Housing Subsidies for Medicare Advantage Members Experiencing Housing Cost Burden

In 2021, the number of eligible Medicare beneficiaries exceeded 62 million, and 42% of those beneficiaries were enrolled in a Medicare Advantage or MA plan, offered by a private insurer (Freed, et al., 2021). Enrollment in Medicare Advantage plans has been on the rise since 2004, increasing from 6 million, to an enrollment of 26 million in 2021; projections suggest that the percent of Medicare beneficiaries enrolled in a Medicare Advantage plan, by 2030, will increase to 51% (Freed, et al., 2021). Known by a variety of names, Medicare Advantage plans have been in place since the inception of Medicare (Patel & Guterman, 2017). Often referenced as MA plans, they are available to Medicare eligible members, in lieu of traditional Medicare, through private insurance companies, and differ from traditional Medicare because they offer additional benefits and are often more affordable. Not only have MA plans become increasingly more popular with Medicare eligible members, as referenced above, the number of private insurance companies offering Medicare Advantage plans has also increased (Freed, et al., 2021). Insurers have found the reimbursement from the federal government to be advantageous, and with a focus on preventative services and care management, it has made for a profitable business. MA plans have also been very innovative in benefit design and in meeting the needs of at risk populations. The popularity of Medicare Advantage plans, when compared to traditional Medicare, is the result of availability, convenience, benefits, and cost.

1 HOUSING SUBSIDIES Housing Subsidies for Medicare Advantage Members Experiencing Housing Cost Burden Joel Macey University of Utah College of Nursing Master of Science in Gerontology Submitted in Partial Fulfillment of Degree Requirement November 1, 2021 HOUSING SUBSIDIES 2 In 2021, the number of eligible Medicare beneficiaries exceeded 62 million, and 42% of those beneficiaries were enrolled in a Medicare Advantage or MA plan, offered by a private insurer (Freed, et al., 2021). Enrollment in Medicare Advantage plans has been on the rise since 2004, increasing from 6 million, to an enrollment of 26 million in 2021; projections suggest that the percent of Medicare beneficiaries enrolled in a Medicare Advantage plan, by 2030, will increase to 51% (Freed, et al., 2021). Known by a variety of names, Medicare Advantage plans have been in place since the inception of Medicare (Patel & Guterman, 2017). Often referenced as MA plans, they are available to Medicare eligible members, in lieu of traditional Medicare, through private insurance companies, and differ from traditional Medicare because they offer additional benefits and are often more affordable. Not only have MA plans become increasingly more popular with Medicare eligible members, as referenced above, the number of private insurance companies offering Medicare Advantage plans has also increased (Freed, et al., 2021). Insurers have found the reimbursement from the federal government to be advantageous, and with a focus on preventative services and care management, it has made for a profitable business. MA plans have also been very innovative in benefit design and in meeting the needs of at risk populations. The popularity of Medicare Advantage plans, when compared to traditional Medicare, is the result of availability, convenience, benefits, and cost. On average, a Medicare beneficiary had access to 33 MA plans in 2021, an increase over prior years (Biniek, et al., 2020). Biniek, et al. (2020) reported a total of 3,350 MA plans nationwide, an historic high. Medicare Advantage plans consolidate the multiple parts of traditional Medicare, Part A- hospitalization, Part B- provider services, and Part D- prescription drug benefit, into a single plan. Medicare Advantage plans offer supplemental benefits, not HOUSING SUBSIDIES 3 covered under traditional Medicare. Examples include dental, vision, and hearing care. In the most recent years, benefits have expanded to include non-medical supplemental benefits that enhance the health of members. Many MA plans also offer a low cost or no cost premium, as well as co-pays and out-of-pocket annual maximums that may be more affordable than traditional Medicare. Medicare Advantage plans have been recognized for a focus on more conservative approaches to care, and also on prevention, or preventive care (Patel & Guterman, 2017). Additionally, MA plans have achieved higher quality outcomes, better utilization management, and lower costs, specifically for beneficiaries who are dual eligible, meaning the member is covered by Medicare and Medicaid (Teigland, et al., 2019). Dual eligible members represent some of the highest risk MA members who have more than one serious chronic condition, experience poverty, and are impacted by multiple social risks, such as housing and food insecurities (Better Medicare Alliance, 2021). As mentioned above, supplemental benefits have expanded to include non-medical items that enhance the health of an individual, including meal services, adaptive equipment, modifications to a home, transportation services, and personal care services (Thomas, et al., 2019). Many of these benefits are intended to improve the member’s quality of life by reducing the complications from chronic disease and eliminate unnecessary hospital emergency visits and hospitalizations (Thomas, et al., 2019). In recent years, health systems and health payers have come to understand the importance of social determinants on an individual’s overall health (Summers, 2018). These determinants include food, housing and economic insecurities, race and ethnicity, education and community (Nichols & Taylor, 2018). Decades of research have led to an understanding that to improve HOUSING SUBSIDIES 4 quality of life and the overall health of individuals, social determinants must be addressed (Westphal, 2019). Federal politicians have also recognized the importance of addressing social determinants to improve quality of life for Medicare beneficiaries and this recognition led to the passage of federal legislation; Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act, or CHRONIC, in 2018 (Thomas, et al., 2019). The CHRONIC Care Act provides Medicare Advantage plans some additional flexibility with supplemental benefits. Two significant changes were introduced, the ability to expand benefits for chronically ill members, specifically for nonmedical services, and the option to design benefits for a specific cohort of members, no longer requiring that benefits apply uniformly across the membership (Willink & DuGoff, 2018). The act broadens the definition of supplemental benefits to include services that cover “a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits” (Willink & DuGoff, 2018). The previous definition required the supplemental benefit to meet criteria that would, “prevent, cure, or diminish an illness or injury” Willlink & DuGoff, 2018). Housing insecurity is a significant issue in the older adult population. Housing costs have outpaced incomes for three decades and while mortgages for many are paid off, the cost of property taxes and home maintenance have a negative impact on older adults living on fixed incomes (Fenelon & Mawhorter, 2020). Renters are particularly vulnerable to housing cost burden, defined as spending more than 30% of income on housing, because unlike a house payment, which is fixed, rent increases are often unavoidable for renters (Fenelon & Mawhorter, 2020). Housing is a fundamental determinant of health, financial security, and quality of life (Fenelon & Mawhorter, 2020). 5 HOUSING SUBSIDIES Competing priorities for federal funding make it challenging to secure government funding to reduce the social risks associated with housing insecurity. Other options, beyond federal support, need to be considered. Offering a housing subsidy as a supplemental benefit, for eligible Medicare Advantage beneficiaries, is the purpose of this project. Review of the Literature Medicare Primer In 1962, nearly one half of all older adults had no medical insurance coverage (Moon, 2006). Once older adults left the work force, they were categorized as high risk by many insurers which limited medical coverage options, and in the rare instance that medical coverage was secured, the benefits were often limited (Oberlander, 2015). This backdrop provided an opportunity to correct this public health issue and eventually led to the passage of Medicare, signed into law by President Lyndon Johnson, July 31, 1965 (Oberlander, 2015). Efforts to pass a national health insurance program began early in the twentieth century. Pushing Medicare over the legislative finish line was accomplished by limiting national health insurance to older adults, along with the landslide presidential victory that elected President Johnson, and with Democratic majorities secured in the House and Senate (Oberlander, 2015). Medicare was intended to reduce the burden of expense for older adults for a limited number of acute services, and medical benefits were not intended to be comprehensive or cover chronic conditions (Oberlander, 2015). Cost-sharing between Medicare and Medicare beneficiaries, with much of the cost covered by the beneficiary, and without an annual out-ofpocket cap, was also included in the 1965 law (Oberlander, 2015). The initial priority of Medicare administrators was to ensure a smooth transition for the new program, to demonstrate that national health coverage could work (Oberlander, 2015). Few HOUSING SUBSIDIES 6 limits on payments, and even fewer cost controls, were put into place to mitigate program costs. The absence of payment and control measures led to significant increases in Medicare program costs, which also influenced the rising costs in the broader US healthcare system (Oberlander, 2015). In the 1980’s Congress adopted legislation moving to a prospective payment system, no longer accepting the submitted fees charged by physicians and hospitals (Oberlander, 2015). In subsequent years, Congress and presidents have looked for additional opportunities to reduce the taxpayer cost burden for the Medicare program, and with some success. However, the increase in the older adult population, specifically those 65 and older, will impact sustainability of the program (Oberlander, 2015). Given the popularity of older adults by both political parties and the influence of advocacy groups, expansion of benefits was anticipated much sooner; however, two decades passed before additional benefits were added (Oberlander, 2015). In 1988 the Medicare Catastrophic Coverage Act was passed only to be repealed less than 18 months later as a result of a flawed funding mechanism (Oberlander, 2015). In 2003 the Medicare Modernization Act was passed, ushering in coverage for outpatient prescription drugs (Oliver et al., 2004). The new prescription drug act quickly created discontent among Medicare beneficiaries because of a gap in coverage, commonly referred to as the “doughnut hole” (Oliver et al., 2004). Oberlander (2015) shares that Medicare is a program that most older adults anticipate and come to rely on in their retirement years. It is the largest purchaser of medical services in the United States, supporting hospitals, physicians, home health and hospice organizations, and skilled nursing facilities (Oberlander, 2015). Any changes in Medicare policy have a far reaching impact on the medical community (Oberlander, 2015). To emphasize the financial impact of HOUSING SUBSIDIES 7 Medicare, on the country, Cubanski et al. (2019) reported that Medicare spending in 2018 represented 15 percent of all federal spending, a net monetary cost of $605 billion. Medicare includes Part A, coverage for hospital expenses, and Part B, coverage for physician expenses (Oberlander, 2015). Oberlander (2015) describes additional components that have been added to Medicare over time, including Part D, a prescription drug benefit, administered by private insurers, and Part C, also administered by private insurers, and more commonly referred to as Medicare Advantage (Oberlander, 2015). The new name was adopted in 2003 as part of the Medicare Modernization Act (Adrion, 2020). Centers for Medicare and Medicaid Services (2021) reported 53 million Medicare beneficiaries, 65 years of age and older, in 2019. Beneficiaries enrolled in the traditional fee for service program, Parts A and B, represented 63% of enrollees, compared to 37% enrolled in a Medicare Advantage plan (Centers for Medicare and Medicaid Services, 2021). Medicare beneficiaries have a cost sharing requirement in the traditional Medicare fee for service program (Medicare.gov, n.d.). For most enrolled in Part A, hospital coverage, there is no premium, but a deductible and coinsurance apply to inpatient hospitalizations (Medicare.gov, n.d.). Part B, physician services, requires a monthly premium and in addition a deductible and co-insurance for many covered services (Medicare.gov, n.d.). Part D, prescription drug benefit plans, offered through private insurers, also include a deductible and cost sharing obligations (Medicare.gov, n.d.). Medicare Advantage plans must include coverage for Part A and Part B benefits, and in addition offer supplemental benefits, and many plans offer low cost and no cost premiums and often include Part D benefits as well (Medicare.gov, n.d.). The consolidated approach of HOUSING SUBSIDIES 8 Medicare Advantage plans has led to a significant increase in popularity (Patel & Guterman, 2017). Medicare’s Relationship with Private Insurers Beginning in 1966, the Center for Medicare and Medicaid Services, CMS, contracted with private medical insurance companies to cover Medicare beneficiaries (Patel & Guterman, 2017). The private plans, known at the time as Health Maintenance Organizations, or HMOs, offered an alternative to traditional Medicare (Patel & Guterman, 2017). These private plans were paid using a cost basis methodology that was based on the actual cost the plan incurred to cover the medical expense of its members (Patel & Guterman, 2017). In the early years, Medicare beneficiaries showed little interest in HMOs (Patel & Guterman, 2017). Beginning in the 1980s, different payment models were tested and in the course of these payment experiments it was discovered that HMOs attracted members who were younger, of lower income, and most of the members self-reported as being healthier, but more importantly, was the discovery that physicians often took a more conservative approach to care, with a focus on preventative care (Patel & Guterman, 2017). Politicians and government bureaucrats were enthusiastic towards HMOs because they saw them as a way to reduce Medicare government spending (Patel & Guterman, 2017). The government required HMOs to report their total expenses required to cover Medicare members and when it was discovered that expenses were much less than the payments HMOs were receiving, the government required the surplus be used to provide additional benefits, and in fact, that is exactly what happened (Patel & Guterman, 2017). Some insurers offered a lower premium, others offered dental, hearing and eye care coverage, and some plans offered a benefit for prescription drugs, long before Medicare Part D, was available (Patel & Guterman, 2017). HOUSING SUBSIDIES 9 Beginning in the early eighties and continuing for close to three decades, legislation was passed to curtail Medicare spending and more specifically a focus on reducing the payments to Medicare HMOs, that continued to out-pace the cost of traditional Medicare (Patell & Guterman, 2017). CMS funding wasn’t the only issue to address with Medicare HMOs. HMO membership selection, weighted towards a much younger and healthier cohort, the freedom for beneficiaries to switch back to traditional Medicare, which resulted in traditional Medicare having a lopsided cohort of chronically ill beneficiaries, and the challenges of building a HMO network in rural communities, were also top of mind for CMS administrators (Patell & Guterman, 2017). In 1982, the passage of the Tax Equity and Fiscal Responsibility Act, or TEFRA, changed the payment model for HMOs to a capitated methodology (Adrion, 2020). Setting payment rates at 95% of traditional Medicare costs, all plans were now receiving a monthly payment based on the number of enrollees and the private plans also assumed the liability or risk for all enrolled plan members (Adrion, 2020). A favorable selection of members and effective care management allowed plans to reduce their medical expenses below the payment rates they were receiving from CMS (Adrion, 2020). This provided an opportunity for the private plans to offer additional benefits, and the result was a significant rise in membership (Adrion, 2020). Enrollment in Medicare HMOs grew from roughly 3 percent in 1970 to 14 percent by 1997 (Adrion, 2020). CMS was primarily focused on driving down the cost of care for Medicare members, however, in 1991, The National Committee for Quality Assurance, NCQA, introduced HEDIS, The HMO Employer Data and Information Set, which has since been changed to The Healthcare Effectiveness Data and Information Set (Cushing, 2012). The genesis for HEDIS was based on the fact that HMOs were all offering very similar benefits with similar costs, and it became HOUSING SUBSIDIES 10 challenging for employer groups to distinguish the differences, if any, between the HMO plans (Cushing, 2012). Additionally, there was no mechanism to determine if the plans were delivering quality outcomes (Cushing, 2012). At the time, HEDIS included 60 measures that were intended to measure quality of care, access to care, and use of services (Cushing, 2012). While the measures were tracked, the payment private plans received from Medicare was not influenced, at this point, based on the outcomes of the measures (Patell & Guterman, 2017). The Board of Trustees of the Federal Hospital Insurance Trust Fund (1995) included a high priority message regarding the solvency of Medicare, “the program is severely out of financial balance”, and absent action by congress to reduce expenditures, the program would not survive, using the most optimistic scenario, beyond 2002. The Balanced Budget Act of 1997 once again changed CMS’ payment strategy which reduced payments made to Medicare HMOs (Patell & Guterman, 2017). Medicare+Choice as it would now be called, opened the door for several new plan options, including the option for members to access a broader network of providers, and reduced the opportunity for members to only switch Medicare plans, one time, outside of the traditional enrollment period (Patell & Guterman, 2017). The unexpected result was a drop in Medicare managed plans from a high of 412 in 1999, to a low of 204 in 2003 (Adrion, 2020). Enrollment in these private plans also fell during this same period from a high of 18% in 1999 to 13% in 2003. The expected savings from the passage of the Balanced Budget Act, was not achieved (Patell & Guterman, 2017). In an effort to rebound from a particularly disastrous period for Medicare managed plans, the Medicare Modernization Act or MMA was passed in 2003 which included the prescription drug benefit, Part D, and MMA also changed the name of Part C plans from Medicare+Choice, HOUSING SUBSIDIES 11 to Medicare Advantage, also referred to as MA plans (Adrion, 2020). MMA increased the payment to Medicare Advantage plans at traditional Medicare rates and in some cases higher, to counter the impacts of the Balanced Budget Act (Patell & Guterman, 2017). Plans also offered the prescription drug benefit and received additional payment from CMS to provide the benefit (Patell & Guterman, 2017). The result of the MMA was an increase in the availability of at least one plan to all Medicare beneficiaries, an increase in the number of plans in the market, and the availability of plans for vulnerable populations (Patell & Guterman, 2017). Patell & Guterman (2017), also revealed that enrollment in Medicare Advantage plans skyrocketed, enrolling 24% of Medicare eligible beneficiaries in 2010 up from a 2003 low of 13%. Enrollment wasn’t the only increase, the payment, from CMS to Medicare Advantage plans increased from 107% of traditional Medicare to 114% of traditional Medicare, following passage of the MMA. One important development in Medicare Advantage plans that merits mention, was a turn in focus from reducing cost, to a focus on quality (Patell & Guterman, 2017). This resulted from CMS implementing a 5-star rating initiative in 2018, using HEDIS as the rating tool. Very similar to the introduction of HEDIS, the implementation of star ratings did not include a tie to payment from CMS to the private MA plans. Even without the payment incentive, plans actually showed improvement in HEDIS measures (Patell & Guterman, 2017). The Affordable Care Act, often referred to as ACA or more frequently as “Obamacare”, was enacted in March 2010 (HealthCare.gov, n.d.). As was declared in prior legislation, the ACA included payment reductions (Patell & Guterman, 2017). However, payment for quality was also written into the Act and measured using the previously implemented star ratings. The star ratings determined the rebates and bonuses that were paid to Medicare Advantage plans, for example, all HOUSING SUBSIDIES 12 plans achieving a 3.5 or higher star rating received rebates and bonuses. MA plans achieving a 4 star rating received higher payment bonuses, and 5 star plans were able to enroll new Medicare eligible beneficiaries outside of the traditional enrollment period (Patell & Guterman, 2017). The Act required Medicare Advantage plans to spend at minimum, 85% of the payment received from CMS on member benefits, effectively capping the administrative costs of the plan, and out of pocket spending limits for members were also capped, to protect the sickest of Medicare beneficiaries (Patell & Guterman, 2017). Those opposed to the ACA projected that Medicare Advantage plans would leave the market and that there would be a sharp drop in enrollment; just the opposite, enrollment grew by more than 80% and captured 33% of Medicare beneficiaries in 2017. Other notable impacts of the ACA included a decrease in payments to Medicare Advantage plans from 114% of traditional Medicare costs in 2009, to 100% of Medicare costs in 2017. Average MA plan premiums charged to members dropped by 18% between 2010 and 2017, and by 2017, roughly 50% of advantage plans achieved a rating above 4 stars (Patell & Guterman, 2017). Supplemental benefits are offered by Medicare Advantage plans that are not covered by traditional/fee-for-service Medicare (Kornfield, et al., 2021). Supplemental benefits are offered with the intention of improving a member’s health outcome and addressing other member needs (Kornfield, et al., 2021). Kornfield et al. (2021) emphasizes the work plans perform in allocating resources, and in some cases at a significant cost to deliver supplemental benefits. However, supplemental benefits attract members and can create a competitive advantage for Medicare Advantage plans (Kornfield, et al., 2021). As mentioned earlier, the primary objective outlined by CMS, to private insurers, in the early years of Medicare was focused on reducing Medicare spending, but the objective has expanded over time to include providing Medicare beneficiaries HOUSING SUBSIDIES 13 with more choice and better benefits (Adrion, 2020). Adrion (2020) suggests these objectives maybe in conflict. Highlighting the popularity of MA plans, Better Medicare Alliance (2021) reports a 98% satisfaction rate among members, and members report out-of-pocket spending is much less compared to traditional Medicare. Medicare Advantage plans are here to stay. Whether in an effort to limit the perception of national health insurance, offering more choice to Medicare beneficiaries, or the belief that MA plans provide better outcomes and increase quality, the popularity of these plans is only increasing. A Shift from Cost to Quality When Medicare was introduced over 50 years ago, the primary focus was to cover hospitalization costs for older adults, many who were unable to afford acute care services (Schwartz, 2019). Older adults are now living longer, the majority with chronic conditions and many with multiple chronic conditions, requiring management over long periods of time and more often for the remainder of life (Schwartz, 2019). Schwartz (2019) writes that high-need, high-cost Medicare beneficiaries will best benefit from an integrated care system that encourages early intervention, has a focus on primary care, provides care management resources, and also includes alignment of payments and benefits. The integrated care system Schwartz (2019) proposes, already exists: Medicare Advantage. Medicare advantage plans are incentivized to improve outcomes, promote and support care management, focus on transitions of care, and encourage shared decision making with members. Medicare advantage plans are innovators in care delivery, in particular providing person centered care management which fosters communication among care teams and works to remove barriers to care (Schwartz, 2019). Advantage plans also offer Special Needs Plans, or SNPs, that HOUSING SUBSIDIES 14 focus on specific high risk member cohorts, intervening and engaging with the member early when a medical condition or medical episode is identified (Schwartz, 2019). Teigland, et al. (2020) concluded that between 2012 and 2015 the Medicare Advantage population grew younger, increased in racial and ethnic minority enrollment, enrolled a higher number of low income members, including members living in poor neighborhoods. The study included a review of data on 2 million members in 2012 and 1.8 million members in 2015. Teiland, et al. (2020) were clear in their conclusions that interventions to address social risks were critical. MA members with median income below $30,000 increased by 35% while members living in neighborhoods with 20% or more of the households below the federal poverty level increased by 29%. Members reported as racial or ethnic minorities increased by 22%. The length of hospital stays increased, which could suggest that members were sicker, and hospital observation stays also increased, as did visits to the emergency department. Based on the payment from CMS to private insurers, MA plans are incentivized to promote better health, coordinate care, and manage utilization to avoid unnecessary care while focusing on preventive care. The study authors reported lower readmission rates, fewer hospital admissions and reduce rates of avoidable hospitalizations (Teigland, et al., 2020). Teigland, et al. (2020) recommend that the changing demographic of the Medicare Advantage population will require a more deliberate focus on managing social and medical risks as beneficiaries are poorer and more medically complex. The key findings in research conducted by Teigland, et al. (2019), were reported to show favorable outcomes when comparing dual eligible members, those covered by Medicare and Medicaid, enrolled in traditional Medicare, with dual eligible members enrolled in a Medicare Advantage plan, including quality, utilization and cost. Those enrolled in the MA plan showed HOUSING SUBSIDIES 15 lower rates of hospitalizations, approximately 33% lower, and fewer visits to the emergency room, 42% lower. Office visits were approximately 12% higher, a reflection of more preventive care services. The distribution of the study cohort was similar by age and gender; however, the MA population had a higher proportion of racial and ethnic minority members and a much higher proportion of beneficiaries with social and clinical risk factors which are shown to increase utilization and result in worse outcomes and increased costs. Teigland, et al. (2019) did not adjust for these risk factors, which may have led to underestimating the performance of Medicare Advantage compared to traditional Medicare. In a report published by Better Medicare Alliance (2020), the quality results for high-need high-cost members enrolled in a Medicare Advantage plan were much better when compared to fee-for-service Medicare. Higher pneumonia vaccination rates, higher eye exam rates for diabetics, higher rates for depression screening and lower 30 day readmission rates. Much higher rates, in particular for frail older adults, of visits with a primary care provider within 14 days following a hospitalization. As mentioned previously, the cost of care was also measured and the results revealed that traditional Medicare had costs that were a 16.7% higher for the dual eligible population compared to MA plans, $13,398 versus $11,159 respectively, due to lower inpatient and outpatient expenses for the MA cohort (Teigland, et al., 2019). Although costs were lower, dual eligible members received more preventative care services, had lower rates of complications, particularly in diabetes care, and lower rates of readmissions to the hospital (Teigland, et al., 2019). Medicare Advantage plans demonstrate a 43% lower rate of avoidable hospitalizations for any reason, when compared to traditional Medicare, and a much higher rate of preventative screenings for conditions like cancer and depression (Better Medicare Alliance, 2021). 16 HOUSING SUBSIDIES Addressing Social Risks The health of an individual can be influenced by many factors. While research attributes less of an individual’s overall health to genetics, lifestyle is a much greater contributor to overall health. Social, behavioral, and environmental factors combined, are estimated to influence 60% of an individual’s health outcome (Summers, 2018). U.S. Department of Health and Human Services (n.d.) defines social risks or more often referred to as social determinants of health as, "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." The United States spends more of its gross domestic product on healthcare than any other developed country, but with poorer outcomes, particularly in life expectancy and infant mortality (Stone, 2019). Stone (2019) also suggests that when the ratio of social service expenditures compared to medical expenditures is lower, the result is poorer health outcomes for individuals and communities. Well before an individual presents to a health system for medical care or treatment, their overall health has been influenced by social determinants (Nichols & Taylor, 2018). These social determinants include food insecurity, access to food and more specifically nutritious food, economic insecurity, the neighborhood where they live and more importantly their own housing (Nichols & Taylor, 2018). The impact of these social determinants will influence the success of any medical intervention they receive. Nichols and Taylor (2018), write that decades of research have revealed the positive impact of funding that is allocated to addressing social determinants. However, the funding has been inadequate, and the inadequacy is likely tied to the Free Rider problem. The Free Rider problem suggests that institutions, communities and organizations reap HOUSING SUBSIDIES 17 a benefit from the investment of others, without making their own investment (Nichols & Taylor, 2018). Much of the attention for addressing social determinants is left to healthcare and payer systems at risk for uninsured or underinsured members, members they have a common interest in supporting with funding when addressing social determinants. However, Nichols & Taylor (2018), suggest that it is challenging for these organizations to determine the net benefit of their investments, and there is a reluctance to allow community organizations, which may help realize the benefit, to address the issues with the investments, because the community organizations are outside of the health system and the health system may have difficulty relinquishing oversight and control. Social determinants have a significant influence on chronic conditions and before a chronic condition can be successfully impacted, basic needs, both current and long-term, must be addressed (Westphal, 2019). Often these chronic conditions are discovered when a person accesses the healthcare system, signaling a need to address the determinants that could have potentially prevented or influenced the condition. This is a retrospective way of addressing individuals at risk. The ability to know or predict when an individual is at risk is challenging but moving to address the social determinant’s “upstream” and avoiding the use of the healthcare system, will not only improve quality of life for the individual, but will also reduce and shorten hospital stays, decrease hospital emergency visits, and delay institutionalization (Westphal, 2019). Medicare Advantage plans have a higher percentage of members who experience social risk factors when compared to members enrolled in traditional fee-for-service Medicare. MA members are more likely to qualify as dual eligibility members, those qualifying for Medicare HOUSING SUBSIDIES 18 and Medicaid, have an annual income of less than $24,500, and live in neighborhoods with a higher percentage of households living below the federal poverty level (Better Medicare Alliance, 2021). Better Medicare Alliance (2021) reports that Medicare Advantage plans continue to grow and have currently enrolled 42% of Medicare eligible individuals. The growth is expected to continue, and enrollment is projected to reach 51% by 2030 (Congressional Budget Office, 2020). Murphy-Barron et al. (2020) reported a 60 percent increase in MA enrollment from 2013 to 2019 and for the same time period, traditional or fee-for-service Medicare membership increased by 5 percent. In addition to an increase in enrollment, Medicare Advantage plans have higher enrollment of racial and ethnic minorities. MA members representing racial and ethnic minorities account for 31.5% of total MA membership compared to 20.8% of total fee-forservice Medicare membership. The growth in racial and ethnic minority members is very similar to the growth reported in overall MA membership. Murphy-Barron et al. (2020) found, starting in 2013, that racial and ethnic minorities represented 30.5% of total MA membership and grew to represent 46.3%, in 2019, of total MA membership compared to a decrease in the same cohort over the same time period from 69.5% to 53.7% respectively, for traditional Medicare. It would be expected that a higher percentage of racial and ethnic minorities would also result in a higher cohort of members living in poverty. Better Medicare Alliance (2021), reports that 52.7 percent of Medicare Advantage members are living at less than 200% of the federal poverty level. Supplemental Benefits: A Shift in Paradigm Medicare Advantage plans have been innovators in benefit design, payment design and care delivery options within the larger Medicare program, since inception (Better Medicare HOUSING SUBSIDIES 19 Alliance, 2021). Supplemental benefits are a trademark of Medicare Advantage plans. These benefits are offered to members using rebates paid to MA plans by CMS (Schwartz, 2019). The rebates are based on the cost of providing care, as submitted by the MA plan, and they are also based on quality performance. Rebates can only be used to directly benefit members, most often through supplemental benefits. Although Supplemental benefits such as dental, hearing and vision services are offered by Medicare Advantaged plans, up until 2019, CMS did not allow MA plans to offer benefits that address social needs, which research has shown, have a significant impact on an individuals’ quality of life and often result in higher utilization of healthcare resources (Skopec, et al., 2019). Beginning in 2019, CMS allowed Medicare Advantage plans new flexibility in benefit design by expanding supplemental benefits to include non-medical services (Kornfield, et al., 2021). The definition of “primarily health related” was expanded to include transportation services to support non-emergent hospital, pharmacy, and visits to providers, home safety devices and modifications, like wheelchair ramps and bathroom grab bars, in home support for activities of daily living and instrumental activities of daily living, provided by personal care attendants, palliative care services in the home, adult day care services, and family caregiver support, like respite services (Centers for Medicare and Medicaid Services, 2018). For many MA plan leaders, this came as a bit of a surprise, and the result has been mixed in terms of the expansion of supplemental benefits (Skopec, et al., 2019). Reasons for the hesitancy stem from multiple factors including the cost to fund a new benefit, the return on the investment of a new benefit, the lack of experience in delivering benefits that address social needs, and the tradeoff of offering a new benefit at the expense of a current benefit. Medicare Advantage plans do not receive funding from CMS to provide benefits that are above and HOUSING SUBSIDIES 20 beyond the Part A and Part B benefits offered in traditional Medicare. As previously mentioned, supplemental benefits offered by MA plans are funded using rebate dollars. The average amount of rebate dollars available in 2019, per member, per month, was $107. So, while the definition was expanded providing the opportunity to create new benefits, the funding for those additional supplemental benefits did not increase. Skopec et al. (2019), discovered that meal delivery was the most common expanded benefit following CMS’ announcing more flexibility, and in addition, some MA plans were also offering benefits that supported improvements in home safety, personal care workers, and adult day care. Leaders in Medicare Advantage plans have reported some skepticism that benefits offered to address social needs may not reduce medical expense utilization, like hospitalizations, ED visits, and other medical services, necessary, to provide a return on the investment to cover the cost of the benefit (Skopec, et al., 2019). Adding new benefits can also have an impact on existing benefits. For example, removing or reducing a current benefit, in order to offer a new benefit can impact member satisfaction which can result in a lower star rating. A lower star rating directly influences the amount of rebate dollars available to support supplemental benefits which often attract new members and provide an advantage over competitors (Skopec et al., 2019). Research supports the importance of combining medical care and social services to improve the overall health outcomes of certain populations while at the same time reducing costs (Canavan, et. al., 2016). The authors of the foundation report, call out three areas with the greatest potential for impact, including, housing support, nutritional assistance, and case management. Identifying the people most likely to benefit from social services is the most effective way to capture the benefit (Canavan, et. al., 2016). HOUSING SUBSIDIES 21 Passage of the CHRONIC Care Act, provided additional flexibility for MA plans, beginning in 2020, to offer Special Supplemental Benefits for members with certain chronic conditions that would improve or maintain the health function of the member (Kornfield, et al., 2021). The passage of the act signals a shift in Medicare policy, signaling that other influences, besides medical services, impact health. MA plans are able to offer benefits that promote health but may not be defined as medical. Benefits to prevent, cure or diminish disease have been included. Benefits to aid in improving a member’s functioning as well as improving symptoms can be offered. Benefits can also be tailored to select member cohorts, for example, individuals with one serious chronic condition that is life threatening or significantly impacts overall health. Members who are at high risk for hospitalization or who may require intensive care coordination. An additional challenge for Medicare Advantage plan leaders who plan to design and offer benefits to address social needs is their experience in delivering the benefits (Skopec, et al., 2019). Reliance on a community based organization may be necessary but concerns regarding the band width of community based organizations to deliver the services and more importantly the MA plan’s willingness to relinquish control to a third party could prove to be problematic (Skopec et al., 2019). Many plans are in unfamiliar territory when it comes to partnering with community based organizations. Build versus buy is an important discussion when considering benefits that address social risk factors and while it might make sense to contract with a community organization, building referral systems and monitoring quality are initiatives that need to be addressed. Some Medicare Advantage plans are leading out. Anthem, with headquarters in Indiana, offers Medicare Advantage products in multiple states and covers over 43 million members. In 2020 Anthem offered members in select markets the option to choose one new benefit from a HOUSING SUBSIDIES 22 menu of 10. The options ranged from acupuncture and massage visits to meal delivery, following hospitalization or for members with a hemoglobin A1c over 9, to pest control services, access to a dietician, or an annual allowance to support a service dog (Hostetter & Klein, 2020). Value Based Insurance Design or VBID, is administered by CMS through the CMS Center for Medicare and Medicaid Innovation (Center for Medicare and Medicaid Services [CMS], 2019). The model is intended to reduce Medicare expenditures, improve quality of care, and improve the efficiency of care delivery for Medicare members. In 2020, VBID interventions included increased access to tele-health services, supplemental benefits designed to address certain health conditions and socioeconomic status for low income and dual eligibility members and health and wellness planning. In calendar year 2021, VBID introduced the option for MA plans to design a hospice benefit, historically covered by traditional Medicare, for MA members. Maintaining member satisfaction and building member loyalty are high priorities for Medicare Advantage plans. Additionally, Medicare Advantage plans will need to identify interventions that will address and impact the social risks of their beneficiaries, avoiding medical complications and improving adherence to prescribed medications (Teigland, et al., 2020). Housing Cost Burden Fenelon & Mawhorter (2021), report that the cost of housing has surpassed the increase in income in the United States for more than 30 years, while at the same time population of older adults continues to rise, and older adults face a larger financial burden than do working adults. The convergence of these facts is shining a light on housing affordability, or the lack thereof, for older adults and generating scholarly and public policy discussions. Housing is a fundamental determinant of health (Fenelon & Mawhorter, 2021). 23 HOUSING SUBSIDIES Following retirement, most older adults rely on fixed incomes. The majority of income, 65% for retired older adults, comes from social security. Social security represents more than 90% of income for over one-third of retired older adults (Social Security Administration, 2014). Fenelon & Mawhorter (2021) suggest the challenges that are faced by post-retirement fixed income older adults, both homeowners and renters. While the majority of older adults own a home, 26% experience cost burden and for the 21% of older adults that are renters, more than half are cost burden (Joint Center for Housing Studies, 2019). Renters are a particularly vulnerable cohort because they are subject to rising rents and have few protections from rising housing costs compared to homeowners. Encountering the housing cost burden predicament often leads to a reduction of expenditures on necessary items or an unstable housing situation (Fenelon & Mawhorter, 2021). Many older adults have paid off home mortgages, however, there has been a steady increase in the percent of older adults who hold a mortgage, and over a period of twenty years the percentage has increased from 25% as reported in 1998 to 37% in 2019, and even without a mortgage, homeownership requires the payment of property taxes and housing maintenance costs. (Fenelon & Mawhorter, 2021). In research conducted by Herbert, et al. (2021), an acknowledgement of the increase in the number of adults holding a mortgage was referenced, as was a significant increase, on average, in the loan to value ratio of the mortgage, which increased from 13% in 1989 to 39% in 2016, suggesting that the amount of the mortgage compared to the value of the property had grown. Black and Hispanic homeowners are more likely to have mortgages as older adults, and homeowners aged 75 and older have the highest rate of foreclosure of any other age group (Fenelon & Mawhorter, 2021). HOUSING SUBSIDIES 24 High housing related costs can have significant consequences on older adult renters who are subject to rising rents while on fixed incomes. Older adults spending 30% or more of their monthly income on housing expenses are considered to have housing cost burden. In addition to the stress that results from the cost burden, they often reduce or forego food purchases, transportation, and medical care, all important to their overall health and quality of life (Stone, 2018). In 2012 older adult renters with significant cost burden reported reducing purchases associated with transportation by 67%, food purchases by 37%, and medical care by 51%. Similar results were reported by homeowners with high housing cost burden (Joint Center for Housing Studies, 2016). The lack of affordable housing in the United States is becoming an economic burden and more importantly, a health burden for older adults. Fenelon and Mawhorter (2021) write that housing is a fundamental determinant that influences an individuals’ health, financial security and quality of life. Housing affordability and security over a lifetime can positively influence the well-being of the older adult. Mortgage debt influences healthcare utilization according to Herbert et al. (2021). In their study, looking at pharmaceutical purchases, the researchers discovered that spending on medications increased by 25% when an individual’s mortgage was paid off, for those age 65 and older, and a 50% increase for the age group 50-64, suggesting that homeowners place housing cost over healthcare needs, and to reduce the trade-off, income supports and subsidies for adults 65 and older may be beneficial (Herbert et al., 2021). The population of older adults living in homeless or transitional shelters has increased by 76% in the last ten years (HUD, 2018). Availability of publicly subsidized housing and vouchers is inadequate to meet the current demand for the older adult population in need of rental HOUSING SUBSIDIES 25 assistance (Stone, 2018). According to a report published in 2012, waiting lists for those requesting support from Section 202 Supportive Housing for the Elderly Program, exceeded one year, on average (Vandawalker, et al., 2012). Some have argued that the use of nursing homes among Medicaid recipients with disabilities has a direct correlation to affordable housing (Crossley, 2018; Rosenbaum, 2016). The Bipartisan Policy Center (2016) released the Healthy Aging Begins at Home report that outlined an approach to ensure that older adults have adequate housing and an opportunity to successfully age in their communities of choice, regardless of their economic, health, or functional status. While the issues of housing cost burden are well recognized, many organizations are calling for increases in the federal programs that are currently in place to mitigate the housing cost burden faced by older adults. Despite the call for increases, federal funding is not keeping pace. Section 202 funding has not had an increase in capital funding, necessary to expand the number of housing units, since fiscal year 2011; and the funding that has been received is barely keeping up with costs (Stone, 2018). Reliance on government funding, with the myriad of competing priorities that face federal and state lawmakers cannot be the only solution. Other alternatives must be considered. It has been broadly referenced in many research studies that most older adults prefer to age in place (AARP, 2005). Finding ways to reduce the economic burden and in turn the health burden, will allow more older adults to age in place. The lone solution to the shortage of public and subsidized housing cannot be to increase the number of units by way of construction and acquisition. With competing priorities for federal funding, this would be very short sighted. Other alternatives need to be explored and considered. 26 HOUSING SUBSIDIES Public policy has included a limit on the increase of property taxes and in some municipalities property taxes are actually paid by local governments with a low interest loan that includes a lien against the property, with the intent of recovering the payment, including interest when the property is sold (Fenelon & Mawhorter, 2021). Studies have demonstrated that creating housing security among older adults, and in particular when federal rental assistance is extended, decreases the percentage of older adults reporting poor health, psychological distress, and delays in medical care. Housing programs that include supportive services may improve physical functioning and limit problems with older adults accessing medications. Unfortunately, federal foreclosure prevention programs supported through other federal programs no longer exist, and eviction prevention programs are scarce (Fenelon & Mawhorter, 2021). Project Aims This project was directed by the following aims: 1) understand the role of Medicare Advantage (MA) plans in delivering preventive medicine, improving quality of care, addressing the social determinants of health and reducing federal spending, 2) using semi-structured interviews, explore the perspective of stakeholders, including benefit designers and case managers in two MA plans to determine the attitudes and ideas of these representative health insurers in consideration of a housing subsidy for members experiencing housing cost burden as a means for improving the members’ quality of health, 3) summarize the findings in a white paper that includes a proposal for a housing subsidy, as a member benefit, for qualifying MA members, and as appropriate, and 4) design an elegant pilot study to gauge the impact of a housing subsidy on a subset of qualified MA members, comparing two markets in Salt Lake County with similar demographics. Briefly, one market would receive a subsidy for a 12-month HOUSING SUBSIDIES 27 period, while the other market would serve as a control group. Metrics to determine outcomes will be identified and recommended. Rationale for the Project: Current Scope of MA Plans Private insurers contracted with Medicare to offer Medicare Advantage plans submit an annual bid that represents the amount the MA plan will spend to cover part A and Part B benefits for plan members. The bids are evaluated based on benchmark data that is county specific. Plans that exceed the benchmark data, receive funding at the benchmark level and in order to make up the difference, the cost to the member is increased, usually through an increase in the member monthly premium. Plans that submit bids below the baseline data are eligible for rebates. The rebates are based on the annual star rating the MA plan received the prior year. The rebates range from 50% - 70% of the difference between the bid and the benchmark. Rebates must be used to benefit members by offering additional supplemental benefits, reducing monthly premiums and out of pocket costs. Medicare Advantage plans are designed to reduce medical expense by keeping members healthy. The benefits offered in Medicare Advantage plans, which go well beyond the benefits offered in traditional Medicare, are designed to optimize member health and function. Members who are able to maintain a healthy lifestyle, manage their chronic conditions, consistently take medications as prescribed, and mitigate social determinants that put them at risk, reduce the likelihood of a hospital admission or readmission and a visit to the emergency room, where medical care is provided, most often, at the highest cost. Receiving care in the community, in an ambulatory setting or preferably at home, reduces cost and is most often the preferred choice of members. 28 HOUSING SUBSIDIES Method The method used for the project were: 1) an in-depth literature review of Medicare Advantage plans to understand the original objectives behind creating the plans, how the objectives have evolved, the impact on health outcomes, and the results of various benefit designs, 2) using the literature to develop a suitable interview guide to obtain rich interview data, and 3) semi-structured interviews conducted with three health insurance benefit design leaders/influencers and two health insurance case managers who were assigned to manage high risk patients. All of the interviewees represented three unique Medicare Advantage organizations, representing a variety of MA approaches in Western states. The interviews were designed to reveal the level of interest a Medicare Advantage plan may have for a housing subsidy, for qualified members. Key informants included two different disciplines within an MA organization, benefit design leaders and influencers, and case managers. Benefit design leaders were selected to understand how supplemental benefits are selected and implemented according to cost/benefit analyses. The interviews were conducted using a set of questions designed for benefit design leaders and a separate set for case managers (see Appendix A). The leader questions were developed with the intent of understanding the variety of supplemental benefits offered by the health plan, the process for identifying future benefits, the process for prioritizing and determining return on investment, and most importantly for the purpose of this project, understanding if a housing subsidy would be a feasible supplemental benefit. Case managers develop a plan of care designed to support the physical, emotional, and social needs of Medicare Advantage members. They work one on one with members and determine available resources, including supplemental benefits, that enhance quality of life. 29 HOUSING SUBSIDIES Interview questions for case managers were designed to understand, based on the experiences of the case manager, the supplemental benefits that are most important to members, the needs of members resulting from social risks, experience with housing issues, and how housing issues are addressed when identified. Semi-structured interviews were conducted with health insurance leaders from three separate Medicare Advantage plans; located in Utah, Southern California and Nevada. Interviewees were selected based on their influence and responsibility for benefit plan design. In addition, a case manager representing the Utah plan was interviewed and a case manager representing a Nevada plan was also interviewed. Case managers were selected based on their assignments working directly with MA members. Interviews were conducted using a virtual application that supports audio and video, with all parties enabling video, creating a virtual face-to-face interview. Each interview was approximately 45 minutes in length and allowed for follow-up questions that were not identified in advance, and the flexibility for the interviewee to guide portions of the interview. Results Key Informant-Stakeholders Benefit Design Informant 1 (personal communication, October 28, 2021) is a medical director for a Medicare Advantage plan in Southern California. The plan serves 70,000 Medicare members, including 1500 members living in institutional settings enrolled in a Special Needs Plan, I-SNP. Special Needs Plans serving members with severe or disabling chronic conditions, C-SNP, and members who have dual coverage, covered by Medicare and Medicaid, D-SNP, are also offered. Benefit Design Informant 1 has served Medicare beneficiaries, including the medically frail, for several years. HOUSING SUBSIDIES 30 The Southern California plan offers supplemental benefits to members including, acupuncture and chiropractic services, gym memberships, and a 24 hour physician and nurse advice line. Membership, particularly in the Special Needs Plans, includes members who represent more racial and ethnic diversity and are poorer than a traditional Medicare Advantage plan. Benefit Design Informant 1 stated, “the percentage of minority enrollees choosing a traditional Medicare Advantage plan, is increasing, as is the percentage of enrollees experiencing poverty, who choose a traditional MA plan.” Benefit Design Informant 1 described a benefit that highlights quality care and reduces medical expense, Using an assisted living facility instead of a skilled nursing facility for medical management and infusion services, is typically not an option, however an exception was granted using a waiver and MA members prefer the assisted living setting as it promotes more independence and privacy, and the MA plan recognizes a better quality of care and also a reduction in medical expense as the assisted living cost per day averages $300, versus a skilled nursing facility which averages $700-$800 per day. “Supplemental benefits offered to members are reviewed annually and most often, those benefits that reduce hospital admissions, rise to the top as the cost savings realized allows for implementation of additional supplemental benefits” (Benefit Design Informant 1, 2021). When asked about a supplemental benefit that addresses housing, Benefit Design Informant 1 stated, I’m not aware of any MA plans offering a supplemental benefit to address housing, I’m aware of housing challenges among MA members including, the availability of housing and more specifically safe housing, both in short supply, resulting in members moving into institutional settings sooner than necessary. HOUSING SUBSIDIES 31 Does a supplemental benefit addressing housing cost burden make sense? Benefit Design Informant 1 believes it does. Individuals often lose their dignity and privacy when they move to an institutional setting and their overall health can decline. However, a supplemental benefit may not be in the MA member’s best interest, if their housing is deemed unsafe, or is not aging friendly. Additionally, social isolation is an important consideration. Providing a benefit to a member who lacks the support of community, family, or other support group may not be beneficial. There are social benefits for many individuals who move to congregate housing, and their overall health may improve. Benefit Design Informant 1 continued, Like any supplemental benefit, understanding the value the benefit adds for members, as well as where the potential savings will be derived, are both important. A benefit to support housing, where more dollars are required to make an impact and an amount that will be greater than the amount for a typical benefit will require a pilot study, to show the value, and should include a control group with a focus on how it influences the rate of hospital admissions per 1000 members. The idea is to demonstrate an improvement in a member’s overall health, along with fewer visits to the hospital, and the medical expense savings necessary to provide the benefit. Skopec, et. al (2019) reported that on average, MA plans had $107.00 per member per month in 2019 to cover the cost of supplemental benefits, are congruent with Benefit Design Informant 1 regarding the importance of making certain that quality and cost are achieved. Benefit Design Informant 2 & 3 (personal communication, September 15, 2021) are charged with MA product and benefit design for a not-for-profit Utah based health insurance HOUSING SUBSIDIES 32 company. The company serves approximately 29,000 Medicare members in Utah and areas of Idaho and Nevada. A Medicare Advantage Health Maintenance Organization, or HMO, Health Maintenance Organization Special Needs Plan, or HMO-SNP, and a Health Maintenance Organization Dual Eligible Special Needs Plan, or HMO D-SNP, are products offerred by the health plan. The SNPs as the name indicates are tailored to meet the needs of MA members who have certain diseases and chronic conditions. In addition to covering services offered from traditional Medicare, Parts A and B, the health plan also offers Part D, prescription benefit coverage. Benefits are also offered that cover dental, eye, and hearing services. More recent supplemental benefits include non-emergent transportation, covering travel for health care visits and prescription medications, companionship services, and meals for 14 days following a hospitalization. Benefit Design Informant 2 discussed the process for vetting supplemental benefits and using an example said, A benefit to lower the amount of cardiac rehabilitation visit co-pays was implemented with the intent to encourage members to complete the full course of rehabilitation. Completing rehabilitation increased the likelihood of the member having an improved quality of life, and any lost revenue to the health plan, that resulted from the lowering of the co-pay, was more than made-up in future medical expense avoidance. As a not-forprofit health plan, the benefits offered may not always have a monetary return on the investment. Decisions are made with a focus on member health, implementing those that improve the overall health of the member. Benefits are also offered to be market competitive, but also as a differentiator of other plans in the market. Benefit Design Informant 2 continues, HOUSING SUBSIDIES 33 Prioritization of a new supplemental benefit can be influenced by the number of members that will use the benefit along with the likelihood of reducing medical expense. When considering a new benefit, there is also a tradeoff, including whether to reduce or eliminate a current benefit, to allow for the introduction of a new benefit. Benefit Design Informant 3 added, Supplemental benefits are primarily designed to improve the overall health for the majority of MA members, but this strategy may only generate a small savings in medical expense. Another benefits strategy is designed for a smaller number of members but generates a large reduction in medical expense. In either scenario the health of the member is improved, and the savings gained can be a small amount for a large cohort and large amount for a small cohort. When asked about housing insecurity experienced by MA members, Benefit Design Informant 2 acknowledged, That MA members experience housing challenges, particularly those who are enrolled in the dual eligible, Medicare and Medicaid, special needs plan. While aware of the challenges, the cost required to have a meaningful impact on housing insecurity would lead to a reduction or elimination of existing benefits, and further-more a clear understanding of the value proposition would need to be quantified. It would require a big lift and it is a steep hill to climb to get the savings. When data is not available to ascertain the value of a supplemental benefit, Benefit Design Leader 3 said, I look to current literature to find reliable data showing the potential return on investment for a new supplemental benefit. Designing and implementing a pilot as a precursor to HOUSING SUBSIDIES 34 implementation is also given consideration, which I would recommend for determining the value of a housing benefit. Benefit Design Informant provides a measure of hope when it comes to a including a supplemental housing benefit: Don’t give up. If five years ago someone would have told me our health plan would be paying for dental, eye and hearing services, I would have said, no way! Now these benefits are table stakes to stay market competitive. With the exception of Parts A and B, benefits offered through a MA plan are not offered through traditional Medicare (Schwartz, 2019). However, Benefit Design Informant 2 shared, Congress is considering a proposal that would expand the benefits offered through traditional Medicare to cover dental, eye, and hearing services and products. If the proposal advances and becomes a law, Medicare Advantage plans will receive additional per-member per-month funding, based on benchmark data, to cover those benefits. This may free-up funds for additional supplemental benefits. Benefit Design Informant 3 also suggested, A partnership between Medicaid and the MA plan, that includes a portion of the subsidy covered by Medicaid and a portion covered by Medicare for the dual eligible members, including the use of grant funds that may also be available from community partners to support a housing benefit. The benefit design leaders and influencers are key to the establishment of supplemental benefits and to the return on the investment, not only focused on cost, but also focused on improving members quality of health. Not to be overlooked, to understand the MA population and the overall wellbeing of the population, are case managers who work closely with the MA HOUSING SUBSIDIES 35 members most at risk and who influence their health behaviors and address their physical, mental and social risks. Case managers are most often a registered nurse, RN, or a licensed clinical social worker, LCSW. Case managers develop trusting relationships with MA members which are necessary to assess the needs of the members. They assist in identifying supplemental benefits and other resources, including community resources, that will support members in their efforts to manage their chronic conditions, their mental health challenges, and their adherence to medication regiments. Case managers also assist in scheduling visits with medical providers, and arrange for laboratory testing and medical procedures, when necessary. In addition, they identify and work to address issues that are influenced by social risks. This can include addressing food insecurity and housing insecurity. As needs are identified that can potentially be met with a supplemental benefit that doesn’t currently exist, the case manager will often bring the issue forward to the attention of those with responsibility for benefit design, one way of identifying future supplemental benefits. Case Manager Informant 1 (personal communication, October 11, 2021) employed by the Utah health plan, reported the following, A case load for care managers consists of 65 Medicare Advantage members, unless those members have dual eligibility, meaning they are covered by Medicare and Medicaid, then the case load is reduced to 50 members. The case load is determined using a number of metrics including, frequency of emergency department visits, hospitalizations, readmission to the hospital within 30 days, behavioral health needs, and adherence to medication orders. I have a special assignment to work with dual eligibility members, in a HOUSING SUBSIDIES 36 pilot study, that includes community health workers, who focus on social determinants of health. This population of members are likely to have health and social complexities. When asked about any concerns regarding housing insecurities for MA members, Case Manager Informant 1 reports, Housing is a high need for many dual eligibility members. There is a shortage of subsidized housing and members are often on waiting lists for extended periods of time. Members been evicted from their homes for failure to pay rent and will often look to family members or friends, who may also face housing challenges. As an option, and in some situations, members are moved to congregate living facilities including assisted living and skilled nursing facilities. A supplemental benefit to pay for housing doesn’t currently exist, however Case Manager Informant 1 acknowledges, With financial support for housing the member could then afford food and medications. However, housing needs to be safe, and a good person-environment fit, and while a housing subsidy would be a great option, it may not be the best option for members who are in unsafe housing, housing that isn’t aging friendly, and where social isolation exists. It’s important for older adults to stay in their home, it allows for emotional stability and adds value. Leaving their home often brings grief and a loss of dignity, and older adults often view leaving their home as a death sentence stating, “I’m leaving my home to die.” Case Manager Informant 2 (personal communication, November 8, 2021) works for a private medical group in Nevada that serves 100,000 members of which 85% are Medicare Advantage members covered by three major private insurers contracted with the private medical HOUSING SUBSIDIES 37 group. Case Manager Informant 2 is a registered nurse who recently moved into a leadership role supervising a team of case managers. Case Manager Informant 2 reports, Case managers are assigned to a primary care clinic where they support providers, and members assigned to those providers and average a case load of 1500-2200 members. The case manager receives support from a medical assistant and working as a team, coordinate care for all assigned members, but with a focus on the high need, high utilizer members. During the interview the discussion turned to supplemental benefits and specifically the benefits most frequently used and gaps in services where benefits could have an impact. Case Manager Informant 2 reported, Transportation and meals are supplemental benefits that are most frequently used. However, housing is a significant challenge for many of the low income and dual eligibility members. Among Medicare Advantage members are members without homes, as a result of circumstance, or in some cases by choice. Often the community shelters are unable to accommodate people without homes during some periods and individuals are placed on a waiting list where it not uncommon to wait 3-4 months for a vacancy in a shelter. Individuals using oxygen are not accommodated and those in a wheelchair, are not accommodated, unless the wheelchair is a folding chair. Case Manager Informant 2 provided some interesting insight when a member is faced with a shortage of resources, stating, Case managers are able to predict the time of year when low income members begin to experience hardships. In September of each year, there is a drop in adherence to taking prescribed medications, tied to what is commonly referred to as the “donut hole.” The HOUSING SUBSIDIES 38 “donut hole” is a gap in Part D prescription drug coverage, which is uncovered amount between the maximum amount the insurer will pay, and when the catastrophic coverage begins. Members are unable to afford their medications during this period and rather than forgo rent and food, opt out of taking their medications. Case Manager Informant 2 was very much in favor of a supplemental benefit that subsidized rent and suggested, “a housing subsidy would make a significant difference for low income and dual eligibility members who often sacrifice medications and, in some situations, medical care and nutritious food, to pay for housing.” Case Manager Informant 2 added an observation, Some members are reluctant to move into congregate housing, like assisted living or skilled nursing facilities, because their monthly income will be absorbed by those institutions to provide services. Many will forgo shelter to keep their income because they believe they are giving up their freedom and independence. Synthesis of Key Informant Comments The primary themes derived from the responses and feedback from each of the interviewees include, 1) Medicare Advantage members experience housing insecurity, including lack of affordable, safe, and aging friendly housing, and those most impacted are members who are enrolled in special needs plans, most often members in a dual eligible, Medicare and Medicaid plan. 2) Housing insecurity exacerbates chronic health conditions and results in members foregoing healthcare services and reducing compliance with their prescribed medications. Additionally, members more frequently end up in a hospital emergency room and experience a higher than expected rate of hospitalizations. 3) CMS has allowed MA plans to offer more flexibility in benefit design, including offering nonmedical supplemental benefits. 4) 39 HOUSING SUBSIDIES A housing benefit may not be in the best interest of members experiencing housing insecurity when it perpetuates social isolation or residing in unsafe housing. 5) The cost associated with a housing supplemental benefit may require the elimination or reduction of another benefit, and finally, 6) a pilot would be required to show the impact of a housing benefit that would include improvement in the overall health of the member receiving the benefit and a reduction in medical expense to the health plan by a reduction in emergency room utilization and hospitalizations. While one interviewee mentioned some reluctance to the prospect of introducing a housing benefit in the short term, all of those interviewed had a positive response to the idea and agreed that the need should be addressed. Discussion The Potential Value of a Housing Supplemental Benefit Traditional Medicare is limited in the benefits that are offered to eligible Medicare members. Benefits addressing social risks are not available to those who select traditional Medicare for healthcare coverage. While traditional Medicare currently enrolls a higher percentage of Medicare eligible older adults, a trend is developing signaling that more older adults are opting for Medicare Advantage plans. This is due to the attractiveness of low-cost and no-cost monthly premiums, the variety of supplemental benefits offered, and a focus on prevention and wellness. Additionally, MA plan leaders, responsible for developing benefits, are becoming more creative in addressing the needs of members, by expanding the menu of supplemental benefits, particularly with the flexibility that has been granted to the plans by Medicare in the last few years. The amount of research conducted on social determinants and social risks is growing and revealing the importance of addressing the risks in order to impact the overall health of HOUSING SUBSIDIES 40 individuals and communities. Housing insecurity is a social risk that impacts families but becomes a much more significant issue for older adults, particularly when they transition to a fixed level of income in their retirement years. Medicare Advantage plan representatives who were interviewed, acknowledge the housing challenges of MA members. These challenges include the lack of affordable housing, aging friendly housing, and safe housing. Those most familiar with the needs of members, social workers and nurses, acting as case managers, work to identify benefits and other community resources to improve the overall health of MA members, reporting that members are waiting for months and even years to secure affordable housing and they have personally worked with members who are evicted from their homes and, in a few circumstances, have ended up without housing. Housing cost burden impacts members of the community who are paying 30 percent or more of their income towards housing. Renters experience housing cost burden at a higher percentage than homeowners. Demographically, renters are persons of color, have lower levels of education, and experience a higher percentage of poverty, compared to homeowners. There are no differences in these characteristics in the older adult population. The innovation that occurs within Medicare Advantage plans provides an opportunity to design and propose a pilot study. The Medicare Advantage members that have the highest likelihood of benefiting from a housing benefit are members who have dual eligibility, meaning they receive medical coverage from Medicare and Medicaid, simultaneously. Medicaid is a joint program that is funded with federal and state funds. States have different requirements. Medicaid supports low income members and provides some additional services like in-home personal care services as well as HOUSING SUBSIDIES 41 coverage for the cost of a skilled nursing facility. Most if not all of a member’s medical care will be fully covered with the dual coverage. Dual eligibility members are most often renters, and, as such, fit into the demographic outlined above. That is, they are more likely to experience housing cost burden, are people of color, and they have lower educational attainment. They may also have experienced a lifetime of low wage jobs and presently live on fixed incomes. These members also have multiple health comorbidities with multiple health complications that can be challenging to manage. They are also “high utilizers” of healthcare and the health system. High utilizers, by definition, experience multiple visits to hospital emergency departments, have multiple hospital admissions, experience mental health issues, and are often socially isolated. Because of their poverty, which is often intergenerational, these individuals experience multiple social risks that include housing insecurity, inadequate and unsafe housing, food insecurity, unsafe neighborhoods, and communities that are impacted by noise and air pollution. In order to maintain their housing, they often forego other necessities that support their quality of health. A Pilot Proposal to Explore the Value of a Housing Benefit Within MA Plans The National Science Foundation (n.d.) defines a pilot study as a small, preliminary exercise that is intended to be a test, or trial run, used to improve a program prior to expanding the program on a larger scale. A pilot study is necessary in order to determine the feasibility and more importantly the value, which is the measured improvement of a member’s health, compared to the cost to achieve that improvement, of a Medicare Advantage housing supplemental benefit (Teisberg, et al., 2020). HOUSING SUBSIDIES 42 Salt Lake County is the largest county in the State of Utah with over 1 million residents. Salt Lake County also has the greatest percentage of households renting a home when compared to all other counties in the state (Benway & Pace, 2020). Within Salt Lake County, Salt Lake City is the largest city in the county and leads all other cities in the county with the highest number of renter households, with close to 48 percent of city residents in rental residences (Benway & Pace, 2020). Salt Lake City also has the highest number of households with income below the poverty level. The percent of the retirement age population living in Salt Lake City is comparable to percentages for Salt Lake County and the state. This proposed pilot study will include Medicare Advantage dual eligibility members living in the Salt Lake City. Members from the communities of Fairpark, Jordan Meadows, Rose Park, Westpointe, Glendale and Poplar, are represented by two zip codes, 84104 and 84116. Kem C. Gardner Policy Institute (2020) reports these communities as having the highest percentage of households with income below the poverty level, 20.1 percent and 20.2 percent respectively. Older adults living within the 84104 zip code represent 7.8 percent of residents, and 8.7 percent of the residents in 84116 are older adults, the socioeconomic factors in all communities are quite similar. The average monthly rent for the two zip codes combined is $959 (Benway & Pace, 2020). The average Social Security benefit in 2021 is $1,543. Using these two variables, cost calculation show that an older adult would be spending 62% of their income on rent. This assumes that Social Security is their only source of retirement income. Sample The study sample will represent Medicare Advantage members who have dual eligibility, Medicare and Medicaid coverage, living in Salt Lake City zip codes, 84104 and 84116. These HOUSING SUBSIDIES 43 two zip codes have the highest percentages of poverty in the city. These MA members will reportedly be using, at minimum, 30% or more of their income to cover rent and utilities. Study Method Dual eligibility members living within the boundaries of the geographic area will be selected using stratified simple random sampling. Two hundred members will be randomly selected. Half selected from zip code 84104, will receive a housing subsidy and the other half representing the second zip code 84116, will not receive a housing subsidy. However, all other benefits and supports, for example the support of a case manager, will remain in place for all members. This study will be approved by the Health System Institutional Review Board. Hypothesis The study hypothesis is that a housing supplemental benefit for eligible MA members will reduce housing cost burden and improve the quality of health for the member and reduce the medical expense for the Medicare Advantage plan. The medical expense will be reduced by a decrease in utilization including fewer visits to the ED, fewer hospitalizations, and fewer ambulatory visits. The savings are expected to exceed the cost of providing the benefit. The housing benefit that will be offered is $600 per month. The benefit was calculated using the average Social Security payment in 2021, $1,543, and the average rent in the two zip codes, $959. A housing cost reduction of $600 per month would bring the net rent to $359, 23% of income, well below the defined housing cost burden percentage of 30%. Variables Impact will be measured using three categories of variables: health status, housing status, and subjective well-being. Health outcomes will include the impact on healthcare utilization, including, hospital emergency department visits, unscheduled hospital admissions, adherence to HOUSING SUBSIDIES 44 medications and treatments, missed scheduled provider appointments, and any new diagnosis or condition the member may receive. Medical expense attributed to the member will also be tracked. Housing measures will include, missed rent payments, utility shut-offs, evictions resulting in a move to another house, and evictions resulting in homelessness. Subjective wellbeing will be measured using two broadly used and well recognized scales, the Perceived Stress Scale (PSS) (Cohen and Mermelstein, 1983), and the Quality of Life Scale (QOLS) (Burckhardt and Anderson, 2003) (see Appendix B). The Perceived Stress Scale was selected because it has been widely used as an instrument to measure perceived stress across many types of individuals and situations. The scale is easy to understand and designed for individuals with at least a junior high education. The PSS has a reported reliability of Cronbach’s  of .78 and a validity r = .26 to r = .36 (Cohen & Williamson, 1988). Similarly, the QOLS is a reliable instrument and has been validated in multiple studies. Burckhardt and Anderson (2003), report Cronbach’s  = .82 to .92, and a validity r = 0.78 to r = 0.84. The scale has been used in studies with individuals experiencing chronic diseases including, chronic obstructive pulmonary disease, cardiac disease, osteoarthritis, and diabetes (Burckhardt & Anderson, 2003). Demographic variables will also be collected including age, ethnicity and race, gender identification, income level, number in household, employment status, and number of chronic conditions—all these demographic data points will be obtained by the case manage using the MA member’s record. Prior to the start of the pilot, baseline data for the three categories along with demographics will be reported by the case manager. The pilot will run for one calendar year. During the year, cost and utilization data, for the two groups, will be gathered and reviewed quarterly. HOUSING SUBSIDIES 45 Additionally, health status, housing status, and objective well-being data will be gathered prior to the study, at 6 months, and at 12 months, the end of the study. The study coordinator, who will be blinded to members assignment within the study, will gather the objective wellbeing data using a telephone interview at pre-study, 6 months and post-study. At the end of the calendar year, a final analysis will be conducted for the two groups, to assess the impact of the housing benefit. Data Management and Analysis Data will be deidentified, cleaned and entered into SPSS 28 to be analyzed by our statistical team using Repeated Measures Analysis of Variance to determine differences between the control condition (no benefit) and the experimental condition (received housing benefit). I predict that among the sample of people who received the housing benefit, 1) housing security will remain stable or improved for the majority of individuals, 2) health status will remain stable, and any noted declines in health will be explainable by factors other than hospital emergency department visits, admission unscheduled hospital admissions, adherence to medications and treatments, missed scheduled provider appointments (for example a new cancer diagnosis or other intervening health event), and 3) well-being, as measured by the Perceived Stress Scale and Quality of Life Scale will be stable or improved. This modest pilot study will provide preliminary justification for developing a new benefit for certain dual eligible MA plan members that may suggest a larger fully powered cost/benefit analysis. Once the information as outlined above has been gathered and compiled, the results will be published for review for Medicare Advantage benefit design leaders and influencers. A 46 HOUSING SUBSIDIES recommendation will also be included in the published document. The likely recommendations will include, adoption of a supplemental benefit, not offering a supplemental benefit, or if merited, continuing the pilot with or without adjustments in order to gather additional information. Thinking ahead, one plausible option that could tie to the recommendation to adopt a supplemental benefit is using the housing subsidy as a bridge until the member can access government subsidized housing or more affordable housing that eliminates any housing cost burden. Conclusion Gervenak and Mike (2021) report every dollar spent by CMS for Medicare Advantage results in more benefits to the MA member and lower cost sharing for the member, compared to traditional Medicare. The overall per-member-per-month cost for MA plans is slightly lower when comparing the same cost for traditional Medicare and MA members receive benefits above and beyond the benefits offered in traditional Medicare (Gervenak and Mike, 2021). Medicare is a higher overall value. Throughout this paper an effort has been made to demonstrate the value of Medicare Advantage plans, specifically in their ability to deliver a higher quality of health for members, that in recent years also includes addressing the social risks of their members. When compared to traditional Medicare, MA plans demonstrate a higher value. In addition, the writing has included the innovation exercised by Medicare Advantage plans in terms of supplemental benefit design, adjustments to accept changing payment models, and efficiencies in medical care delivery. Medicare Advantage plans have been shown to have a higher percentage of members from racial and ethnic minority populations as well as low-income members. Medicare Advantage plans also HOUSING SUBSIDIES 47 offer Special Needs Plans, SNP, that focus on specific member cohorts including dual eligibility members, members in institutional settings, and members with severe chronic conditions. While relatively new, Medicare Advantage plans are working to define benefits to address social determinants of health, with no additional funding from CMS. The top social risks include food insecurity, transportation, housing instability, and social isolation (Non Partisan and Objective Research Organization [NORC], 2021). Many MA plans are leading out offering benefits for in home support, non-medical transportation, and meals following a hospitalization. Addressing social determinants is relatively new for most health plans and health systems and it requires coordination and partnering with community based social services organizations that have managed and are much more familiar with social risks (NORC, 2021). Cost burdens associated with housing impact the overall health of individuals and left unaddressed result in a lower quality of life and the potential for homelessness and moves to higher cost institutional settings. Several private health insurance companies have provided funding for affordable housing projects in various locations in the United States (Kabel and Stewart, 2021). These contributions have been capital investments to fund building projects. While there is no known housing supplemental benefit offered by an MA plan at this time, it is conceivable that a benefit would be designed and offered to eligible members in the near future. Conducting a pilot study, as recommended, will provide the data and facts necessary to make an informed decision. 48 HOUSING SUBSIDIES References AARP. (2005). 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Evaluation of the section 202 demonstration predevelopment grant program. https://www.huduser.gov/Publications/pdf/ HUD493_Section_202.pdf Westphal, E. (2019). Managing chronic disease in an evolving healthcare environment. Generations – Journal of the American Society on Aging, Supplement, 4-7. https://web-aebscohost-com.ezproxy.lib.utah.edu/chc/pdf?vid=21&sid=5072c295-0f34-4a62-86673f7c64fce395%40sessionmgr4007 Willink, A., & DuGoff, E.H. (2018). Integrating medical and nonmedical services – The promise and pitfalls of the CHRONIC Care Act. New England Journal of Medicine, 378(23), 2153-2155. https://www-nejm-org.ezproxy.lib.utah.edu/doi/pdf/10.1056/NEJMp1803292 58 HOUSING SUBSIDIES Appendix A Semi-Structured Interview Questions Semi-structured, in depth, individual interviews were conducted with benefit designers and influencers representing two separate Medicare Advantage plans. Care managers, representing Medicare Advantage plans were also interviewed. The interview best fits this project as interviews allow for collecting insights into opinions, experiences, and motivations of those being interviewed (Hak, 2004). Pre-defined, open-ended, questions and topics will guide the interview. The purpose for using open-ended questions is based on the recommendations of Singleton & Straits (2017), which includes seeking information based on opinions, and the intensity with which those opinions are held. 59 HOUSING SUBSIDIES Questions for MA Benefit Designer Date: Name: Position: Organization: MA Plans & Enrollment: 1. What type of benefits are offered by your MA plan outside of the traditional Medicare benefit? Vision, dental? 2. Research suggests that more MA enrollees are low income and more diverse. Are you seeing this demographic change in your MA plan membership? 3. In 2018 when Medicare allowed MA plans more flexibility in benefit design, particularly for non-medical benefits, did your MA plan offer any additional benefits? 4. I recognize that there are many suggestions for benefits and all of them are pitched to reduce medical expense, mostly through lower ED visits and admissions. Are there any benefits in particular where you are seeing this play out? 5. I’m aware of some health insurance organizations, like Humana, making investments in housing in an effort to increase the inventory of low income and or affordable housing. Is your organization investing in housing? 6. What is the process for prioritizing benefits and then determining ROI? 7. In your opinion, does a housing subsidy benefit make sense, would you see a need? Is there any consideration for a benefit tied to housing security? 8. Is a pilot an option for determining if a housing subsidy has merit? 9. What dollar amount would you say is reasonable for a housing benefit? 10. Are decisions made on improving the overall health, with cost reductions to follow? Or the other way around, cost reductions as a primary focus with overall health to follow? 60 HOUSING SUBSIDIES Questions for MA Case Manager Date: Name: Position: Organization: MA Plans & Enrollment: 1. What benefits do you consider to be most beneficial to MA members? 2. What gaps do you identify when talking to members; what members need vs. benefits available? 3. How do you discover and then address MA Members with social determinants needs? 4. Describe your case load? 5. Are you working with dual eligible, Medicare/Medicaid members? Special needs populations? 6. How is the case load assigned? 7. Have you encountered MA members who struggle with housing? 8. When a housing need is identified, what solutions are available? Are there any current supplemental benefits that help? 9. I’m exploring the idea of offering a benefit, in the form of a subsidy or payment, for rent or housing expense, for members who experience housing insecurity. Do you see a need for this type of benefit? 61 HOUSING SUBSIDIES Appendix B Scales Perceived Stress Scale The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by circling how often you felt or thought a certain way. Name __________________________________________________________ Date _________ Age ________ Gender (Circle): M F Other ____________________________________ Never 1 In the last month, how often have you been upset because of something that happened unexpectedly? 2 In the last month, how often have you felt that you were unable to control the important things in your life? 3 In the last month, how often have you felt nervous and “stressed”? 4 In the last month, how often have you felt confident about your ability to handle your personal problems? 5 In the last month, how often have you felt that things were going your way? 6 In the last month, how often have you found that you could not cope with all the things that you had to do? 7 In the last month, how often have you been able to control irritations in your life? 8 In the last month, how often have you felt that you were on top of things? 9 In the last month, how often have you been angered because of things that were outside of your control 10 In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? 0 Almost Never 1 Some times 2 Fairly Often 3 Very Often 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 62 HOUSING SUBSIDIES Scoring: PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 & 4 = 0) to the four positively stated items (items 4, 5, 7, & 8) and then summing across all scale items. A short 4 item scale can be made from questions 2, 4, 5 and 10 of the PSS 10 item scale. Please feel free to use the Perceived Stress Scale for your research. Mind Garden, Inc. [e-mail] www.mindgarden.com References The PSS Scale is reprinted with permission of the American Sociological Association, from Cohen, S., Kamarck, T., and Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386-396. Cohen, S. and Williamson, G. Perceived Stress in a Probability Sample of the United States. Spacapan, S. and Oskamp, S. (Eds.) The Social Psychology of Health. Newbury Park, CA: Sage, 1988. 63 HOUSING SUBSIDIES Quality of Life Scale (QOL) Please read each item and circle the number that best describes how satisfied you are at this time. Please answer each item even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the relationship. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Material comforts home, food, conveniences, financial security Health - being physically fit and vigorous Relationships with parents, siblings & other relatives- communicating, visiting, helping Close relationships with spouse or significant other Close relationships with spouse or significant other Close friends Helping and encouraging others, volunteering, giving advice Participating in organizations and public affairs Learning- attending school, improving understanding, getting additional knowledge Understanding yourself - knowing your assets and limitations - knowing what life is about Work - job or in home Expressing yourself creatively Socializing - meeting other people, doing things, parties, etc. Reading, listening to music, or observing entertainment Participating in active recreation Independence, doing for yourself Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 7 6 6 5 5 4 4 3 3 2 2 1 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 7 6 6 5 5 4 4 3 3 2 2 1 1 HOUSING SUBSIDIES 64 Instructions for Scoring the Quality of Life Scale This form of the Quality of Life Scale (QOLS) has 16 items rather than the 15 found in the original Flanagan version. Item #16, “Independence, doing for yourself” was added after a qualitative study indicated that the instrument had content validity in chronic illness groups but that it needed an item that reflected the importance to these people of remaining independent and able to care for themselves. The instrument is scored by summing the items to make a total score. Subjects should be encouraged to fill out every item even if they are not currently engaged in it. (e.g., they can be satisfied even if they do not currently participate in organizations. Or they can be satisfied about not having children.) Missing data can be treated by entering the mean score for the item. If you wish to compare scores in your groups with any scores that have been published, please be aware that most of the Burckhardt references published so far use the 15 item scale. More recent and forthcoming publications all use the 16 item scale. So be sure to check the methods section of the reference before comparing your means to published ones. If you have further questions, please write to me or call. Carol S. Burakhardt, PhD, RN Professor of Mental Health Nursing School of Nursing - SNMH Oregon Health Sciences University 3181 SW Sam Jackson Park Road Portland, OR 97201-3098 phone - [phone] FAX - [phone] e-mail - [e-mail]