Eligibility for publicly financed home care

OBJECTIVES

Proposals for publicly financed home care for the elderly now tend to include cognitive impairment criteria as well as activities of daily living (ADL) criteria. The numbers of elderly deemed eligible for services will depend on the definitions of ADL and cognitive impairment used.

METHODS

Data from the 1984 National Long-Term Care Survey were used to generate a series of estimates of the community-dwelling elderly with ADL disabilities and cognitive impairment.

RESULTS

When only ADL criteria are used, estimates of disability range from 472,000 to over 3 million (1.6% to 12.5% of the community-dwelling elderly). These estimates increase to approximately 1 million to 4.2 million (3.5% to 14.0% of the community-dwelling elderly) when cognitive impairment criteria are added.

CONCLUSIONS

The use of more stringent or more liberal eligibility criteria will have dramatic effects on the number of elders who qualify for services. The nature of the eligibility criteria employed in any expansion of federally financed home care benefits will be a major factor in determining the costs of such a program.

The changing definition of AIDS. What's in a name?

Earlier this year, the U.S. Centers for Disease Control proposed altering its definition of acquired immune deficiency syndrome (AIDS) to include those with 200 or fewer CD4 cells. That proposal, scheduled to take effect April 1, 1992, would dramatically increase the number of Americans officially considered as having AIDS. The previous definition relied on a list of specific opportunistic infections, tumors, or itemized manifestations of HIV disease. While eventually the definition of AIDS should be replaced with a definition of HIV disease--which would include all those who are infected with the human immunodeficiency virus--the CDC proposal would be a useful stopgap measure. It would provide access to needed treatments such as AZT to thousands of men and women who now are excluded from reimbursement systems including private health insurance and Medicaid.

Attendance allowance

Images

Ethics and Medicaid: a new look at an old problem

Recent proposals to reform Medicaid, driven primarily by the need for cost containment, rarely pay explicit attention to values. This paper presents the Medicaid Values Framework, the authors' interpretation of a set of societal ideals embodied in Title XIX of the Social Security Amendments of 1965. The Framework comprises seven interlocking values that are stratified into three interdependent tiers--access, quality, and equity. We use the access and equity tiers to analyze treatment of Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI) recipients under Medicaid. We document striking inequities in eligibility standards and in funding for the two groups--inequities that unexpectedly fail to translate into marked disparities in access to Medicaid. In conclusion, we comment on why the present inequities exist and why they are ethically unacceptable.

Improving state Medicaid programs for pregnant women and children

Beginning in 1986, States have made the reduction of infant mortality a major policy priority. As progress on important maternal and infant health indicators has slowed and/or worsened. States have taken advantage of numerous Federal Medicaid options to implement innovative strategies to enhance low-income women's access to prenatal care and to improve the content of that care. Acting initially to expand Medicaid eligibility up to and above the Federal poverty level, States have moved to further improve programs by streamlining eligibility systems, enhancing outreach initiatives, attempting to recruit obstetrical providers into participating in Medicaid, and adding enriched nonmedical prenatal benefits to their State plans. Although policymakers must await formal evaluation results, State reforms appear encouraging.

Baseline characteristics in the Hypertension Prevention Trial. Hypertension Prevention Trial Research Group

The Hypertension Prevention Trial (HPT) was a randomized, controlled, multicenter (four clinics, four resource centers) trial designed to test the feasibility of achieving and sustaining dietary changes in the intake of calories, sodium, and potassium and to assess the effect of those changes on blood pressure in a normotensive population. The trial involved 841 men and women (plus a test cohort of 78) who, at the first baseline (BL) examination were in the age range of 25-49 years and had diastolic pressure (DBP) greater than or equal to 76 but less than 100 mm Hg (average of two readings), and at the examination prior to randomization (BL 2), had DBP greater than or equal to 78 but less than 90 mm Hg (also averaged). Participants were randomly assigned to a control treatment group (no dietary counseling) or to one of four dietary treatment groups involving counseling designed to reduce calorie intake; reduce sodium intake, reduce sodium and calorie intake, and reduce sodium and increase potassium intake. This chapter presents HPT baseline characteristics by weight stratum, clinic, and treatment group for various demographic, medical history, and nutritional characteristics, for several physiologic variables used in monitoring treatment compliance, and for blood pressure. The degree of comparability observed among treatment groups was within the range expected for the randomization procedure used.

Recruitment in the Hypertension Prevention trial. Hypertension Prevention Trial Research Group

The Hypertension Prevention Trial (HPT) was a randomized, controlled, multicenter (four clinics, four resource centers) trial designed to test the feasibility of achieving and sustaining dietary changes in the intake of calories, sodium, and potassium and to assess the effect of those changes on blood pressure in a normotensive population. The trial involved 841 men and women (plus a test cohort of 78) who, at the first baseline (BL) examination were in the age range of 25-49 years and had diastolic blood pressure (DBP) greater than or equal to 76 but less than 100 mm Hg (average of two readings), and at the examination prior to randomization (BL 2), had DBP greater than or equal to 78 but less than 90 mm Hg (also averaged). Participants were randomly assigned to a control treatment group (no dietary counseling) or to one of four dietary treatment groups involving counseling designed to reduce calorie intake, reduce sodium intake, reduce sodium and calorie intake, and reduce sodium and increase potassium intake. This chapter describes the process of recruiting participants for the trial. Methods used to identify and contact study participants are presented. Details of the steps involved in the recruitment process and strategies for reducing costs are discussed.

Guidelines for clinical protocols for chronic lymphocytic leukemia: recommendations of the National Cancer Institute-sponsored working group

The National Cancer Institute (NCI)-sponsored Chronic Lymphocytic Leukemia (CLL) Working Group was convened to develop a set of standardized eligibility, response, and toxicity criteria for clinical trials. We recognized the previous efforts in 1967 (published again in 1973 as the report of the Chronic Leukemia-Myeloma Task Force [1] and 1978 of Cancer and Leukemia Group B (CALGB) [2]). We have used these reports for guidance during the current effort. Several noteworthy developments in the past few years have made it necessary to modify the previous guidelines. First, the diagnostic criteria for CLL and its clinical staging have been developed and well defined. Second, although staging systems facilitated entry of comparable and relatively homogeneous groups of patients in clinical trials, the definitions of response (CR) and partial response (PR) were not uniformly adopted from the previous guidelines in the clinical trials (Tables IA, IB); therefore, comparisons of results obtained in different studies became difficult. Third, there has been an improvement in our understanding of the immunology and biology of CLL. Finally, we are witnessing the emergence of several chemotherapy agents that promise impressive activity in CLL (e.g., 2'-deoxycoformycin [3], fludarabine monophosphate [4, 5]), and thereby offer the potential for improving survival time in this disease. To best identify regimens worthy of continued pursuit in large comparative trials, standardized guidelines for evaluation are essential. A number of laboratory investigations are also presented for which scientific interest is high yet relevance remains to be determined; thus, they are presented as companion studies to the clinical trials. This mechanism allows for flexibility in the testing of these questions and for additional ideas in the future without requiring modification of an entire treatment protocol. The following guidelines were developed to be used as a form of standardization for clinical trials, incorporating current technologies, yet remaining relevant to the general hematology/oncology community. Based on the membership of the Working Group, it is expected that these guidelines will serve as the criteria for most clinical trials in the near future.

A profile of clients referred for psychiatric evaluation for Social Security Disability Income and Supplemental Security Income: implications for psychiatry

A study of the psychiatric evaluations of 248 consecutive clients whose cases were in the process of adjudication for approval or renewal of Supplemental Security Income and/or Social Security Disability Income in 1982 and 1983 showed an overrepresentation of individuals with chronic moderate to severe psychiatric impairment. The author suggests that the criteria and guidelines for eligibility for these two programs are too stringent for individuals with psychiatric impairment and that some of these individuals are unable to provide information necessary to build a proper case for disability because of their psychopathology. The implications for psychiatrists, other mental health professionals, and social policy planners are discussed.

Medicaid program; state residency requirements--HCFA. Final rule

We are revising Medicaid regulations to clarify State residency requirements for Medicaid eligibility. The rule will assist States in making determinations of residency for individuals receiving out-of-State care, and will establish more uniform requirements pertaining to the medical documentation needed to establish that an individual is incapable of indicating intent to reside.