Expanding Access to Health Care for Social Security Disability Insurance Beneficiaries: Early Findings from the Accelerated Benefits Demonstration

by Robert Weathers, Chris Silanskis, Michelle Stegman, John Jones, and Susan Kalasunas
Social Security Bulletin, Vol. 70 No. 4, 2010

Text description for Chart 1.
Anticipated flow of outcomes in Accelerated Benefits (AB) and AB Plus study groups

Chart 1 is a flow chart with fifteen labeled boxes linked by arrows. There are four starting points in the flow chart. The flow is one-directional; that is, none of the arrows point back to a previous box, although some arrows laterally connect boxes that descend from different starting points. The flows are divided into four distinct panels labeled intervention, direct outcomes, mediating outcomes, and ultimate outcomes.

The starting points represent benefits or services provided to members of the two treatment groups in the Advanced Benefits (AB) demonstration project. The treatment groups are AB Health Care benefits and AB Plus services. The AB Health Care benefits package represents one starting point. The other three starting points comprise the three distinct services provided under AB Plus.

The flows originating with each starting point are presented as lists.

Starting point A

  1. Intervention: AB Health Care benefits.
  2. Direct outcome: Access to care. Would reduce beneficiaries' health care expenditures, increase visits to providers, and reduce unmet medical needs.
  3. Direct outcome: Better care. Both preventive general care and condition-specific care would improve.
  4. Direct outcome: Improved self-care involving diet, exercise, and adherence to treatment and medication regimes.
  5. Mediating outcome: Functional effects. Would improve beneficiaries' self-reported health status and ability to perform ordinary and instrumental activities of daily living and would reduce work limitations and depression.
  6. Mediating outcome: Use of work supports such as Ticket to Work and state vocational rehabilitation agencies.
  7. Mediating outcome: Short-term employment and earnings.
  8. Ultimate outcome: Long-term employment and earnings. Beneficiary completes trial work period and meets substantial gainful activity criteria.
  9. Ultimate outcome: Reduced Disability Insurance (DI) benefit payments.
  10. Ultimate outcome: Reduced reliance on Medicare and Medicaid.

Starting point B

  1. Intervention: AB Plus services, Medical care management (MCM). Identifies beneficiaries' unmet needs, makes referrals, and monitors treatment.
  2. Direct outcome: Better care. Both preventive general care and condition-specific care would improve.
  3. Direct outcome: Improved self-care involving diet, exercise, and adherence to treatment and medication regimes.
  4. Mediating outcome: Functional effects. Would improve beneficiaries' self-reported health status and ability to perform ordinary and instrumental activities of daily living and would reduce work limitations and depression.
  5. Mediating outcome: Use of work supports such as Ticket to Work and state vocational rehabilitation agencies.
  6. Mediating outcome: Short-term employment and earnings.
  7. Ultimate outcome: Long-term employment and earnings. Beneficiary completes trial work period and meets substantial gainful activity criteria.
  8. Ultimate outcome: Reduced Disability Insurance (DI) benefit payments.
  9. Ultimate outcome: Reduced reliance on Medicare and Medicaid.

Starting point C

  1. Intervention: AB Plus services, Progressive Goal Attainment Program (PGAP). Encourages beneficiaries to increase activity and overcome barriers to behavioral change.
  2. Direct outcome: Change in perception of disability. Would reduce psychosocial barriers to the rehabilitation process and promote reintegration of life roles.
  3. Direct outcome: Improved self-care—involving diet, exercise, and adherence to treatment and medication regimes.
  4. Direct outcome: Better care. Both preventive general care and condition-specific care would improve.
  5. Mediating outcome: Functional effects. Would improve beneficiaries' self-reported health status and ability to perform ordinary and instrumental activities of daily living and would reduce work limitations and depression.
  6. Mediating outcome: Use of work supports—such as Ticket to Work and state vocational rehabilitation agencies.
  7. Mediating outcome: Short-term employment and earnings.
  8. Ultimate outcome: Long-term employment and earnings. Beneficiary completes trial work period and meets substantial gainful activity criteria.
  9. Ultimate outcome: Reduced Disability Insurance (DI) benefit payments.
  10. Ultimate outcome: Reduced reliance on Medicare and Medicaid.

Starting point D

  1. Intervention: AB Plus services, employment and benefits counseling (EBC). Provides information on benefits, local employment supports, career counseling, and job search assistance.
  2. Mediating outcome: Use of work supports—such as Ticket to Work and state vocational rehabilitation agencies.
  3. Mediating outcome: Short-term employment and earnings.
  4. Ultimate outcome: Long-term employment and earnings. Beneficiary completes trial work period and meets substantial gainful activity criteria.
  5. Ultimate outcome: Reduced Disability Insurance (DI) benefit payments.
  6. Ultimate outcome: Reduced reliance on Medicare and Medicaid.

Text description for Chart 2.
Accelerated Benefits study Phase 2 sites

Atlanta, Georgia
Austin, Texas
Baltimore, Maryland
Birmingham, Alabama
Boston, Massachusetts-New Hampshire
Buffalo, New York
Charlotte, North Carolina-South Carolina
Chicago, Illinois
Cincinnati, Ohio-Kentucky-Indiana
Cleveland, Ohio
Columbus, Ohio
Dallas, Texas
Denver, Colorado
Detroit, Michigan
Fort Lauderdale, Florida
Fort Worth, Texas
Grand Rapids, Michigan
Greensboro, North Carolina
Hartford, Connecticut
Houston, Texas
Indianapolis, Indiana
Jacksonville, Florida
Kansas City, Missouri-Kansas
Las Vegas, Nevada-Arizona
Los Angeles, California
Louisville, Kentucky-Indiana
Miami, Florida
Milwaukee, Wisconsin
Minneapolis, Minnesota-Wisconsin
Nassau-Suffolk, New York
Newark, New Jersey
New Orleans, Louisiana New York, New York
Norfolk, Virginia-North Carolina
Oakland, California
Oklahoma City, Oklahoma
Orlando, Florida
Orange County, California
Philadelphia, Pennsylvania-New Jersey
Phoenix, Arizona
Pittsburgh, Pennsylvania
Portland, Oregon-Washington
Providence, Rhode Island-Massachusetts
Richmond, Virginia
Riverside, California
Rochester, New York
Sacramento, California
San Antonio, Texas
San Diego, California
Seattle, Washington
St. Louis, Missouri-Illinois
Tampa, Florida
Washington DC area

Text description for Chart 3.
Accelerated Benefits (AB) study population selection

Chart 3 is a flow chart with thirteen labeled boxes linked by arrows. The flow is one-directional; that is, none of the arrows point back to a previous box.

The chart presents the seven-level process of selecting the population that ultimately participated in the Advanced Benefits (AB) demonstration project. Each box represents a population subgroup and includes a title identifying that subgroup and the number of people in Phase 1 and Phase 2 of the project comprising that subgroup. Boxes for subgroups that were excluded from the project sometimes also include reasons for exclusion. Some boxes include explanatory notes.

The boxes are arranged by level and described individually below. Those that flow to the next level are noted.

1. Title: Total cases identified as eligible. Numbers: Phase 1, 3,359; Phase 2, 25,953. Note: Social Security Administration (SSA) identified beneficiaries as meeting initial eligibility criteria based on administrative data and provided a list of these beneficiaries to Mathematica Policy Research, Inc. (MPR). Box 2 descends from this box.

2. Title: Sample selected. Numbers: Phase 1, 1,503; Phase 2, 21,109. Note: MPR selected a random sample of the beneficiaries identified by SSA and sent them a letter describing the demonstration project and inviting them to participate. Boxes 3A and 3B descend from this box.

3A. Title: Individuals not contacted: Numbers: Phase 1, 834; Phase 2, 3,233. Reasons not contacted: unlocatable, no longer met study criteria, or field period ended without contact.

3B. Title: Individuals contacted. Numbers: Phase 1, 669; Phase 2, 17,876. Boxes 4A and 4B descend from this box.

4A. Title: Completed health insurance questionnaire. Numbers: Phase 1, 358; Phase 2, 15,796. Boxes 5A and 5B descend from this box.

4B. Title: Ineligible for other reasons. Numbers: Phase 1, 311; Phase 2, 2,080. Reasons ineligible: refused before screening, language barriers, deceased, physical or cognitive barrier, or did not meet study criteria.

5A. Title: Eligible (uninsured). Numbers: Phase 1, 70; Phase 2, 1,979. Boxes 6A and 6B descend from this box.

5B. Title: Ineligible (insured). Numbers: Phase 1, 288; Phase 2, 13,817.

6A. Title: Nonparticipants. Numbers: Phase 1, 4; Phase 2, 40. Reasons not participating: field period ended, refused after screening, or became ineligible after screening.

6B. Title: Participants. Numbers: Phase 1, 66; Phase 2, 1,939. Boxes 7A, 7B, and 7C descend from this box.

7A. Title: AB Plus group. Numbers: Phase 1, 26; Phase 2, 590. Note: One AB Plus participant dropped out of the study after randomization.

7B. Title: AB group. Numbers: Phase 1, 13; Phase 2, 388.

7C. Title: Control group. Numbers: Phase 1, 27; Phase 2, 961.

Table equivalent for Chart 4. Uninsurance rate among Disability Insurance (DI) beneficiaries selected and contacted for Accelerated Benefits (AB) study, by site
Metropolitan Area Uninsurance Rate
Oklahoma City, Oklahoma 21.7
Louisville, Kentucky-Indiana 20.9
Jacksonville, Florida 20.6
Fort Worth, Texas 20.2
Austin, Texas 19.4
Orlando, Florida 19.3
Dallas, Texas 19.1
New Orleans, Louisiana 18.9
Houston, Texas 18.0
Grand Rapids, Michigan 16.5
Birmingham, Alabama 16.3
Las Vegas, Nevada-Arizona 16.2
Hartford, Connecticut 15.1
Charlotte, North Carolina-South Carolina 15.0
Greensboro, North Carolina 14.2
Atlanta, Georgia 14.2
Norfolk, Virginia-North Carolina 14.0
Fort Lauderdale, Florida 14.0
Cincinnati, Ohio-Kentucky-Indiana 13.8
Columbus, Ohio 13.7
Providence, Rhode Island-Massachusetts 13.5
Newark, New Jersey 13.4
Tampa, Florida 13.2
San Diego, California 12.9
Detroit, Michigan 12.9
Baltimore, Maryland 12.2
Phoenix, Arizona 12.1
Miami, Florida 12.1
Milwaukee, Wisconsin 11.8
Philadelphia, Pennsylvania-New Jersey 11.7
Cleveland, Ohio 11.7
San Antonio, Texas 11.4
Seattle, Washington 10.9
Los Angeles, California 10.7
Richmond, Virginia 10.6
New York, New York 10.6
St. Louis, Missouri-Louisiana 10.4
Washington DC area 10.2
Kansas City, Missouri-Kansas 10.1
Indianapolis, Indiana 10.1
Rochester, New York 10.0
Denver, Colorado 9.7
Chicago, Illinois 9.7
Pittsburgh, Pennsylvania 9.4
Nassau-Suffolk, New York 9.4
Sacramento, California 9.1
Portland, Oregon-Washington 8.8
Orange County, California 7.5
Riverside, California 7.4
Oakland, California 7.2
Boston, Massachusetts-New Hampshire 6.7
Minneapolis, Minnesota-Wisconsin 6.6
Buffalo, New York 3.8
 
Table equivalent for Chart 5. Number of months to reach the $100,000 spending limit, by primary diagnosis
  Cardiovascular impairments Malignant neoplastic diseases Mental disorders Muscuskeletal impairments Neurological impairments
Lower adjacent value 4.9 3.9 13.94 4.9 6.0
25th percentile 8.8 6.8 13.94 6.4 11.2
Median 13.8 9.1 14.92 13.1 16.8
75th percentile 18.8 11.4 16.83 16.9 18.4
Upper adjacent value 22.3 17.0 17.23 26.4 22.6