Michalopoulos, C., Wittenburg, D., Israel, D., Schore, J., Warren, A., Zutshi, A., Freedman, S., & Schwartz, L. (2011). The Accelerated Benefits Demonstration and Evaluation project: Impacts on health and employment at twelve months, volume 1. New York: MDRC.
- This report presented an interim implementation and impact analysis on the Accelerated Benefits Demonstration (ABD), an effort to provide immediate health insurance and employment and benefits counseling to new, uninsured Social Security Disability Insurance (SSDI) recipients during the 24-month Medicare eligibility waiting period. This profile focused on the implementation analysis.
- The study examined implementation of ABD in 53 qualifying U.S. metropolitan areas, focusing on service delivery and use, and challenges and solutions to implementation. The authors conducted qualitative analysis of interviews with program staff, discussions from regular team meetings, and a document review, along with quantitative analysis of health plan claims and service use data from the AB Plus management information system.
- Overall, the study found that almost all program group members used the AB health plan. Most members of the AB Plus group, which had access to additional programming, completed intake and a substantial proportion used services. Under the AB Plus plan, the behavioral motivational coaching and employment and benefits counseling were largely implemented as designed, but the intake process and medical case management were refined over time.
- Because of limitations in the study’s discussion of its research methods, it is unclear whether findings are potentially applicable to other projects that provide employment-related services to people with disabilities.
Accelerated Benefits Demonstration
Features of the Intervention
Almost all new SSDI recipients must wait 24 months after their SSDI eligibility date to be eligible for Medicare benefits. Some SSDI recipients have no health insurance during this Medicare waiting period. The ABD provided health insurance to new, uninsured SSDI recipients (that is, no concurrent Supplemental Security Income/SSDI recipients), ages 18 to 54, who had at least 18 months to wait before Medicare eligibility.
For the demonstration, 1,997 volunteers living in 53 qualifying U.S. metropolitan areas were randomly assigned to receive either AB, AB Plus, or no additional services (that is, control). AB and AB Plus members received immediate health insurance with greater benefits coverage, lower copayments, and a more comprehensive provider network than Medicare. AB Plus members were also eligible for three voluntary services delivered by telephone: a behavioral health motivation program, employment and public assistance benefits counseling, and medical case management.
Expected effects of ABD included increased health care use; reduced reported unmet medical needs and out-of-pocket medical expenses; increased short-term employment, use of employment supports, and use of vocational rehabilitation services to return to work; improved health and functioning; and ultimately, increased employment and reduced SSDI payments. POMCO, a third-party benefits administrator, administered the health plan, and Medco, a pharmacy benefits manager, administered prescription drug claims. Coaches and nurses from CareGuide, a national disease management company, delivered the coaching and medical case management under the AB Plus program. Counselors from TransCen, which specializes in employment and benefits counseling for people with disabilities, administered this counseling under the program.
Features of the Study
The implementation portion of the study sought to describe the first year of ABD implementation. The study described major aspects of implementation, including the target population, inputs and resources, service delivery, and participants’ characteristics. The study drew on program documents; telephone interviews with program staff and minutes from regular team meetings held among program staff, advisors, and the study team; service provision data from the program’s management information system, and baseline and 12-month follow-up surveys of participants. The study was conducted from October 2007 through July 2010, with interviews occurring in 2008 and 2010.
The implementation analysis found that service use was high: almost all those randomly assigned to the AB or AB Plus groups used the AB health plan during the year after random assignment. Almost 90 percent had at least one paid claim and very few members disenrolled. Total claims for the AB health plan in its first year were nearly $19.5 million, with average total claims of $19,265. Those who reported being in poor health at enrollment had higher claim payments than those who reported being in fair or better health (average expenditures were $21,402 and $17,377, respectively). Those with primary diagnoses of neoplasm (usually related to a form of cancer) had higher claim payments than those without that diagnosis (average expenditures were $39,697 and $17,072, respectively)
For AB Plus, two-thirds of participants used at least one of the three voluntary services offered during the year after random assignment: about 36 percent participated in coaching, 42 percent in case management, 35 percent in counseling, and more than 10 percent participated in all three services.
The AB Plus program faced several challenges in delivering the three voluntary services to participants and, as a result, modified the service delivery approach over the course of implementation.
- Intake process. The intake process for AB Plus involved a formal medical assessment to identify barriers, including mental health disorders, and target services appropriately, including referrals to medical case management. Staff felt that this discouraged participants, so they began gathering this information through several telephone calls instead.
- Coaching and benefits counseling. As time went on, AB Plus was redesigned to focus more at overcoming short-term health barriers to starting coaching, and to help group members reintegrate into physical, social, and occupational activities. Coaches and benefits counselors had flexibility to adapt the delivery and duration of their modules and lessons. However, low literacy made it difficult for some participants to self-administer assessments and respond to writing assignments. Coaches or counselors would administer assignments, but this was time-consuming and not always appropriate for the lessons.
- Maintaining contact. Not all participants contacted employment counselors after a referral, so staff initiated a warm transfer process to encourage contact. Overall, considerable resources were used to maintain contact with participants.
- Case management. The program group had a wider range of diagnoses and limitations than participants in previous demonstrations, making it difficult to apply a standard approach to case management. As a result, nurses and coaches tailored case management to focus on addressing specific short-term barriers to starting behavioral motivational coaching.
- Other barriers. Some AB Plus participants had serious financial problems and needed assistance for basic purchases, such as food and shelter, or help with managing debt. These needs had to be met before participants would consider taking part in AB Plus services, so staff shared financial assistance resources with them.
Considerations for Interpreting the Findings
The study clearly identified the research questions and explored an array of data sources to explore them. The study included a systematic description of findings, which were supported by qualitative data, and quantitative claims and service use data. However, the study would have benefited from including a more thorough description of its respondent sources, data collection techniques, analysis methods, and data quality control techniques. Also, the study did not interview program group participants, which would have been a relevant source for triangulating findings. Given the lack of description of study methods, the study findings might not apply to other health care plan and return-to-work programs for SSDI beneficiaries and people with disabilities.