@mastersthesis {10882, title = {Unintended Consequences of Medicaid Policy for High-Need Beneficiaries}, volume = {Doctor of Philosophy}, year = {2020}, school = {University of Chicago}, address = {Chicago}, abstract = {This dissertation examines how two healthcare policies impact older adults and individuals with disabilities: long-term care and Medicaid managed care. The first chapter provides the first national examination of long-term care (LTC) setting, hospitalization and spending among the elderly, Medicare-Medicaid dually enrolled. Using national Medicaid claims data, we found that overall hospitalization rates were similar for HCBS and nursing facility users, despite nursing facility users generally being sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than whites, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than non-whites; higher Medicare and Medicaid spending on hospitalizations for blacks and Hispanics did not offset this difference. In the second chapter, I analyze the Health and Retirement Study (HRS) to estimate the effect of home care versus nursing home care on several measures of physical and mental health. While the analysis in Chapter 1 used claims data to study the effects of Medicaid-paid LTC, the use of the nationally representative HRS allows me to estimate effects of care setting across all payers and across a wider variety of health outcomes than can be studied in the claims data alone. Instrumental variables methods were used to estimate plausibly causal effects of care setting for a specific group of {\textquoteleft}{\textquoteleft}marginal{\textquoteright}{\textquoteright} individuals: those using home care (versus nursing home care) because of state-level Medicaid policies. I find that hospitalization rates were higher but functional decline was slower among home care users. While I find differences in observable characteristics by LTC setting by race and ethnicity, the state-level instrument lacked sufficient power in the black and Hispanic subsamples to explore differences in causal effects of care setting by race/ethnicity. Finally, in the third chapter I examine effects of another Medicaid policy change: inclusion of the Medicare-Medicaid dually enrolled (duals) in Medicaid managed care (MMC). In order to control program costs, many states have recently expanded their MMC programs to include duals. This chapter provides the first national estimates of the effects of MMC expansions from 2005 to 2012 for duals. I use difference-in-differences (DID) and instrumental variables (IV) methods to estimate plausibly causal impacts of three different types of MMC: comprehensive managed care (CMC), managed long-term service and supports (MLTSS), and primary care case management (PCCM). MLTSS plans are associated with increases in hospitalization and potentially avoidable hospitalization and these increases are concentrated among beneficiaries with many chronic conditions. I find mixed effects of CMC expansion: in mandatory enrollment settings, I find modest increased hospitalization while in voluntary enrollment settings, I find decreased hospitalization. Finally, PCCM plans are not associated with changes in hospital use. This study provides the first national estimates of how a major financing change, the inclusion of duals in MMC, impacts hospital use, providing policymakers with much needed evidence as they face the challenge of financing public health insurance programs as health care costs rise and the population ages.}, keywords = {Long-term Care, Managed care, Medicaid}, doi = {10.6082/uchicago.2238}, author = {Rebecca Jean Gorges} } @article {8818, title = {The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses.}, journal = {J Pain Symptom Manage}, volume = {53}, year = {2017}, month = {2017 02}, pages = {178-187.e1}, abstract = {

CONTEXT: Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression.

OBJECTIVES: The objective of this study was to determine the association between patients{\textquoteright} use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses.

METHODS: We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65~years and older who died between 2000 and 2011 (n~=~1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses.

RESULTS: Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range~=~0-8) and a greater likelihood of clinically significant depression (odds ratio~=~1.51) compared with a matched sample of spouses of those who did not have procedures (P~<~0.05).

CONCLUSION: Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors{\textquoteright} negative mental health consequences and how best to provide appropriate support.

}, keywords = {Aged, Aged, 80 and over, Caregivers, depression, Female, Humans, Intubation, Longitudinal Studies, Male, Mental Health, Respiration, Artificial, Spouses, Survivors, Terminal Care}, issn = {1873-6513}, doi = {10.1016/j.jpainsymman.2016.08.023}, url = {http://linkinghub.elsevier.com/retrieve/pii/S0885392416307850http://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/plainhttp://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/xml}, author = {Katherine A Ornstein and Melissa D. Aldridge and Melissa M Garrido and Rebecca Jean Gorges and Bollens-Lund, Evan and Albert L Siu and Kenneth M. Langa and Amy Kelley} }