Health Insurance for the AEed: The Statistical Program

Transcription

1 Health Insurance for the AEed: The Statstcal Program u v by HOWARD WEST* On July, 966, the health nsurance program for the aged under the Socal Securty Act went nto effect. Ths program helps to close a major gap n the economc securty of tle elderly by provdng protecton aganst the hgh costs of hosptal and medcal care. The progmm,wzz have a sgnfcant mpact on the organzaton, provson, and fnancng of health and medcal care n the country. Informaton on the broad scope of benefts and the large populaton group nvolved h b.eng ncorporated n a comprehensve datacollecton, system that wll provde a mean9 for rvaluatng the effectveness of the program. Ths artcle descrbes brefly the provsons of the heazth nsurance program for the aged, outlnes the varous components of the statstcal system for collecton and mantenance of data on the utlzaton and fnancng of hosptal and medcal servces and delneates the analytcal studes envsoned. Xtate data are presented on the number of hosptab and home health agences partcpatng under the program. Also presented are 3 months data on clams pad, based on the blls receved from hosptals that have been processed and approved for payment by ntermedares under the hosptal nsurance program. Basc Provsons of Law The 965 amendments to the Socal Securty -4ct added ttle XVIII to the Act, whch provdes for two coordnated programs of health nsurance for the aged: a basc hosptal nsurance plan (part A) and a voluntary supplementary medcal nsurance plan (part B).I * Drector, Dvson of Health Insurance Studes, Offce of Research and Statstcs. For a full descrpton of the provsons of the health nsurance program, see Wlbur J. Cohen and Robert 3. Ball, Socal Securty Amendments of 965: Summary and Legslatve Hstory, Socal Securty Bulletn, September 965; see also Robert M. Ball, Health Insurance for People Aged 65 and Over: Frst Steps n Admnstraton, the Bulletn, February 966. BENEFITS The hosptal nsurance program provdes payment for a large part of the cost of hosptal servces n a partcpatng hosptal for up to 9 days n a spell of llness (a perod begnnng wth the frst, day of hosptalzaton and endng 6 days after dscharge from a hosptal or an extended-care faclty). The frst 6 days of hosptalzaton are covered essentally n full after a deductble of $4. For each of the remanng 3 covered days n a spell of llness, the patent pays $ of the daly cost. The program pays 8 percent of the cost, of outpatent hosptal dagnostc servces furnshed durng a -day perod, after a deductble of $. The program also covers the cost of care up to days durng a spell of llness n a partcpatng extended-care faclty after transfer from a hosptal followng a stay of 3 or more days. (Ths part of the program began January, 96 7.) The cost of the frst days s covered n full ; the patent pays $5 of the daly cost for each of the remanng 8 covered days. For the cost of home health servces, up to vsts durng the year are covered, followng dscharge from a hosptal (after a stay of at least 3 days) or from an extended-care faclty. The supplementary medcal nsurance program provdes payment for 8 percent of t.he reasonable charges for physcan servces and other covered servces followng payment by the patent of the frst $5 of such charges durng the calendar year. The program covers the followng servces: physcan servces, regardless of place of servce ; up to home health vsts each year; varous other medcal and health servces, such as dagnostc X-ray and laboratory tests; X-ray, radum, and radoactve sotope therapy; prosthetc devces; and the rental of durable medcal equpment. ELIGIBILITY The nearly 9 mllon persons dentfed as elgble for the hosptal nsurance benefts as of July, 966, consst, of all persons aged 65 or over who BUUETIN, JANUARY 967 3

2 are enttled to monthly cash benefts under the old-age, survvors, and dsablty nsurance (OASDI) or ralroad retrement programs and all other aged persons, except retred Federal employees covered under the Federal Employees Health Benefts Act, of 959 and alens admtted for permanent, resdence but havng less than 5 consecutve years of resdence. As of July, 966, about 7.6 mllon persons (ncludng retred Federal employees elgble for the supplemental program) had elected to contrbute $3 a month to pay ther share of the premum for the supplementary medcal nsurance plan. For approxmately l,ooo,ooo persons recevng publc assstance n 5 States, the $3 premum wll be pad by the State welfare agences. About 3, retred Federal employees are enrolled n the supplementary medcal nsurance program but are not, elgble to receve hosptal nsurance benefts. The March ssue of the BULLETIN wll carry data on the number, characterstcs, and State of resdence of persons enrolled n the hosptal and medcal nsurance programs on July, 966. FISCAL INTERMEDIARIES I-nder the hosptal nsurance program, ntermedares are selected by each hosptal to act as the lnk between the hosptals and the Socal Securty Admnstraton. A vtal role of the ntermedares s to revew and pay hosptal clams for the costs of provdng care to the benefcares. The nternredary makes these payments to provders for covered tems and servces on the bass of reasonable cost determnatons and asssts n the applcaton of safeguards aganst unnecessary utlzaton of covered servces. I-nder the supplementary medcal nsurance program, nsurance carrers are selected by t,he Secretary of Health, Educaton, and Welfare to serve as ntermedares. The prncpal functons of these carrers are to determne the reasonable charges n ther respectve areas for each medcal care servce pad for under the program and to revew and pay clams to or n behalf of benefcares for the servces provded. The number and types of ntermedares for each of the health nsurance programs are summarzed below. FINANCING HEALTH INSURANCE BENEFITS The hosptal nsurance program s fnanced on a long-range, self-supportng bass through a separate schedule of ncreasng tax rates on the frst $6,6 of earnngs, wth the same rate for employees, employers, and self-employed persons. The rate was.35 percent n 966, t rose to 5 percent for 967, and t s scheduled to ncrease untl t s.8 percent n 98 7 and thereafter. A separate trust fund was establshed for the hosptal nsurance program. Included n the law s a specal provson to remburse the hosptal nsurance trust, fund from general tax revenues for the cost.s of provdng hosptal nsurance coverage for the almost.5 mllon persons not enttled to monthly socal securty or ralroad retrement. cash beneft,s. The voluntary medcal nsurance program s fnanced by $3 monthly premums from enrollees and a matchng payment from general revenues of the Federal Government. A separate trust fund has also been establshed for ths supplementary program. Type of ntermedary Hosptal nsurance Medcal nsurance Total Rlue Cross-Blue Sheld Commercal nsurance companes Other~...~.~..~..~...~...~...~... 3 New York Department of Health and the Socal Securty Admnstmton, whch deal drectly wth 87 hosptals n 9 States, the Dstrct of Columba. and Puerto Rco. * Group Health Insurance, Inc.. Nebraska Department of Publc Welfare. and the Socal Securty Admnstraton, whch deal drectly wth more than group-practce prepayment plans. The Statstcal System CHARACTERISTICS OF THE SYSTEM The prmary objectve of the statstcal system of the health nsurance program s the provson of data requred to measure and evaluate the operatons and the effectveness of the two parts of the program. The beneft payment operatons furnsh the means of obtanng extensve, systemat,c, and contnuous nformaton about the amount and knd of hosptal and medcal care servces used by the aged, as well as the costs of such 4 SOCIAL SECURITY

3 servces. The applcatons of hosptals and of extended-care facltes to partcpate n the program provde data on the characterstcs of such provders of servces. The clam number that) s assgned to each ndvdual serves as the lnk between the varous servces utlzed under the program and the demographc characterstcs of each ndvdual recorded h the elgblty fles. The dat,a-collecton system has two nherent characterstcs that determne to a consderable degree the scope, detal, and flexblty of the avalable data. Frst, data are collected and mant,aned on an ndvdual bass so that the benefcary and hs medcal experence under the program form the basc unt. Second, records for each bll pad under the hosptal nsurance program and for a sample of benefcares under the medcal nsurance program are mantaned on a centralzed bass. Except for ntermedary operatng statst,cs sucll as t,hose relat,ng to lvorkloads, tme lags, costs, and the lke, all program statstcs are centrally prepared. Ths record was used to create the health nsurance card that was sent to each nsured person. The card contans the ndvdual s clam number (an adaptaton of the nunlber used for OSSDI or ralroad retrement monthly cash beneft) and ndcates the elgblty of the ndvdual for the two parts of the program. The clam number s the lnk between the elgblty record and all other records used n the program. The master elgblty record also contans nformaton dentfyng the State and county of resdence, date of brth, sex, and color of each enrolled person. In addton, the record has been further annotated to ndcate selected subgroups, such as publc assstance recpents whose medcal nsurance premum s beng pad by the State welfare agency, as well as other major groups. The master elgblty record thus provdes sgnfcant demographc characterstcs lnked to the utlzaton and cost data for both parts of the program. Fnally, the elgblty record provdes the populaton data for each part of the program and therefore serves as the base for the computaton of a varety of utlzaton rates, lmted only by ts demographc content. The statstcal system s based on fve dstnct but related computer-tape record systems : master elgblty record, provder record, hosptal nsurance (part,i) utlzaton record, medcal nsurance (part, 3) payment record, and the record cwntanng a sample of medcal nsurance blls. Master Elgblty Record The master elgblty record dentfes each aged person elgble for health nsurance benefts and ndcates whether he s enttled to hosptal benefts, to supplementary medcal nsurance benefts, or to both. J!le master elgblty fle was establshed by combnng the exstng OASDI and ralroad retrement benefcary records wth the records created from the applcatons of unnsured persons aged 65 and over to partcpate n the health nsurance program. The same sources are used to mantan the elgblty records on a current bass-to add the newly aged, elmnate those who de, and dentfy those who wthdraw from the supplementary medcal nsurance program. Provder Record Every hosptal, home health agency, extendedcare faclty, and ndependent laboratory must apply for partcpaton n the hosptal nsurance program n order to be rembursed for servces provded. Each nsttuton or agency must also meet the condtons of partcpaton spelled out n the health nsurance provsons of the Socal Securty Act and by the regulatons under the Act. Desgnated State agences, operatng under agreement wth the Department of Health, Edu- &on, and Welfare, hare the responsblty for determnng the extent to whch each nsttuton or agency meets these health and safety condtons for partcpaton and for certfyng those that satsfactorly do SO.~ Data ncluded on the applcaton forms used by these nsttutons (SSA-54 for hosptals, For a full descrpton of the condtons, see Socal Securty Admnstraton, Condtons for Partcpaton fop Hosptals (HIJILl), Condtons for.. Home Health Agcnccs (HIM-), Condtons for... Extended Cart Pacltes (HIM-S), and Coldton.s for... Independmt Laboratores (HIM-4). BULLETIN, JANUARY 967 5

4 SSI-55 for home health agences, SSL4-56 for extended-care facltes, and SSh-l-57 for ndependent laboratores) to ndcate ther desre to partcpate and to provde needed nformaton llave been recorded n the central provder record ald wll be updated as facltes are recertfed perodcally, as new ones apply for partcpaton, or as some leave the program. These applcatjon forms are the source for a varety of data on the characterstcs of hosptals, llome health agences, extendecl-care facltes, and ndependent lnborntores partcpatng n the program. The detaled nformaton about each provder recorded n the statstcal tapes ncludes such tems as the State and county n whch the nsttuton s located ; the number of beds ; type of control ; the major types of servces provded; accredtaton status, medcal school afflaton, and approved tranng programs; staff characterstcs, ncludng the number of physcans, regstered nurses, qualfed speech therapsts, lcensed practcal nurses, home health ades, and other sklled medcal care personnel; the annual total of adult admssons and dscharges; the number of pat,ent days ant persons served ; tlld the current renbursement rate. When the nformaton n ths provder fle s combned wth utlzaton data, t serves to relate tle characterstcs of facltes and agences that Ijrovde care to the knds and amounts of servce used by the aged. Utlzaton Record For Hosptal Insurance Tlw ndmstraton of the hosptal nsurance )rogram requres that two tems of nformaton be known about each aged person at the tme of lls admsson to a hosptal-hs elgblty under the program and the extent to whch he has used the benefts avalable to hm under the spell of lness concept. It s therefore necessary to matan a master record of the number of days of care receved by each aged person n a hosptal or extended-care faclty and of the number of home health vsts receved. Ths central record system s mantaned on computer tape by the Socal Securty L4dmnstraton. When the patent s admtted to a hosptal, the admsson secton of the Inpatent Hosptal Admsson and Bllng Form (SE%-453) s completed by the hosptal alld forwarded through ts ntermedary to the Socal Securty L4dmnstraton central record. As soon as the record s checked, normally n less than -- hours, the hosptal s nformed of the patent s elgblty!:tatus aud of the number of days remanng durng the spell of llness. At dscharge, the hosptal completes the bllng secton of the form and sends t to the ntermedary for payment. JVlen ai)i)roval for payment has been made, the ntermedary forwards the clam to the Socal Securty Admnstraton for recordng n the central record. Copes of admsson and bllng forms are handled n a comparable manner by home health agences ( ML\-48 7) and extended-care facltes (SSA- 4%). The outpatent dagnostc bllng form (MA-483) s also transmtted to the Socal Securty Admnstraton for recordng n the central record after the bll s approved for payment by the ntermedary. z4 the nformaton on utlzaton experence n hosptal and extended-care facltes that s needed to admnster the spell of llness provson s recorded n the central record. Ths nformat.on ncludes stays n noni) rtcp:~tng nsttutons and days of care not covered or rembursable under the program. As a byproduct of the admsson and bllng procedures a hstory wll be bult up for each ndvdual that wll permt the summarzng or cumulaton of a consderable varety of statstcal nformat,on. The more mportant of these tems are the dates of admsson to and dscharge from hosptals and extendetl-care facltes; length of stay, frequency of use, and dscharge status (alve or dead) ; charge and payment data (ncludng both the covered and noncovered charges, wth the former separated wth respect to the amount rembursed and the deductble and consurance amounts not rembursed) ; the payment source for charges to patents; a report of one or more hosptal dscharge dagnoses, wth the prmary dagnoss coded for a SO-percent sample of all benefcares; surgcal procedures, ncludng the dates of surgery, wth the procedure related to the prmary dscharge dagnoss or the most sgnfcant procedure coded for the same -percent sample ; and dagnostc nformaton coded from all blls from home health agences and extendedcare facltes. For outpatent dagnostc blls, 6 SOCIAL SECURITY

5 dagnoss and procedure data are coded for 4 percent of the benefcares. Each admsson and bllng form cont,ans both the benefcary s clam number and the provder s number, and the resultng tape record can be readly matched to the benefcary fles and the provder fles. By ths process, a statstcal tape record s created that contans all the avalable nformaton needed for tabulaton from the three fles. Payment Record For Medcal Insurance 4. Admnstraton of the supplementary medcal nsurance program does not requre the establshment of a detaled central record of provders snce all lcensed physcans and osteopaths are elgble to partcpate n the program. No spell of llness concept s nvolved, and payment or rembursement s made only after recept by the carrers of blls havng reasonable charges exceedng $5 durng a calendar perod.3 Carrers need to know from a central source only that the deduct ble has been met ; durng the remander of the calendar year, no addtonal nformaton s requred for rembursement or payment purposes. For admnstraton and operaton of the program, the Socal Securty Admnstraton must have accurate and complet,e nformaton on the amounts pad by the carrers for physcan servces and for other servces and supples under ths part of the program. For outpatent psychatrc servces, the maxmum payment lmtaton of $5 requres that a cumulatve central fgure be mantaned. To meet these needs, carrers were nstructed to furnsh a payment record consstng of tape, punched card, or other machne-readable record of each bll pad. A bll s defned as a request for payment from or n behalf of a benefcary as the result of servces provded by t sngle physcan or suppler. The payment record also contans selected tems of nformaton needed to provde an effcent bass for drawng samples of the blls. These tems pro- 3 In fgurng the $5 deductble, reasonable charges for servces receved between January and December 3 are consdered unless the $5 s not met untl the last quarter of the year. In such cases, charges for servces receved n the last 3 months of the year can be used to meet the deductble for the next year. vde a samplng frame that wll be used to draw addtonal small samples desgned to provde specf& nformaton not obtanable from t,he blls furnshed for the basc 5-percent sample of elgble persons under the medcal nsurance program. (Ths sample s descrbed n a later secton.) The tems n the payment record are: Code number assgned by the carrer to each physcan and medcal suppler Physcan s specalty and board certfcaton Identfcaton of medcal degree (M.D., D.O., or D.D.S.) Dollar amount of the reasonable charge as determned by the ntermedary for the most expensve procedure temzed on the bll Place (offce, home, npatent hosptal, extendedcare faclty, outpatent hosptal, ndependent laboratory, other) where the most expensve procedure took place Type of servce represented by the most expensve procedure (surgery, medcal care, consultaton, dagnostc X-ray, dagnostc laboratory, radaton therapy, anesthesa, assstance at surgery, other) The number of dates of servce shown on the bll The number of dollar charges shown on the bll Indcaton of payment to benefcary or to the physcan Indcaton of whether the llness or njury requrng treatment was employment-related. Sample of Blls Under Medcal Insurance Whle the payment record provdes a rapd method for summarzng payment data and a samplng frame for effcently drawng addtonal samples of blls, t does not provde specfc data on dagnoses, procedures, and related charges. Basc statstcs on the utlzaton of physcan and other servces covered under the supplementary medcal nsurance program are derved from a contnuous sample of the blls pad by ntermedares to or n behalf of 5 percent of all enrolled persons. Intermedares have been gven specfc dgts of the health nsurance clam number to be used n selectng the sample. The payment record for all blls provdes the nformaton needed to assure the Socal Securty Admnstraton that the sample s complete. The Request, for Payment Form (SSA-4) s desgned to provde nformaton on the tme and place of each servce, the exact procedure carred out or servce provded, the condton BULLETIN, JANUARY 967 7

6 treated (dagnoss), and the physcan s or suppler s charge for the specfc servce. For nonsurgcal medcal servces, ths nformat on wll provde comprehensve and descrptve data on the type of servces provded by the physcan durng each vst. For surgcal cases, whcrc the usual practce s to report the surgcal procedure, the dagnoss, and the charge wthout specfyng the number of tmes the patent may have been seen by the surgeon, the statstcal unt wll be the surgcal procedure and not the vst. As prevously ndcated, data reflectng physcan and other servces are based on blls pad. For persons n the 5-percent> sample to and for whom payment s made under the program, all ther blls, ncludng those used to meet the amual $5 deductble, wll be ncluded n the sample and coded. Data wll not, however, be avalable through these procedures for persons n the sample who do not meet the $5 deductble. Such data are beng collected by means of the Current Medcare Survey, whch wll be descrbed n detal n a subsequent ssue of the HULLETI~~;. For hosptal-based physcans who have authorzed the provder to collect the fee for ther servces, Form SS-55- (Provder Rllng for Patent Servces by Physcans) s used. Ths form s to be completed for each patent. It also ncludes descrptve nformaton on the date and place of each servce, the dagnoses, procedures, and the charges. The same form wll be furnshed for the 5-percent sample of benefcares. Intal Operatng Data The statstcal system outlned above wll provde consderable data about, the provders of servces, the characterstcs of the aged persons enrolled, and the utlzaton and fnancng of health servces under the hosptal and medcal nsurance programs. Basc program operatng data wll be reported n the BULLETIN and n specal reports to be ssued by the Offce of Research and Statstcs as the data become avalable. Ths frst report presents State data on the number of partcpatng hosptals and home health agences as well as selected characterstcs of the provders on a natonal bass. Prelmnary dat,a on the number and amount of npatent hosptal clams approved for payment under the hosptal nsurance program durng the frst 3 months of operaton have also been reported. Because of lags n reportng and recordng the data on the statstcal tape record, these data are ncomplete and wll be revsecl each month n a ne\\ seres of tables to be publshed monthly n the hi,letih-, whch wll also publsh a monthly seres clams pad, based on the blls receved from physcans or enrollees that have been ljrocessed by ntermedares under the supplementary medcal nsurance program. PARTICIPATING PROVIDERS As of September 3, 66, there were 6,68 hosptals and,4 home health agences certfed for partcpaton n the program. Certfcatons are made by State agences to the I)epartnent of Health, IMucaton, and Welfare ndcatng that the provders meet the condtons for partcpaton )romulpated by the Secretary of Health, Educnton, and Welfare. A partcpatng provder s a certfed nsttuton that has entered nto an agreement wth the Socal Securty,~drnstratoll not to make charges for covered tems and servces except deductbles and consurance amounts; to ret urn any money ncorrectly collected ; and to provde servces on a lolldscrlllll:~tor.y bass n complance wth ttle VI of the Cvl Rghts Act of 964. Al~proxmately 8 hosptals that had appled for partcpaton n the program were not certfed, on the bass of noncomplance wth the standards. Ths number does not, reflect an u- known number of hosptals that wthdrew ther applcatons when t appeared certan that they could not meet the standards and be certfed. At the same tme, about 75 addtonal hosptals falecl to meet the cvl rghts requrements. Hosptals and other provders of servce could have been certfed for partcpaton under the program f they were found to be n substantal complance wth the condtons for partcpaton, despte the fact that sgnfcant defcences were found wth respect to one or more standards. In order to be certfed as beng n substantal complance n the presence of sgnfcant defcences, the provder must be n general complance wth the ntal statement of each condton, must develop an adequate plan to correct the defcences, and the defcences must not be so serous 8 SOCIAL SECURITY

7 as to nterfere wth adequate care or represent cences wth respect to one or more condtons of hazards to health and safety. Of the 6,68 hos- partcpaton. A thrd of these hosptals are ptals that are now partcpatng under the reported to have sgnfcant defcences n sx or program, more than, have sgnfcant def- more condtons of partcpaton, ncludng prob- TABLE l.-health nsurance for the aged: Number of partcpatng hosptals and beds, by type of faclty, geographc dvson, and State, as of September 3, 966 Gographc dvson and State - ~ I Total Hosptals Unted States ,56 New England ~~-..~ Mone New Hampshre Mddle Atlantc New York ~...-. New Jersey...~...~.~... Pennsylvana~...~.~.~.~... E&North Central Oho...~.~.~...~~~~...~. Indana...~~... Illnos...~...~~...~.~~~...~.~..~...~.~... Mchgan Wsconsn...~.~.~... We&North Central Mnnesota...~...~...~.. Iowa..~...~.~.~...~~..~~~~~...~...~ Mssour...~.~...~.~...~...~.~~.. North Dakota...~.~...~...~. South Dakota...~...~...~...~~... Nebraska...~.~...~...~.. Kansas SouthAtlantc Delaware~...~...~~~~...~.~.~~..~~.. Maryland...~.~...~~~...~. DstrctofColumba Vrgna..~~.~.~...~...~..~...~~..~~~..~~~~~.. WestVrgna...~~...~~~...~.. North Csrolne...~.~...~ - South Carolna Georga~.~~...~...~.~...~~..~~~~~~~~~~...~ - Flords~.~~~~.~~~..~~~.~~~..~..~...~...~ - East South Central Kentucky Tennessee...~.~~.~...~...~~...~~.~.. Alabama.~~~..~~~...~.~~~~..~~.~~~..~~...~~...~. Msssspp West South Central Arkansss~~...~~~..~.~..~~.~.~...~~~.~...~..~~..-. Lousana...~..~...~..~.~...~...~~~..- Oklahoma..~...~...~...~~~~~...~~~~.. Terss ~ountan.~..~...~~~.~~~~...~...~...~~~.~..- - Montana...~...~..~...~~~~...~...- Idaho~~.~.~...~~.~~~~~.~.~~~~~~~..~.~~~ Wyomng...~~~.~~...~~.~~~~~.~...~...~.~.~~...~. Colorado...~...~...~.~.~~~~~~~...~.. New Mexco Arzona~.~.~...~...~...~~... Utah...~...~...~...~~..~..~~~.~...~~.. Nevsda.~...~.~...~..~~~~.~.~~...~~.~... Pacfc..~.~.~.~...~~...~...~~~... Washngton ~-... Oregon.~...~.~...~...~...~~~~...~. Calforna Alssks...~.~.~~~..~.~~~~...~..~.~...~~~...~~.. Hawa~...~...~~.~~.~ - Other jursdctons Amercan Samoa Guam...~..~.~...~~ Puerto Rco...~...~...~...~... VrgnIsIands.~.~...~.~~..~..~~..~~~~~.~~~~~ ,964 4,866 5, 3,75 53,495 7, 9, : : ,84 4,66,53,79 3y;; lo: , , , ,35 7 4,6 7 3, , ,774, ;;. ;:; ,683 3,863, 64, , , ,7 8 63, , , , , , , ,8 56, , ,46 6 4,93 6 3,8 3 9, , ,854 55, :: 67 37,96,764 3,695,7 4,8,3 8,47,38 3,86 3, : 8 36 :: 59 97,54,588,96 5,3 3,58 8,377 6,69 6,633,48, , ,4 4 6, 3,7 48 7,6 4 5, ,88 3 9, , , :: ; ,794 8,883,45 4,734 48,76 38,5 3,683,4,7 6,68 3,38 5,58 3,86,63 84 : :: , , , , ,z: a:, , General J I Psychatrc Beds 4 Sosptals Beds 4,,447 6, 798,5 95 : ,988 7,455 9,75 9,766 4,6 3, 3,46,4,444,8 3,5 5,69 3,6,63 96,49,795,65 7, 574,864 6, , a 6 Beds 379,799 3, ,4,85 6, , ,94 8,3 3,97 74,639,7 5,89 5,8 8,34,98 3,65 6,95,96,834,695.75,765 3,974 35,676,,35 6,75 45,66 3% 5, ,46 4, s C 3,96,4E 7lC 4,96E 6,854 5,97f 4 ( 3,z 6 6 8C ( 5,4 3,445 4, : 68,394 I,934 ( Hosptals Tuberculoss Beds 4 3,498, :: 3, ,894,47 63,46,7 494, , ,494 68:,456, 99,39 53,846 :, ' 95 4':, ' * Excludes approxmately 56 hosptals certfed for partcpaton, but not recorded n the provder record. Includes 4 Federal hosptals; excludes 7 Chrstan Scence sanatora. J Short-stay and long-stay hosptals. 4 Adult beds only; for psychatrc and tuberculoss nsttutons not accredted by the Jont Commsson on Accredtaton of Hosptals, only actve care beds are ncluded. BULLETIN, JANUARY 967 9

8 lems wth respect to medcal staff, pharmacy, nursng servces, detary arrangements, medcal records, and physcal envronment. State agences nre now n the process of assstng hosptals to upgrade ther facltes, staff, or servces so that ther cjefcences wll be reduced. Table gves the number of partcpatng hasptnls and beds by type of faclty, geographc dvson, and State. IMa are presented for the 6,56 hosptals that were recorded n the provder record as of September 3. The remanng 54 hosptals were certfed but not recorded because the data. were ncomplete. Data on number and type of hosptals do not agree wth those reported by the hmercan Hosptal Assocaton n ther :~nnual gude ssue j and by other agences for several reasons. As ndcated above, the group of hosptals partcpatng untler the Socal Securty Act excludes those delletl and those not applyng for certfcaton. The Amercan Hosptal,\ssoc:lton does not accept hosptals wth less than sx beds for regstraton; there s no such lmtaton for p:wtcl)at on under the cert fcaton rrqurements. In Lddt, the partcpatng hosl)tals nclude about general hosptals that are actually dst wt l>ll ts of psycllatrc and tuberculoss hosptals not accredted by tle *Jont (:onmsson on Accredtat on of Hosptals and represent the actve-care medcal lilt surgcal beds n these facltes. I some nstances, actve-care )sychntrc unts of tle same hosptals may also be c~ountetl here as )sychatrc hosptals. -t the same tme, :L nuber of medcal centers are counted ls oe losl)tll whle, n other cases, dfferent c olnponents of the medcal centers are c*ounted separately. Fnally, only adult-care beds are reported by sptlls l):~rtcpatng under the program. percent of the beds. Only 5 percent of the hosl)tnls and 3 percent of the beds are n partclxttng )sychatrc hosptals. The remanng percent of the hosptals and percent, of the beds are n tuberculoss hosptnls. Analyss of the hosptal data by type of control shons that the vast majorty of the general hos- )tnls are Ilongovernmentnl and manly under voluntary control. Of the 6, general hosptals )artcpatng under the program, 58 percent are voluntary hosptals and nclude 65 percent of the general llospttl beds. Beds n local government general hospt~ls consttute percent of the total (table ). As would be expected, the type of control n partcpatng psychatrc and tuberculoss hosptals s dfferent from that of general hosptals: 9 out of psychatrc hosptal beds and 6 out of tuberculoss hospttl beds are n State-oxned facltes. I artcpntng ~Sycllltrc and tuberculoss hosl tals also dffer from partcpatng general hosl)t:tls n terms of number of beds (table 3). The general llosptals are consderably smaller: about three-ffths hare fewer than becls, compared wth less than one-fourth for the psychatrc and tuberculoss losptals. More tllkll half the psychltr(h llosl)t>tls hare 5 beds or over. I Iosl)tal sze vares consderably wth type of TABLE.-Health nsurance for the aged: Kumber and percentage dstrbuton of partcpatng hosptals and beds, by type of control and type of hosptal, as of September 3, 966 HOSPITALS The 6,56 hosptals recorded as partcpatng nclude. mllon adult beds. General hosptals comprse 4 percent of the total and nclude 66 John TV. Cashman, Medcarc: Standards of Serccc n a NCUJ Program-Lccnsurc-Certfcaton--Bccrcdtaton, paper presented at the 94th Annual Meetng of the Amercan Publc Health Assocaton, San Francsco, Calforna, October 3, 966. Hosptals (Journal of the Amercan Hosptal Assocaton), Gude Issue, August, 966. Total. 6,56/ loo. loo. loo.. ~- States Local..., Voluntary.. 3,64 3, Propretary Total...., , states... 48,686 6,68353,464 3, Local ,444 9, Voluntary.. 5%;:;; 5::;;:; ;;;; l,;;;, 4::; 6;:; ;:$ ;:; Propretary. I / I I Includes 4 Federal hosptals; excludes 7 Chrstan Scence sanatora. Short-stay and long-stay hosptals. 3 Includes 4 Federal hosptals. 4 Adult beds only: for psychatrc and tuberculoss nsttutons not accredted by the Jont Commsson on Accredtaton of Hosptals, only actvecare beds are ncluded. SOCIAL SECURITY

9 TABLE 3.-Health nsurance for the aged: R umber and percentage dstrbuton of partcpatng hosptals, by sze and type of hosptal, as of September 3, Number of beds I I / Total General Number Psychatrc Total , Under l,e ,6?E 5 ~ ,75 : M &49x E 46 :: 5 and over Includes 4 Federal hosptals; excludes 7 Chrstan Scence sanatora. Tuberculoss : : Percentage dstrbuton ~? Short-stay and long-stay hosptals. Tuberculoss :: :; !: ; hosptal control (table 4). State hosptals are by ftr the largest, wth 43 percent n the 5-orover bed category. Ths category ncludes no propretary hosptals and only 4 percent and 3 percent, respectvely, of the local and voluntary hosptals. The smallest partcpatng hosptals are propretary, wth 86 percent havng fewer than beds and one-ffth wth fewer than 5. Local government hosptals are also relatvely small, wth nearly three-fourths n the less-thanloo-bed category. Home Health Agences About,4 home health agences are certfed for part,cpaton under the program. The provder record s stll ncomplete so that defntve data are avalable at ths tme only for,75 agences, whch are shown n table 5 by type of agency, geographc dvson, and State. Of the,75 agences, 579 or 45 percent are offcal health agences. Vstng nursng assocatons also represent a large proporton of the agences-about 4 percent. Of the total agences, combnaton government and voluntary agences comprse 7 percent, hosptal-based programs comprse 6 percent, and the remanng agences, classfed as other, percent. Home health agences must provde sklled nursng servces and at least one other therapeutc servce. The followng tabulaton summarzes the number of agences otl erng specfed therapeutc servces. Type of servce Agences offerng servce Number Percent Physcal therapy Occupatonal therapy Speech therapy ~...~.--~~~---..-~~ Medcal socal servce Home health ade npatent Hosptal Clams Approved for Payment Data relatng to npatent hosptal clams for the frst, 3 months of the program, approved for I TABLE 4.-Health nsurance for the aged: Number and percentage dstrbuton of partcpatng hosptals, by- sze and type of control, as of September 3, 966 Total... Number of beds Under W9...~...~.~.~~~~~...~ M ~...~~~..~~~~~~ -99~...~~...~~...~~~ ~399...~..~.~~...~~~...~ 4o(t and over Total ,56.6, :z Number Percentage dstrbuton state Local Voluntary Propretary Total State Local Voluntary -~ - ~ - Propretary ,64 97 loo... loo ~ E :: s :: ! : :! Includes 4 Federal hosptals; excludes 7 Chrstan Scence ssnatora. * Includes 4 Federal hosptals. BULLETIN, JANUARY 967

10 payment as of October 5, 966, are presented n rembursed by the hosptal nsurance program, as table 6. Expendtures by the hosptal nsurance sl~own n table 6, does not concde wth the trust fund are reported elsewhere n ths ssue of amount for trust fund expendtures reported by the HULLETIN (table M-5, page 36). The amount the Treasury Department for the perod. There TABLE 5.-Health nsurance for the aged: Number of partcpatng home health agences, by type of agency, geographc dvson, and State, as of October 5, 966 Geographc dvson and State! Total New England Msne...~.~...~...~.~~~...~.~~.~...~~.~...~~~...~~~~...~~~~...~~~....- New Hampshre...~~~~.~..~~.~~...~~~~...~.~.~.~.~...~~~~...~~...~~~... Vermont Massachusetts RhodeIsland*.~..~...~...~~~...~~...~~...~~~...~~~~...- Connectcut...~~~~...~.~...~~~~...~.~~...~~~...~~...~..~..~~... MddleAtlantc...~~...~...~~~~...~...~... New York ~ I NewJersey~~~...~...~...~~...~.~...~~~~...~~... Pennsylvana~...~..~~~...~.~...~~~~...~...~.~~...~~.~...~...~~... East North Central ~ ~ Oho Indana...~...~~~~...~...~~~~...~~~...~~.~..~.~~~~...~...~~... Illnos...~...~.~~~~...~.~..~~..~~...~.~~...~.~...~~~~... Mchgsn Wsconsn...~...~~~...~~~~~...~~.~..~~~~...~~...~~...~~ - 77 AIHSKa~..-.~-.~~.~.~~~~.~~~~-~..~.~~~~~.~.~~~~.~.-..~~~..-~~~..---~.~--.-.~... Hawa I Other Amercan Samoa Guarn ~.~.~.~...~~~~~~.-~~~~~-~~.~~.~~~~~..--~~.-.-..~ ~--..- Puerto Rco VrgnIslands~..--~...~...~~~~~..-~~~~~.-~~~-~-~~~..-~~~~~~~~~~.~~~~~.~~~~.~~~. Excludes about 5 home health agences certfed for partcpaton but not recorded n the provder record. For these States, approved applcatons submtted by the State Health : 97 : ; : : k 33.- * - Vstng nurse rssocaton : : : 8 : : :.. - Combnaton gowrlment and voluntary *gc?iey a ; 5 8 ; :. 9 ; Offcal health agency ; ; 9 3 Y : 8 ; IIFo&al program Other 8 6 t.!! 6 : -.- Department nclude 4-5 local (mostly county) departments. Informaton dentfyng each of these local subunts s currently beng collected. SOCIAL SECURITY

11 TABLE 6.-Hosptal nsurance: Number of clams approved for pavment, days of npatent hosptal care, and amount of payments, by month of clam approval and type of hosptal, as of October 5, 966 I I Approved clams I Rembursed by hosptal nsurance --- Total Month of clam approval * Days of care hosptal -- charges (n Amount Percent Number thousands) (n of total Per Per Total Average thousands) charges * clam day per clam Total npatent hosptal servces 3 -- I I I I I -- I I - Short-stay hosptals 4 Total I 384,48 / I 65,7 8, July August September ~ Long-stay hosptals 5 Total , /,854 /,667 / 89.9 / 59 6 Month n whch the ntermedary approved the clam for payment. Based on unrounded fgures. s Includes 6 clams wth type of hosptal unknown. General and specal hosptals wth average stays of less then 3 days. 5 General and specal hosptals wth average stays of 3 days or over; tuberculoss, psychatrc, and chronc dsease hosptals; and Chrstan Scence ssntors. NOTE: Includes only those clams approved and recorded n the Socal Securty Admnstraton central utlzaton record before October 5, 966. are several reasons for ths dfference. Trust fund expendtures nclude-n addton to blls pad by ntermedares-current fnancng and emergency payments. Current fnancng s an optonal fnancal arrangement for rembursement to provders to pay on a current, bass for hosptal servces ncurred by benefcares. Computaton for current fnancng payments s made quarterly and s based on provder operaton experence for the last month of the precedng quarter. Intermedares may dsburse current fnancng payments up to the amount arrved at through these quarterly computatons. Emergency payments represent specal advancements to provders to cover cost of servces actually provded but for whch blls had not yet been processed by the ntermedary. When the system has been n operaton for a tme, such advances should no longer be necessary. In addton, the data reported n table 6 are based on the month n whch the clam s approved by the ntermedary and subsequently recorded n the Socal Securty Admnstraton central utlzaton record, There s a short lag between the tme that the clam s approved and the tme of actual payment to the provder of servce. Furthermore, not all the clams for the frst 3 months had been receved and recorded n the statstcal tape record as of the tme of summarzaton of the data. Corrected fgures wll be publshed Inter. The followng tabulaton compares the monthly amounts reported for trust fund expendtures and for clams approved as of October 5, 966, under the hosptal nsurance program. Month, 966 [In thousands] Inpatent hosptal clams approved for payment Total I $7,389 / $3.86 July August September ,49 7,53 5,46 Data from table M-5, page 36 of ths ssue. *Amounts recorded n Socal Securty Admnstraton central utlzaton record, as of Oct. 5, 966. Days of care as well as total charges and rembursement data are reported n table 6. For the BULLETIN, JANUARY 967 3

12 frst quarter of the fscal year 96 7, 387,43 npatent hosptal clams had been reported by October 5, 966, as approved for payment by the ntermedary. Almost all of these clams (99 percent) are for rembursement, for care n short-stay hosptals. As would be expected, the average number of days per short-stay hosptal clam s consderably less than n the long-stay hospt,als :.3 days compared wth 3. days n long-stay hosptals (general and specal hosptals wth average stays of 3 days or over; tuberculoss, psychatrc, and chronc dsease hosptals ; and Chrstan Scence santora). As the program contnues, average hosptal stays wll undoubtedly be greater because the clams presented here are only for the frst quarter of the program s operaton-a perod not long enough to reflect many long stays. Total charges for the 387,43 clams amounted to approxmately $67 mllon. Almost fourffths-78 percent-of the total hosptal charges were pad by the hosptal nsurance program. The deductbles and noncovered tems on the bll account for dfferences between total charges and rembursed amounts. The actual amounts rembursed to hosptals are based on nterm per dem rates that wll be adjusted n the future on the bass of actual reasonable costs. The rembursed amount per clam averaged $334 n short-stay hosptals and almost twce that amount n long-stay hosptals because of the consderably longer stays n the latter. Total charges averaged $9 per day n long-stay hosptals, compared wth $4 per day n short-stay hosptals. Because rembursement by the hosptal nsurance program was only for npatent care begnnng July, average stays per clam approved n the program s frst month were consderably shorter than for the next months. For example, the average length of stay n short-stay general hosptals was only 6.7 days n July, compared wth. days n August and.7 days n September. Average stays n long-stay hosptals n each of the 3 months reported show a smlar pattern. July clams obvously ncluded a consderable number of stays for aged persons who were n hosptals on July, and August clams also ncluded some who were admtted before the effectve date of the program. The small number of npatent hosptal clams for the month of July-B.5 percent of the 3-month total-reflects the delays n transmttal of forms and clams at the begnnng of the program rather than a small number of aged persons recevng npatent hosptal care durng the month. Lkewse, clams approved n September and recorded n the Socal Securty Admnstraton tape record as of October 5 are 4 percent below the number for August because of the lags n reportng and recordng the data. These data wll be updated and revsed each month and more complete nformaton for the earler months wll be reported n future ssues of the BULLETIN. Analytcal Studes In addton to provdng basc data on program operatons on a recurrent bass, the statstcal system has been desgned to provde the bass for a varet,y of analytcal studes to evaluate the program and measure ts performance. These studes wll be concerned wth assessment of program operaton and achevements n terms of the program goals: to protect the aged person aganst the catastrophc costs of hosptalzaton and llness and to provde qualt,y hosptal and medcal care n the most, effcent and economcal manner. The statstcal system has been desgned to make possble studes to analyze the utlzaton experence n relaton to the demographc data avalable from the elgblt,y records, to the charges and costs of provders, and to carrer operatons. Such studes wll provde the knowledge necessary for apprasng the program? attanment of ts purposes and for determnng the need for legslatve changes to facltate effectve operaton. These studes can be categorzed n three man groups: utlzaton and costs of health servces, effectveness of admnstraton, and questons relatng to specfc provsons of the law. Several examples of the type of analytcal studes to be undertaken are sketched below. STUDIES OF UTILIZATION AND COSTS OF HEALTH SERVICES The avalablty of a populaton base permts the calculaton and presentaton of a wde varety of utlzaton rates for populaton subgroups. In addton to the utlzaton data, the basc statstcs 4 SOCIAL SECURITY

13 nclude data on total and covered charges for the varous types of servces. The potentaltes for combnng and cross-classfyng utlzaton data by characterstcs of benefcares and provders of servces open new vstas for analyss and study of varatons n patterns of use for hosptal and medcal servces and the factors affectng such varaton, ncludng geographc and certan demographc dfferences. The avalablty of statstcal data on utlzaton of hosptal and medcal servces for each ndvdual benefcary provdes the opportunty for longtudnal studes of the patterns of covered servces receved by ndvduals over a perod of tme. Use of servces by specfc groups of ndvduals, begnnng at age 65 (or the start of the program), can be followed and studed n terms of the characterstcs of the benefcares and the t.ype and extent of servces receved. A te-n wth the basc record system of the Socal Securty Admnstraton wll make possble a unque opportunty for analyss of the medcal hstory after age 65 n relaton to the person s work hstory n covered employment, age at. retrement, and beneft status. The consderable fund of data relatng to the characterstcs of the provders of servce, ther rembursement rates, and the utlzat,on of ther servces provdes the bass for a varety of studes. Geographc dfferences n rembursement rates wll be analyzed n terms of the provders and the servces provded. Studes wll be undertaken to determne where benefcares n a gven geographc area receve ther medcal servces and where hosptalzed persons come from. STUDIES OF EFFECTIVENESS OF ADMINISTRATION The central statstcal system wll provde the data requred for a varety of studes of the program s admnstraton. Under the hosptal nsurance plan each group of provders, or assocaton of provders n behalf of ther members, has nomnated a natonal, State, or other publc or prvate agency or organzat,on to serve as fscal ntermedares between themselves and the Federal Government. The ntermedary determnes the amount of payments due on recept of blls from hosptals and other nsttutonal provders and makes such payments. Studes wll be undertaken to analyze the operatons of the ntermedares wth respect, to the effectlve operaton of the program. Dfferences among carrers n ther operatng costs, methods of payments, procedures for clams revew, bllng lags, and other admnstratve responsbltes wll be revewed and analyzed n detal. Where payment s OII the bass of charges for physcan servces and medcal and other health servces, the ntermedares or carrers are to take acton to assure that the charge on whch the rembursement s based s reasonable and not hgher than the charge used for rembursement n behalf of the carrers own polcyholders or subscrbers under comparable crcumstances. In determnng reasonable charges, the carrers are to consder the customary charges for servces generally made by the physcan furnshng the covered servces, as well as prevalng charges n the localty for smlar servces. Analyss wll be made of the geographc varaton n actual charges for physcan servces for comparable procedures n relaton to ther characterstcs and those of benefcares. The studes wll gve some clues on the extent to whch the carrers are effectvely carryng out ths mportant functon. Hosptals and extended-care facltes partcpatng n the hosptal nsurance program must have a utlzaton revew plan n effect, provdng for revew, on a sample or other bass, of the followng : admssons of benefcares of the hosptal nsurance program to the nsttuton, length of stays, and the medcal necessty for servces provded. Statstcal studes analyzng the varat ons n nsttutonal stays for comparable dagnostc categores n terms of geographc locaton and types of nsttuton wll assst n evaluaton of the utlzaton revew process. STUDIES RELATING TO SPECIFIC PROVISIONS The 965 amendments to the Socal Securty Act nclude several specal provsons embodyng unque concepts n health nsurance programs, the effects of whch wll be studed and analyzed. For example, npatent hosptal and extended-care servces wthn specfed lmtatons are provded under the law for each spell of llness. The term spell of llness s defned as begnnng the frst day (not n a prevous spell of llness) n whch an ndvdual s furnshed covered npatent hosptal or extended-care servces and endng wth the BULLETIN, JANUARY 967 5

14 last day of the frst perod of 6 consecutve days durng whch he was not an npatent n a hosptal or extended-care faclty. Studes of the mpact. of ths requrement wll be made n terms of the average duraton of spells of llness, number of benefcares who exhaust benefts durng sngle spells of llness, average duraton of tme between exhauston of benefts and begnnng of a new spell of llness, and the proporton of total costs of care n hosptals not covered because of the spell-of-llness concept. Payments to provders of servce under the hosptal nsurance program are made on the bass of reasonable costs for the servces furnshed. The costs of servces n hosptals and extendedcare facltes vary wdely from one nsttuton to another, reflectng dfferences n qualty and ntensty of care. Rembursement rates and the method for determnng reasonable costs wll be analyzed n terms of geographc varatons, type of facltes, and servces provded. One of the condtons of partcpaton for an extended-care faclty s that t, must have a transfer agreement, wth at least. one partcpatng hosptal (except under specal crcumstances). A transfer agreement, s one that provdes, n wrtng, for the transfer whenever such acton s medcally approprate, as determned by the attendng physcans. Analyss wll be made of the varous types of transfer agreements, the mplementaton of ths requrement, on a geographc bass, and ts effect on patterns of care receved under the program. There s a lfetme lmt of 9 days of covered servces n psychatrc hosptals. Psychatrc care n general hosptals, however, does not count aganst the 9day lfetme lmt. Statstcal study wll be undertaken to determne the number of persons who exhaust these benefts, the number and extent of psychatrc servces n general hosptals, and emergng trends n ths area. REPORTING PLANS Many of the analytcal studes descrbed above cannot of course be carred out untl the health nsurance program for the aged has been n operaton for some tme. On the extent of servces alla on charges, the Current, Medcare Survey s desgned to yeld program data on a natonal bass n advance of the detal to be obtaned from the record. Current plans for reportng these survey data as well as basc data on program operatons nclude publcaton of monthly, quarterly, and annual data n the BULLETIN and n specal releases and reports by the Offce of Research and Statstcs as the data become avalable and the studes are completed. The need for statstcal data by agences, organzatons, alla researchers outsde the Socal Securty Admnstraton wll also be taken nto account n our tabulaton plans. In reportng all program data, the Socal Securty Mmnstraton s general polcy relatng to confdentalty wll be contnued. Informaton wll not be released dentfyng ndvdual benefcares and ther specfc utlzaton of servces under the program. The health nsurance program for the aged wll have a sgnfcant mpact on the entre structure of the organzaton and fnancng of health servces n the country n addton to ts mpact on the ablty of the aged ndvdual benefcary to meet the costs of needed hosptal and medcal care. The broad scope of benefts affectng ths large populaton group and the fnancng of these benefts wll requre substantal adjustments n the entre system of health servces, nvolvng not only the aged benefcary but the remander of the populaton. In addton to the analytcal studes outlned above, a broad research program wll be undertaken to measure the mpacts on both publc tlla prvate programs, dentfy and defne program gaps and unmet needs, and examne and evaluate the economc consequences of the program. SOCIAL SECURITY