Access to Health Care Services for the Disabled Elderly

Elderly individualswith limitations in activities of daily living are likely to have more need for health care services compared with persons without such limitations, both because of the direct effects of such limitations as well as the underlying medical conditions that cause them (Neri and Kroll 2003). However, mobility limitations in particular might increase the need for medical care while hindering a person's ability to access such care. Any barrier to the full range of needed medical care could be expected to have negative consequences on the health and level of functioning of elderly persons, and could also lead to increased downstream health care costs. The Medicare program finances health care services for the vast majority of persons age 65 and older in the United States, including many persons with severe activity limitations. Medicare covers outpatient physician and hospital services as well as other care that is especially relevant for the treatment of such persons. For example, home health benefits cover nursing and rehabilitative care, physician visits, and physician oversight of the home health services, and may be more readily accessible to those with difficulties than is outpatient care for which patients must travel (Centers for Medicare and Medicaid Services 2004). However, few physicians visit the home, some office-based services cannot be provided in the home (e.g., radiographs), and the ability to provide oversight for home-based care is limited if the patient cannot be seen and examined. In addition, Medicare finances the purchase of assistive technology devices to aid with disability through its durable medical equipment (DME) benefit. Identifying the appropriate mix of ambulatory, home health, and DME services to be used by elderly beneficiaries with activity limitations may both improve quality of life as well as reduce downstream health care costs. However, some Medicare coverage and payment policies may undermine access to a full range of medical care for disabled beneficiaries. For example, Medicare coverage is limited to DME used in the home, and multiple items for the same condition are not covered (e.g., walker and wheelchair), and long-stay nursing homes are not covered (Palmetto GBA 2003; Centers for Medicare and Medicaid Services 2003a). Thus, Medicare typically would not pay for a wheelchair if the patient could walk in the home with a walker, but needed a wheelchair for accessing their physician's office. Dilemmas such as this have led patient advocacy groups to call for changes in Medicare DME regulations (Bristo et al. 2000; Consortium for Citizens with Disability 2001). Persons with activity limitations report barriers to receiving needed physician services (Iezzoni 2002) and have unmet health needs (Iezzoni et al. 2000). Physically disabled Medicare beneficiaries are more likely to be dissatisfied with their health care (Jha et al. 2002). Yet, disabled adults (persons age 18+) account for 46 percent of total health care expenditures, and they have per capita health care expenditures that are nearly six times greater than nondisabled adults (DeJong et al. 2002). Past studies of health care utilization by persons with limitations typically have controlled for severity or underlying and/or comorbid illnesses in different ways (Chan et al. 2002; DeJong et al. 2002). Thus, it is unclear whether the additional expenditures among these persons are appropriate given their concomitant illness/disability burden. This paper addresses the effect of difficulty walking indoors and the compensatory strategy used for such difficulties on downstream health care use financed by the Medicare program. Specifically we answered the following three questions: (1) Does increased difficulty walking increase downstream health care use after accounting for overall disease burden and health conditions that could contribute to such difficulty? (2) Does the compensatory strategy (use of equipment versus personal assistance) used to address activity limitations affect downstream health care use after accounting for overall disease burden and health conditions that could contribute to such difficulty? (3) Does use of a compensatory strategy that fully compensates for the underlying mobility limitation result in lower downstream health care use after accounting for overall disease burden and health conditions that could contribute to such difficulty? This study takes advantage of the fact that walking difficulty and compensatory strategy used for walking were measured separately at the 1999 National Long Term Care Survey (NLTCS), and downstream use of Medicare-financed services were measured through year end 2000 using Medicare claims. We conclude by discussing implications for Medicare.