July 2004<\/span><\/p>\n The United States has the world’s most expensive healthcare system. <\/span>In 2002, health spending rose to nearly 15 percent of U.S. Gross Domestic Product. Healthcare policymakers charged with balancing cost containment with quality healthcare for consumers are desperate for solutions (Levit, Smith, Cowan, Sensenig, and Catlin, 2004). <\/strong><\/span><\/p>\n Background:<\/strong> Across the U.S. as Medicaid enrollments rise, states struggle with the increasing drain on their budgets; 45 states have now instituted measures to control growth in Medicaid spending (Kaiser Commission on Medicaid and the Underserved, 2002). From 1995 to 1999, Medicaid spending rose by 6.5 percent per year. In 2001 it increased by 10.2 percent, and in 2002 by 11.7 percent. Clearly, states desperately need solutions.<\/p>\n Medicaid is an entitlement program, but each state determines who is eligible based on income and characteristics (people with disabilities, families with children, etc.). In 1980, 33.6% of Medicaid spending went for beneficiaries with disabilities. By 2000, the 17.6% of Medicaid beneficiaries with disabilities accounted for 45.1% of Medicaid spending (Centers for Medicare and Medicaid Services, 2004). In just 20 years, the share of Medicaid spending for people with disabilities grew by 11.5%. Part of this may be attributable to their increased risk for secondary conditions, including expensive medical complications such as pressure ulcers and heart disease (Coyle, Santiago, Shank, Ma, & Boyd, 2000; Seekins, Clay & Ravesloot, 1994).<\/strong><\/p>\n As part of a national health promotion movement for all people with disability, the Centers for Disease Control and Prevention (CDC) support our program of research, development, and services. Researchers at The University of Montana RTC: Rural and at the University of Kansas RTC\/IL have developed and evaluated the Living Well with a Disability<\/em> program, a health promotion program for adults with physical disabilities.<\/p>\n Based on independent living philosophy and rural traditions of self-care, Living Well<\/em> is an eight-week workshop which introduces a goal-setting and goal clarification process, and teaches problem-solving skills. Living Well<\/em> also provides tools for managing health and making healthy lifestyle changes, increasing physical activity, developing and maintaining healthy relationships, improving nutrition, avoiding depression and frustration, and advocating for community changes that help maintain gains. Living Well<\/em> improves participants’ health and reduces medical care costs over 12 months (Research Progress Reports #6<\/a> and #7<\/a>).<\/p>\n The goal of this current research was to examine the effects of the Living Well with a Disability<\/em> program on the cost of providing healthcare to Medicaid beneficiaries. <\/strong><\/p>\n Research Process:<\/strong> Nine centers for independent living in eight states recruited a convenience sample of 122 adult Medicaid recipients with mobility impairments to attend a two-hour Living Well<\/em> session each week for eight weeks. Of the recruits, 103 completed a pre-measure and at least one post-measure and 78 completed pre-, post-, 2-, and 4-month follow-up surveys. Our previous research included a 12-month follow-up survey, but the current study’s sample was too small for a 12-month analysis. We used a staggered baseline experimental design with random assignment to treatment start date. We also used an extended baseline measure collected two months before the intervention to assess the study’s internal validity.<\/p>\n Respondents used the Secondary Condition Surveillance Instrument<\/em> (Seekins, Clay, McCleary & Walsh, 1990) to rate the severity of limitation they experienced from each of 43 secondary conditions. To estimate respondents’ healthcare costs, we used a 2-month retrospective recall of their physician and emergency room visits, outpatient surgeries and hospital days. We multiplied these utilization data by unit Medicare cost estimates to generate medical costs which were depreciated by 30% to estimate Medicaid costs.<\/strong><\/p>\n Results:<\/strong> Participants reported striking reductions in their limitation from secondary conditions over the intervention period. These were maintained at the two- and four-month follow-up (Figure 1), and were consistent with previous reports on the effectiveness of the Living Well with a Disability<\/em> program. Participants’ average secondary condition ratings decreased by 25% between the pre- and the 4-month post-measure. Analysis of the extended baseline data supported the internal validity. No evident change over the baseline period was followed by substantial and statistically significant change during the intervention period.<\/p>\n <\/p>\n <\/a>Figure 1.<\/strong> Description of Figure 1<\/a><\/p>\n <\/p>\n Secondary Condition Severity Rating<\/span><\/strong><\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/a>Healthcare cost outcomes were very positively skewed, precluding the use of parametric statistics. Table 1 includes quartiles and mean for per person\u00a0 healthcare costs at pre-, post-, 2-month and 4-month post period. The Friedman non-parametric repeated measures test was not significant ( 2 3 = 3.71, p = .29), indicating that the change over time was no different than that expected by chance. <\/strong><\/span><\/p>\n In order to increase the sample size and statistical power of the significance test, we also conducted the Wilcoxon paired samples test for the pre- and post-test. This indicated statistically significant change (Wilcoxon Z = 2.82, p = .005) in healthcare costs over the pre- to post-intervention period.<\/p>\n <\/p>\n <\/a>Table 1: Per-Person Healthcare Cost Quartiles for Each Measurement Period<\/strong> Description of Table 1<\/a><\/p>\n![\"Figure](\"..\/..\/images\/Medicaid%20Figure.png\")
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