and Adverse Health Events Amy M. G. Kandilov, Vince Keyes, Noelle - - PowerPoint PPT Presentation

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The Effect of the Vermont Support and Services at Home (SASH) Program on Medicare Expenditures and Adverse Health Events

Amy M. G. Kandilov, Vince Keyes, Noelle Siegfried, Patrick Edwards RTI International Alisha Sanders, Robyn Stone LeadingAge Center for Applied Research Martijn van Hasselt UNC - Greensboro

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Funding Sources

• Funding for this research came from HHS Office of the Assistant

Secretary for Planning and Evaluation (ASPE), in partnership with the Department of Housing and Urban Development (HUD) and the HHS Administration for Community Living (ACL), under contract number HHSP23337006T.

• The statements contained in this presentation are solely those of the

authors and do not necessarily reflect the views or policies of ASPE, HUD, or ACL.

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Introduction to the SASH Program

• The Support and Services at Home (SASH) program in

Vermont was developed by the nonprofit Cathedral Square Corporation to help residents of publicly-assisted housing access the health care and support services they need to stay healthy and age comfortably and safely at home.

• Each SASH “panel” contains up to 100 participants, who

are served by a full-time SASH coordinator and a quarter time wellness nurse

• SASH staff offer participants many services, including

care coordination and wellness programs

• Most panels are operated within a non-profit, affordable

congregate housing site

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Introduction to Multi-Payer Advanced Primary Care Practice Demonstration

• Primary source of funding for the SASH program comes

from the Centers for Medicare & Medicaid Services (CMS), through the MAPCP Demonstration

• In the MAPCP Demonstration, CMS joined eight state

initiatives (including the Blueprint for Health in Vermont) by providing financial incentives for physician practices to become patient-centered medical homes

• CMS provides $68,000 per year per 100-participant

panel, which is roughly 2/3 of SASH panel operating costs

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Research Objective

• Our objective is to estimate the impact of the first three

years of the SASH program on the Medicare expenditures and adverse health events of SASH participants living in affordable congregate housing

• Outcomes of interest: Medicare expenditures, all-cause

hospitalizations, and ER visits (all-cause, and ER visits not leading to hospitalization)

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Study Design

• We use a difference-in-differences linear regression

model for the expenditure outcomes, comparing the change in the quarterly outcomes among the SASH participants with the change in the quarterly outcomes for a comparison group of Medicare beneficiaries in affordable congregate housing who are not participating in SASH.

• Our model controls for beneficiary-level demographic

and health characteristics, and it includes fixed effects for the time quarters and for each of the congregate housing properties.

• Comparison group is chosen through propensity score

matching

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Population Studied

• Across the first three years of the SASH program (July

2011 through June 2014), there were 3,485 SASH participants

• The intervention group for this study consists of 1,602

Medicare fee-for-service beneficiaries participating in the SASH program and living in SASH housing sites

• Both intervention and comparison groups are residents
• f properties that receive funding assistance through the

U.S. Department of Housing and Urban Development,

• r tax credits through the Low Income Housing Tax

Credit.

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SASH Participants Included in the Regression Analysis

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3,485 SASH participants with start date before 7/1/14 2,260 Medicare FFS beneficiaries attributed to Blueprint for Health practices 1,602 included in sample: 1,252 matched to PIC/TRACS 350 matched to LIHTC only 1,225 excluded: 313 not Medicare FFS 912 not attributed to Blueprint practices 658 excluded: not found in PIC/TRACS or LIHTC housing records

NOTES: SASH, Support and Services at Home; FFS, fee-for-service; PIC, Public and Indian Housing Information Center database; TRACS, Tenant Rental Assistance Certification System; LIHTC, Low Income Housing Tax Credit

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Subgroups of SASH panels

• We examine how the effects of SASH differ between early SASH

panels (starting before April 1, 2012) and late SASH panels (starting

• n or after April 1, 2012)
• Given considerable start-up efforts, early panels may be more

effective at reducing health care expenditures/utilization

• We also consider how the effect of SASH differs in site-based

panels vs. mixed panels.

• The majority of participants in site-based panels live in the SASH

housing host site; the majority of participants in mixed panels live in the community

• Panels will a high concentration of community participants may have

fewer resources available to assist each participant

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Effect of the SASH program on monthly Medicare expenditures

Expenditure type (1) All SASH participants (n=1,602) (2) Early SASH panels (n=699) (3) Late SASH panels (n=933) (4) Site-based panels (n=1,218) (5) Mixed panels (n=384) Total Medicare

• 12.31
• 127.99*

62.18

• 65.76

121.25

(57.1) (71.7) (71.55) (62.12) (95.78)

Acute care

5.08

• 27.97

26.36

• 15.27

56.25

(33.61) (42.49) (41.7) (36.78) (54.93)

Post-Acute Care

5.44

• 21.91

27.56

• 8.63

48.96

(17.86) (21.23) (22.54) (18.95) (31.03)

Emergency room

• 4.54
• 9.18**
• 2.62
• 6.19
• 1.83

(3.75) (4.17) (4.90) (3.95) (6.47)

Hospital outpatient department

• 10.33
• 26.56*
• 2.13
• 17.95

7.20

(11.70) (14.33) (14.18) (12.44) (19.54)

Primary care/Specialist physician

• 1.69
• 9.11*

3.69

• 4.27

5.57

(4.15) (5.26) (5.21) (4.58) (6.47)

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Source: Authors’ analysis of Medicare claims data January 2006 through June 2014

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Principal findings: Monthly expenditures

• Overall, there is no significant effect of SASH on monthly

Medicare expenditures for the SASH participants as a whole

• SASH participants in early panels have significantly

lower growth in total Medicare costs of $128.

• Expenditures for emergency room, hospital outpatient

departments, and physicians are also lower for the SASH participants in early panels

• No difference in cost growth for other types of SASH

panels

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Effect of the SASH program on monthly Medicare expenditures, annual aggregates

Year (1) All SASH participants (n=1,602) (2) Early SASH panels (n=699) (3) Late SASH panels (n=933) (4) Site-based panels (n=1,218) (5) Mixed panels (n=384) Year one

• 24.54
• 52.55
• 52.28
• 22.43
• 48.66

(79.27) (90.35) (177.12) (84.73) (195.09)

Year two

164.51*

• 33.95

317.4* 108.02 253.51

(81.72) (106.64) (111.43) (91.14) (156.5)

Year three

• 124.07
• 221.25*
• 71.76
• 188.45*

59.8

(76.02) (94.24) (85.91) (81.2) (116.36)

All years combined

• 12.31
• 127.99*

62.18

• 65.76

121.25

(57.1) (71.7) (71.55) (62.12) (95.78)

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Principal findings: Annual aggregate expenditures

• For the early SASH panels, the largest decrease in

Medicare cost growth comes in Year Three

• Site-based SASH panels also have decreased Medicare

cost growth in Year Three, although not overall

• Note that the majority of the early SASH panels are site-

based panels

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Effect of the SASH program on quarterly adverse health event measures

Utilization outcome (1) All SASH participants (n=1,602) (2) Early SASH panels (n=699) (3) Late SASH panels (n=933) (4) Site-based panels (n=1,218) (5) Mixed panels (n=384) All-cause, acute care hospitalizations

2.78

• 5.54

7.28

• 2.05

17.76

(6.33) (7.59) (8.85) (6.41) (14.53)

All-cause ER visits

6.72 3.23 6.53 3.23 18.91

(8.60) (10.49) (11.13) (8.90) (16.79)

ER visits not leading to a hospitalization

2.42 1.53 1.30 1.35 6.53

(5.29) (6.76) (6.79) (5.62) (10.03) 14

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Principal Findings: Adverse health events

• No statistically significant findings for any of the three

utilization measures

• Further research will look at the intensity of the acute

case hospitalizations and ER visits, to better explain why expenditure growth is declining but utilization is not

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Conclusions

• The SASH panels with the earliest start dates

experienced lower growth in Medicare expenditures, with the strongest results in the third year of SASH implementation.

• This decreased growth in Medicare expenditures over

the three years for the early SASH panels is consistent with the hypothesis that the start-up activities for a SASH panel reduce that panel’s ability to make a significant impact on Medicare expenditures and utilization in the first few quarters of operation.

• Site-based SASH panels exhibit lower growth in

Medicare expenditures in the third year of the SASH program

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Policy Implications

• Our principal findings suggest that SASH is a promising

intervention for reducing the growth of Medicare expenditures among a population of elderly and disabled residents living in affordable congregate housing.

• Further research is needed to determine if Medicare

cost growth can be reduced as newer SASH panels mature

• This model of providing in-home services for elderly

residents of affordable congregate housing properties may have viability beyond Vermont.

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More Information

Amy M. G. Kandilov, PhD Senior Research Economist RTI International 919-541-7111 akandilov@rti.org Full report available here: https://aspe.hhs.gov/pdf- report/support-and- services-home-sash- evaluation-second- annual-report

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