Functional impairment levels in PACE enrollees.

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enrollees that participated in the survey.




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Functional Impairment Levels in PACE Enrollees
Edith G. Walsh, Ph.D., Galina Khatutsky, M.S., and Louis Johnson, Ph.D.
introduCtion
A variant of the Health Outcomes Sur­
vey, the Medicare Health Outcomes Sur­
vey-Modified (HOS-M) is a brief mixed
mode annual survey (mail with telephone
followup) specifically designed to collect
functional status information from enroll­
ees in the Program of All Inclusive Care
for the Elderly (PACE) organizations or
in the dually eligible beneficiaries demon­
strations. CMS uses the HOS-M results
to adjust Medicare capitation rates paid to
these plans, taking the frailty of the enroll­
ees into account. The frailty adjuster is
applied in conjunction with the CMS-Hier­
archical 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 pre­
sent the results from the 2006 HOS-M to
describe the health status of the PACE
deSCriPtion
HoS-M
Previously called the PACE Health Sur­
vey, 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 calculat­
ing the frailty factor. Proxy respondents
are encouraged and represent a substan­
tial 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 instru­
ment 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 Qual­
ity 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 catego­
ries of enrollees, PACE individual enroll­
ees are included in the HOS-M sample if
they are age 55 or over, reside in the com­
munity, 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.
NOTE: Highlights are not peer reviewed.
Edith Walsh and Galina Khatutsky are with RTI International.
Louis Johnson is with the Centers for Medicare & Medicaid
Services (CMS). The research in this article was supported
by CMS under Contract Number HHSM-500-2005-00291(TO6).
The statements expressed in this article are those of the au­
thors and do not necessarily reflect the views or policies of RTI
International or CMS.
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ed in the HOS-M sample for plans enroll­
ing less than 1,400 beneficiaries (31 PACE
plan) while we drew a sample of 1,000 eli­
gible beneficiaries from the Medicare files
for 1 PACE plan with larger enrollment.

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 oper­
ated by PACE staff comprised of physi­
cians, nurses, social workers, rehabilitation
therapists, and other ancillary providers,
as well as inhome services. A small pro­
portion of PACE enrollees become resi­
dents 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 ben­
eficiaries 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.1
1 Plans that have been in operation for at least 1 calendar year.
reSultS
In 2006, 6,247 of the 8,649 PACE eligibles
responded to the HOS-M, yielding an over­
all response rate of 72.2 percent for PACE
plan enrollees. This response rate is simi­
lar to those for previous years. Thirty-two
PACE plans participated in 2006 HOS-M.
The entire eligible enrollment was includ­
reFerenCeS
Walsh, E.G., Nason, C.A., Moore, A., et al.: Pilot
Test of the Medicare Health Survey for PACE and
EverCare. RTI International. Waltham, MA. July 23,
2003.
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ciaries age 55 or over.
•  HOS-M respondents’ demographic information was obtained from the Medicare Enroll­
ment Database as it is not collected by the HOS-M to preserve the instrument’s brevity.
•  PACE enrollees represent an older segment of the Medicare population, with an average
age of 80 for females and 76.6 for males.
             

          
               

Figure 1
Demographic Characteristics of the Medicare Health Outcomes Survey-Modified
(HOS-M) Respondents: Mean Age by Sex
SOURCE: RTI International’s analysis of the Medicare Health Outcomes Survey-Modifjed data, 2006.
50
55
60
65
70
75
80
85
90
Male
76.6
Female
80.0
Age
Sex
•  Program of All Inclusive Care for the Elderly (PACE) program enrolls Medicare benefi­
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Figure 2?�
Mean Unadjusted VR-12 Physical Component and Mental Component Summary Scores ?
(PCS and MCS)?�
0
10
20
30
40
50
PCS
28.9
43.9
MCS
Summary Score
Component
NOTES: PCS and MCS VR-12 summary scores presented are not case-mix adjusted. They are derived from the Veterans
RAND-12 (VR-12) instrument and are widely used to describe physical health (PCS) and mental health (MCS). The scores are
normalized to the general population with a mean = 50 (standard deviation = 10). Higher scores indicate better functioning.
SOURCE: RTI International’s analysis of the Medicare Health Outcomes Survey-Modifjed data, 2006.
• The average PCS score of the Program of All Inclusive Care for the Elderly (PACE)
enrollees, all of whom have nursing home level of need, is 28.9, about 20 points lower
than for the general population, signifying a subpopulation in relatively poor physical
health.
• The MCS scores for PACE enrollees average around 44, signifying that PACE enrollees
report better mental health than physical health; the scores are only 6 points lower than
those of the general population.
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only 12.2 percent reported no ADL limitations, and over 40 percent reported maximum
levels of frailty (5 to 6 ADL impairments).
 

       

     

Figure 3?�
Functional Status: Levels of Activities of Daily Living (ADL) Impairment?�
SOURCE: RTI International’s analysis of the Medicare Health Outcomes Survey-Modifjed data, 2006.
0
10
20
30
40
50
No ADLs 1-2 ADLs 3-4 ADLs 5-6 ADLs
12.2
23.8
23.2
40.8
Percent
Impairment
• ADL impairment is defined as being unable to do or having difficulty in the activity. Six
ADLs are included: bathing, dressing, walking, transferring, toileting, and eating.
•  Program of All Inclusive Care for the Elderly enrollees reported high levels of frailty:
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