WIELAND ET AL.
particular importance of an integrated, team-managed med-
ical home for the older, more disabled participants more
commonly admitted to PACE.
Our study has several limitations. First, it employs sec-
ondary analysis of clinicoadministrative information col-
lected for other purposes (15). Second, baseline risk
differences between program cohorts in this quasiexperi-
mental study were manifest, raising the challenge of risk
adjustment. Here, we examined the validity of the PPI in
our population and performed simple risk stratiﬁcation, in-
stead of ﬁtting (and probably overﬁtting) a multivariable
model of program-related survival using miscellaneous ad-
mission predictors available in the analytic data set. Risk
adjustment issues aside, results concerning comparative
program mortality outcomes reﬂect speciﬁcally local condi-
tions, and may not be observed everywhere. For example,
although nationally PACE comprises comprehensive, inte-
grated care with a strong medical management component,
the quality and accessibility of primary, consultative, emer-
gency, and acute care for waiver clients may vary consider-
ably. The extent to which Medicaid beneﬁciaries in such
waiver programs enroll in medical homes, special needs
plans, and other programs unavailable in SC at the time of
study could affect outcomes for those groups.
Moreover, we were unable to address the important issue
of selection bias (16). Much of the large survival advantage
of both CC and PSC over NH (Figure 3A–C) very likely
reﬂects adverse selection to the latter, as well as probable
ceiling effects of the PPI in NH admissions. Thus, we have
not emphasized the survival differences observed between
either of the community cohorts and the NH group in over-
all or stratiﬁed analyses. We must also assume there is se-
lection between CC and PSC programs that may inﬂuence
their outcomes independent of process and/or quality differ-
ences between PSC and CC care. In future research, we
hope to reﬁne our modeling of long-term outcomes by in-
corporating time-varying covariates as we add annual reas-
sessment information to the data set. This will involve
integration of RAI information for reassessments of NH
residents presently missing. Furthermore, we plan study of
the single point-of-entry process in SC, with a view to iden-
tifying instrumental variables affording us some under-
standing and control of selection bias.
The small literature concerned with the comparative ef-
fectiveness of alternative LTC placements usually limits
follow-up to 2 years or less and suffers from other limita-
tions (4). Few states systematically evaluate expenditures
and outcomes across LTC programs over periods longer
than 1 year. Thus, questions linger regarding the longer-
term value of PACE relative to home- and community-based
waiver or NH placements or among LTC programs gener-
ally. Our results suggest that states should make necessary
investments in research and data infrastructure to evaluate
emerging LTC options, and make planning and allocation
decisions based in part on evidence of value for different
levels of need and risk.
The paper was presented at the Academy Health Annual Research Meeting,
Chicago, June 2009.
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