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Health-Care Utilization as a Proxy in Disability Determination (2018)

Chapter: Appendix A: Health-Care Utilizations

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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
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A

Health-Care Utilizations

This appendix identifies different types of health-care utilizations. Health-care utilizations can be delivered at sites and facilities or can involve the use of prescription drugs, durable and nondurable medical products, and so on. The Centers for Medicare & Medicaid Services (CMS) categorizes types of health-care services as follows (CMS, 2017):

  • Hospital care
  • Physician and clinical services
  • Other professional services
  • Dental services
  • Home health care
  • Other health, residential, and personal care
  • Nursing care services
  • Prescription drugs
  • Other nondurable medical products
  • Durable medical products

In general, a health-care service site or facility is any location where health care is provided. Health-care facilities might be privately owned as for-profit businesses, publically owned by local governments or the federal government (e.g., US Department of Veterans Affairs hospitals), or run as nonprofit organizations.

HOSPITALS

According to CMS, a hospital is an institution engaged primarily in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. Hospitals have medical and other professional staff and inpatient facilities. They deliver services 24 hours per day, 7 days per week. They might also include other services such as hospital-based nursing-home care, inpatient rehabilitation, and organ transplantation (CMS, 2007, 2014). Estimates of hospital utilization are based on various factors, including hospital discharge rates, admissions to the emergency department (ED), ED readmissions, length of stay, and percentage of population hospitalized.

The Social Security Administration (SSA), in its Listing of Impairments, includes number of hospitalizations as criteria for receiving disability insurance related to six body systems: respiratory, cardiovascular, digestive, genitourinary, hematologic, and immune. Those criteria require an applicant to have, for a particular medical condition or combination of conditions, “exacerbations or complications requiring three hospitalizations within a 12-month

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
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period and at least 30 days apart” of which “each hospitalization must last at least 48 hours, including hours in a hospital ED immediately before the hospitalization.”

PHYSICIAN AND CLINICAL SERVICES

Physician and clinical services include those rendered by doctors of medicine and doctors of osteopathy in inpatient and outpatient care centers, physician offices, and medical and diagnostic laboratory services (CMS, 2014). This category also comprises services rendered by physician assistants and nurses practicing in advanced practice registered nurse (APRN) roles, such as nurse practitioners, clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. APRNs1 have assumed an increasing role as providers in the healthcare system throughout the United States. Many practice in retail clinics, which have increased by 47 percent since 2014 and will soon have the capacity to accommodate 25 million annual visits (Hempstead, 2017).

Practicing psychologists can help with social and mental health problems and use various evidence-based treatments. Therapy (often referred to as psychotherapy or talk therapy) includes cognitive, behavioral, cognitive–behavioral, interpersonal, humanistic, and psychodynamic therapy. It can be useful for individuals, couples, families, and other groups.

OTHER PROFESSIONAL SERVICES

Emergency Medical Services

Emergency medical services (EMS)—most commonly thought of as ambulance service but also including aeromedical and other prehospital services—constitutes another health-care utilization and plays a critical role in the health-care system by providing timely out-of-hospital emergency medical care (EMS.gov, 2017a). EMS is a coordinated and comprehensive system that works with various entities—including trauma centers, hospitals, and transportation networks—to provide emergency care (EMS.gov, 2017a). It is regarded as the first step in the spectrum of emergency care delivery by improving community health and providing prehospital care directly to patients who have acute illnesses and injuries (EMS.gov, 2017b).

Certified EMS providers respond to and treat more than 18 million patients annually in the United States (Meisel et al., 2011). Those people are first-responders who provide various services, including responses to 911 calls, prehospital acute medical care, stabilization, hospital transportation, and interfacility transport (IOM, 2007).

Ambulances—from government, fire or police, voluntary, private, or hospital-based entities—provide the most recognized type of EMS services (EMS.gov, 2017b). Some 14 percent of ED visits in 2003 were by patients who arrived by ambulance; these patients were more likely to be older, require emergency or urgent care, and be hospitalized (Burt et al., 2006). The most common reasons for patients to arrive by ambulance were chest pain and shortness of breath (Meisel et al., 2011).

___________________

1 APRNs complete specialty-specific graduate programs that include education, training, and practice experience needed to complete a national board certification examination before entry into practice.

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

DENTAL SERVICES

Dental services are concerned with treating the teeth and associated structures of the oral cavity, including prevention diagnosis of, treatment for disease, and restoration of defective or missing teeth. A recent article in the Journal of Dental Education notes that there has been a remarkable decline in dental caries in the United States, which has resulted in substantial declines in the use of reparative and restorative dental services. Because fewer teeth are compromised, extractions and their sequelae are also declining, and periodontal maintenance care can be provided by allied dental personnel (Eklund, 2017).

HOME HEALTH CARE

Home health care is the provision of services to people in their homes. Most home healthcare patients are elderly. According to the US Department of Health and Human Services, direct care workers—such as nurse aides, home health aides, and home-care aides—are the primary providers of paid care for more than 13 million elderly and disabled Americans. They assist with a broad array of support, such as preparing meals, helping with medications, bathing, and dressing. Direct care workers constitute one of the largest and fastest-growing sectors of the workforce. The chronically ill, terminally ill, and disabled are those most likely to use such services, which include, for example, homemaker services, intravenous administration of antibiotics, transfusion therapy, infusion therapy, chemotherapy, dialysis, enteral and parenteral nutrition, and long-term oxygen therapy (NCHS, 2003).

OTHER TYPES OF HEALTH-CARE UTILIZATIONS

The committee notes here a few other types of facilities and programs, although with some exceptions data on these are scarce or nonexistent. The committee thought it important to include them, however, as they might indicate other types of health-care utilization to be considered by SSA.

Workplace Site

According to the National Association of Worksite Health Centers (NAWHC), workplace “onsite clinics” are settings where employers offer medical and wellness services delivered by licensed providers to all or a designated portion of their active populations and other eligible people. Such clinics are typically referred to as health and wellness centers because of the wide variety of first aid, occupational health, acute, primary, specialty, condition management, wellness, and other services offered.

Workplace programs are often part of the health benefit options that employers offer to their workers. The objective is to provide easy access and immediate attention, at little or no cost, for a host of services and products that an employee would normally have to leave the workplace to obtain (NAWHC, 2017).

Employee Assistance Programs (EAPs) are voluntary, work-based programs that offer free and confidential assessments, short-term counseling, referrals, and followup services to employees who have personal or work-related problems. EAPs address a broad array of complex

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

issues, including mental and emotional well-being, such as alcohol and other substance abuse, stress, grief, family problems, and psychologic disorders. EAP counselors also consult with managers and supervisors to address employee and organizational challenges and needs. Many EAPs are active in helping organizations to prevent and cope with workplace violence, trauma, and other emergency response situation (OPM, 2017).

Urgent Care

Urgent care facilities—as distinct from hospitals, physicians’ offices, and clinics—provide basic medical care for unscheduled, ambulatory patients who are seeking immediate medical attention (CMS, 2015). Unlike emergency departments, urgent care facilities typically are not open 24 hours per day. Basic medical care includes diagnoses that do not require advanced laboratory imaging and treatments that do not require complex procedures (Mehrotra et al., 2009).

Utilization of urgent care facilities has increased in recent years as an alternative to ED, hospital, and clinic visits, but their clinical efficacy remains unclear. A recent Cochrane systematic review found no controlled-trial evidence on the quality of care provided by urgent-care facilities (Chen et al., 2017).

Day Centers for Severe Mental Illness

The National Alliance on Mental Illness notes that the treatment setting for mental health varies from physicians’ offices to community or county mental health centers. A community or county mental health care center can provide public mental health care services when a referral to a private doctor or therapist is not possible. Centers are operated by local governments to meet the needs of people whose mental health condition seriously affects their daily functioning. Services that a person might receive from a community or county mental health center include psychiatry, outpatient services, medication management, case-management services, intensive community treatment services, and help with employment and substance-use issues. Psychiatrists, psychologists, social workers, counselors, and peer-support specialists work at centers to provide the various services that clients need.

A 2005 World Health Organization report examined five main forms of day care for adults who have severe mental health disorders. It notes that the evidence on different forms of day care services for such peoples is not easy to interpret (WHO, 2005).

Substance-Abuse Treatment Centers

Some people who have mental health conditions might also have substance-abuse problems. The most widely used form of treatment is integrated intervention, in which a person receives care for both a specific mental illness and substance abuse. Types of substance-abuse centers include detoxification facilities, acute residential treatment programs, and intensive outpatient programs (NAMI, 2017).

Assisted-Living Facilities

Assisted-living facilities provide a wide variety of supportive services, such as housekeeping and transportation, to people who want to maintain some level of independence but require support in activities of daily living. They might have apartment-style living on

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

grounds where community health workers or aides help with such activities as laundry, baths, cooking, and shopping. Assisted-living facilities are not as highly regulated as skilled nursing facilities (SNFs). They are paid for privately and have no limitations on length of stay (Mitty and Flores, 2007).

SKILLED NURSING FACILITIES

SNFs provide a high level of medical care through a team of trained people that might include registered nurses (RNs), social workers, psychiatrists, dietitians, and physical, speech, and occupational therapists. Such services can be rendered over the short term for rehabilitation purposes or over the long term for patients who need frequent or around-the-clock care because of chronic medical conditions (Garcia et al., 2016). Typically, SNFs involve short-stay high-intensity care in a long-term care setting, such as a nursing home. The short-term stay is often paid for by Medicare for up to 90 days. If medically necessary, stays might be extended into long-term care paid through Medicaid or private payers with no limits in length of stay, depending on state and federal benefit regulations.

PRESCRIPTION DRUGS

Prescription drugs are pharmaceutical agents that are used to prevent or delay the onset of chronic disease and disability, control or cure disease, and provide relief from pain (NCHS, 2014).

From 2007 to 2010, almost half the US population took at least one prescription drug in the preceding month and one-tenth reported taking five or more drugs. According to the National Center for Health Statistics, Americans’ use of prescription drugs has grown over the past half-century for a variety of reasons, such as the development of new and innovative drug therapies, the expansion of prescription drug coverage by public and private payers, and increased marketing by pharmaceutical companies.

Prescription drug development in the second half of the 20th century has focused on chronic diseases, such as cancer, heart disease, diabetes, and mental health disorders. Drugs that treat those conditions were among the most commonly used by adults. The widespread use of chemotherapy and other biologics contributed to raising 5-year cancer survival rates to 67 percent in 2009 (NCHS, 2014). Drugs for heart disease have led to better treatment and control of the risk factors for heart disease, and prescription drugs are an important component in the treatment of mental health disorders.

DURABLE AND NONDURABLE MEDICAL PRODUCTS

Durable medical products are defined by CMS as reusable or nondisposable medical equipment that serves a medical purpose and is appropriate for use in the home. They include hospital beds, wheelchairs, walkers, canes, commode chairs, blood pressure and blood glucose monitors, orthopedic products, hearing aids, and home oxygen equipment (CMS, 2014). Nondurable medical products are medical supplies that can be discarded after use. Examples include examination gloves, needles, and surgical instruments, such as surgical dressings (CMS, 2014).

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

REFERENCES

Burt, C. W., L. F. McCaig, and R. H. Valverde. 2006. Analysis of ambulance transports and diversions among US emergency departments. Annals of Emergency Medicine 47(4):317–326.

Chen, C. E., C. T. Chen, J. Hu, and A. Mehrotra. 2017. Walk-in clinics versus physician offices and emergency rooms for urgent care and chronic disease management. The Cochrane Database of Systematic Reviews 2:CD011774.

CMS (Centers for Medicare & Medicaid Services). 2007. CMS manual system pub 100-04 Medicare claims processing: New web site for approved transplant centers. Washington, DC: CMS. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1341CP.pdf (accessed May 25, 2017).

CMS. 2014. National health expenditures accounts: Methodology paper, 2014. In Definitions, Sources, and Methods. Washington, DC: CMS. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/dsm-14.pdf (accessed May 25, 2017).

CMS. 2015. CMS manual system pub 100-04 Medicare claims processing: New and revised place of service codes (POS) for outpatient hospital. Washington, DC: CMS. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3315CP.pdf (accessed May 25, 2017).

CMS. 2017. Projections of national health expenditures: Methodology and model specification. Washington, DC: CMS. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/projectionsmethodology.pdf (accessed May 25, 2017).

Eklund, S. A. 2017. The impact of improved oral health on the utilization of dental services. Journal of Dental Education 81(8):eS110–eS119.

EMS.gov. 2017a. What is EMS? https://www.ems.gov/whatisems.html (accessed November 8, 2017).

EMS.gov. 2017b. National EMS scope of practice model. https://www.ems.gov/education/EMSScope.pdf (accessed November 8, 2017).

Garcia, T. J., T. C. Harrison, and J. S. Goodwin. 2016. Nursing home stakeholder views of resident involvement in medical care decisions. Qualitative Health Research 26(5):712–728.

Hempstead, K. 2017. How is health care utilization changing? https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2016.pdf (accessed November 7, 2017).

IOM (Institute of Medicine). 2007. Emergency medical services: At the crossroads. Washington, DC: The National Academies Press.

Mehrotra, A., H. Liu, J. L. Adams, M. C. Wang, J. R. Lave, N. M. Thygeson, L. I. Solberg, and E. A. McGlynn. 2009. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Annals of Internal Medicine 151(5):321–328.

Meisel, Z. F., J. M. Pines, D. Polsky, J. P. Metlay, M. D. Neuman, and C. C. Branas. 2011. Variations in ambulance use in the United States: The role of health insurance. Academic Emergency Medicine 18(10):1036–1044.

Mitty, E., and S. Flores. 2007. Assisted living nursing practice: Medication management: Part 1. Assessing the resident for self-medication ability. Geriatric Nursing 28(2):83–89.

NAMI (National Alliance on Mental Illness). 2017. Treatment settings. https://www.nami.org/Learn-More/Treatment/Treatment-Settings (accessed November 8, 2017).

NAWHC (National Association of Worksite Health Centers). 2017. What is an onsite clinic? https://www.nawhc.org/about-nawhc/what-onsite-clinic (accessed May 27, 2017).

NCHS (National Center for Health Statistics). 2003. Healthcare in America: Trends in utilization. Hyattsville, MD: HHS (US Department of Health and Human Services). https://www.cdc.gov/nchs/data/misc/healthcare.pdf (accessed March 1, 2017).

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

NCHS. 2014. Health, United States. In Health, United States, 2013: With special feature on prescription drugs. Hyattsville (MD): National Center for Health Statistics (US).

OPM (Office of Personnel Management). 2017. Work-life: Employee assistance programs. https://www.opm.gov/policy-data-oversight/worklife/employee-assistance-programs (accessed May 27, 2017).

WHO (World Health Organization). 2005. How effective are different types of day care services for people with severe mental disorders? Copenhagen, Denmark: WHO Regional Office for Europe.

Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×

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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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Suggested Citation:"Appendix A: Health-Care Utilizations." National Academies of Sciences, Engineering, and Medicine. 2018. Health-Care Utilization as a Proxy in Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/24969.
×
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The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.

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