933 2) Medicareprogram impacts (payment); and3)plan andproviderimpacts (market, program administration, Description: This project is designedto evaluate participation). quantitatively andqualitativelythe Qualified Medicare Beneficiary (QMB) andthe Specified Low-Income Status: This newly initiatedproject is inthe startup Medicare Beneficiary (SLMB) Programs inthe phase. following areas: 1) the motivations andperceptions of enrollees andnonenrollees, 2) reasons for State variation inenrollmentpatterns, 3) the impact of enrollmenton Medicare and Medicaidcosts and serviceuse, and4)the impactofenrollmentonout-of- pocketcosts ofeligible individuals. Primary data collection activities will include: a survey ofanational sample ofQMB and SLMB enrollees andofeligible CMFS> Theme Monitoringand Evaluating CMS Programs I: y-