ISSUE BRIEF October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era Courtney Harold Van Houtven Walter D. Dawson Professor Assistant Professor Department of Population Health Science Department of Neurology Duke University School of Medicine Oregon Health & Science University School of Medicine ABSTRACT TOPLINES ISSUE: The impact of the COVID-19 pandemic on Medicare home health Data on COVID-19 infection has received little attention. rates in home health are not systematically reported. GOALS: Understand the effects of COVID-19 on Medicare home health beneficiaries, providers, and policies, and examine changes to improve Home health could be an home health care during and after the pandemic. important care option for METHODS: An analysis of the current Medicare home health sector, Medicare beneficiaries during including interviews with home health agencies, and a review of recent the pandemic. policy changes. KEY FINDINGS: Data on COVID-19’s impact on home health are lacking. COVID-19 infection rates among Medicare beneficiaries and the workforce have not been systematically reported during the pandemic. Federal policy changes made in response to COVID-19 have provided financial support to home health agencies, expanded provider licensures to certify use of home health, facilitated wider use of telehealth, and increased flexibility in Medicare Advantage plans. CONCLUSION: Home health care is well positioned to provide services to Medicare beneficiaries. However, the current design of the Medicare home health benefit is not sufficient to meet the needs of postacute beneficiaries. Policy changes could potentially increase the value of the Medicare home health benefit in the COVID-19 era. Questions also remain about the relative quality of services, particularly among home health agencies working with Medicare Advantage plans. Medicare and Home Health: Taking Stock in the COVID-19 Era 2 INTRODUCTION WHAT DOES MEDICARE CURRENTLY COVER The COVID-19 pandemic has upended the entire health FOR HOME HEALTH? care delivery system in the United States, including home health. Older adults and individuals with What It Covers underlying chronic health conditions are at greater risk Eligibility for home health services through Medicare for complications and death from COVID-19, the very hinges on an individual’s homebound status. The two population served by Medicare’s home health benefit.1 Yet primary groups eligible for home health services are the full impact of COVID-19 on Medicare beneficiaries and 1) individuals who need postacute, skilled care after the home health workforce remains unknown. a hospitalization, and 2) individuals with longer- term, skilled care needs that do not typically follow a To better understand these effects, we analyzed peer- hospitalization. reviewed and grey literature on Medicare home health, interviewed home health providers about their Until 2013, a narrow interpretation of eligibility for those experience during the pandemic, and examined recent in this second group who require continuous skilled federal policy changes made in response to COVID-19. The care had been a barrier to home health care for many findings suggest that the current design of the Medicare beneficiaries. However, the Jimmo v. Sebelius settlement home health benefit is not sufficient to meet the needs of agreement clarified that Medicare coverage of services, postacute beneficiaries. Changes to the benefit could allow including home health, is based on individuals’ need for more Medicare beneficiaries to receive services in their skilled care and not their potential for improvement. own homes, rather than institutional settings, so they may This reaffirms that Medicare must cover the cost of reduce their exposure to COVID-19. home health care for beneficiaries with long-term skilled care needs.2 Exhibit 1 Medicare Exhibit 1. MedicareFee-for-Service Fee-for-Service Spending onPostacute Spending on PostacuteCare, Care,Fiscal Fiscal Year Year 2017 2017 Long-term-care hospitals $4.3 billion 7% Inpatient rehabilitation facilities $7.9 billion 13% Skilled nursing facilities $28.7 billion 49% Home health $18.0 billion 31% Data: Medicare Payment Advisory Commission, 2019. Data: Medicare Payment Advisory Commission, 2019. Source: commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 3 Medicare beneficiaries who need postacute care can FINANCING HOME HEALTH choose among home health, skilled nursing facilities (SNFs), or long-term-care hospitals, and beneficiaries with Sources of Public Funding different preferences may select different options (Exhibit 1). Medicare is the single largest payer of home health Home health includes skilled nursing care, such as services, accounting for $40 billion in fiscal year 2018, physical and occupational therapy, speech language followed by Medicaid ($35 billion in fiscal year 2018).7 This therapy, and medical social services delivered in an $40 billion accounts for 5.3 percent of the $750 billion in individual’s home. Location may drive an individual’s total Medicare spending and more than 31 percent of total choice of setting, as home health is not available in some Medicare spending on postacute care (Exhibit 1). rural areas; the vast majority of providers (84%) are Medicare payment for these services remains a located in urban areas.3 Perceived quality also could drive contentious policy issue. Medicare margins are viewed setting choice, as postacute care quality in an SNF has as high, leading the Medicare Payment Advisory been shown to be higher than in home health.4 Finally, Commission (MedPAC) to recommend a reimbursement availability of a caregiver at home may drive setting choice cut for future years.8 The large amount of federal funding because many basic services needed posthospitalization, directed to this benefit underscores the importance of such as meal preparation, are not covered by Medicare. efforts to ensure Medicare home health is both sustainable and cost-effective for the long term. What It Doesn’t Cover Medicare’s home health benefit is not a long-term services Medicare Payment and supports (LTSS) program, and it does not provide In recent years, the Centers for Medicare and Medicaid unlimited coverage. It is restricted to skilled care (rather Services (CMS) has changed how it pays for home health than support of instrumental activities of daily living, services in an attempt to reduce costs while improving which is covered by Medicaid) and covers fewer than eight quality and outcomes. In 2020, CMS implemented a hours per day and less than 28 hours per week.5 new prospective payment system with a new case-mix These limitations mean that Medicare beneficiaries who classification model, the Patient-Driven Groupings Model. require skilled care and help with activities of daily living The new system shifts reimbursement toward bundled need to secure and coordinate two providers under two payments based on patients’ clinical characteristics rather payment systems: Medicare and either Medicaid or private than fee-for-service payments based on the volume of pay. These beneficiaries may be at risk for poor outcomes therapy visits. Providers receive two separate payments: because of lack of coordination between providers. Home one when care is initiated and the second when the health aide shift changes alone, for example, are associated episode of care is complete, with the episode of care with increased likelihood of hospital readmission within reduced from 60 days to 30 days. 30 days of initial discharge.6 Thus, better care coordination The new prospective payment system should produce a within and across agencies likely could improve home 3.4 percent payment increase for rural providers in 2020, health beneficiary outcomes. on top of existing differences in home health payments between urban and rural areas because of rural add-on payments.9 Yet there is limited evidence that rural add-on payments increase access for rural residents. Rural add-on payments also may not improve quality, as current evidence indicates that quality of care is better in urban areas compared with rural areas.10 commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 4 Other efforts to reduce home health costs while improving Differences in Use by Race/Ethnicity quality and outcomes include the Value-Based Purchasing Racial and ethnic minority groups who use home health Model, implemented in nine states since 2016.11 Value- are more likely than white beneficiaries to have poor based programs support CMS’s mission to provide better health outcomes, including more emergency department individual care and achieve better population health at visits and rehospitalizations.15 Emerging evidence also lower cost by using incentive payments to health care shows these same populations are disproportionally providers.12 impacted by COVID-19, compared with other populations requiring home health.16 DEMOGRAPHICS: WHO USES HOME HEALTH? Despite evidence of poorer outcomes, delayed access to Medicare home health services does not seem to be a Number of Beneficiaries and Providers factor. Overall, there is little evidence of access barriers by Approximately 4.5 million people used some form of home race or ethnicity, with nonwhite beneficiaries more likely health in 2016 (Exhibit 2).13 Most home health users (78%, or to receive services compared with white beneficiaries.17 approximately 3.5 million) were Medicare beneficiaries. Understanding whether there is differential access to high-quality agencies by race and ethnicity and uncovering More than 12,000 home health agencies are registered other driving factors will be critical to understanding in the United States, and the vast majority (81%) are why certain groups using home health have poorer health for-profit entities.14 outcomes. Exhibit 2. Demographics, Characteristics, and Chronic Conditions of Users of Postacute Care Home health Skilled nursing facilities Age Under 65 18.1% 16.5% 65 and older 81.9% 83.5% Sex Male 39.1% 35.4% Female 60.9% 64.6% Race/Ethnicity Hispanic 7.4% 5.4% Non-Hispanic White 76.1% 75.1% Non-Hispanic Black 12.9% 14.3% Other 3.7% 5.1% Chronic conditions Alzheimer’s and other dementias 32.3% 47.8% Arthritis 59.6% 26.2% Diabetes 45.1% 32.0% Heart disease 55.0% 38.1% Hypertension 88.9% 71.5% Note: Definition of heart disease varies slightly by setting. Data: Adapted from Lauren Harris-Kojetin et al., Long-Term Care Providers and Services Users in the United States, 2015–2016, series 3, no. 43 (National Center for Health Statistics, Feb. 2019). commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 5 HOME HEALTH WORKFORCE: WHO ARE THE In a recent survey, 92 percent of home health agencies PROVIDERS? reported lower revenues since the pandemic began, with Approximately 2 million people work as personal care nearly two-thirds reporting a revenue decline of at least 20 aides, and another 800,000 work as home health aides percent; smaller, stand-alone agencies likely experienced serving Medicare, Medicaid, and private-pay patients greater financial challenges than larger agencies.21 with diverse needs.18 There is some overlap in the work COVID-19 infection rates among Medicare home health of personal care aides and home health aides despite beneficiaries or agencies have not been reported during differences in the training and certifications that are the pandemic, and any in-person services are provided required. Home health aides are primarily female (88%), without a clear understanding of whether workers or with a median age of 45 and no formal education beyond beneficiaries are infected. In contrast, data on nursing high school (50%). More than half of home care workers facility cases, including workers and beneficiaries, have are nonwhite, and one-quarter were born outside the been collected and released.22 United States. Lack of Personal Protective Equipment and Median wages among home health aides vary by region Respiratory Services but tend to be low; in 2017, the average hourly wage of home health and personal care aides in the U.S. was Like many health care providers, home health agencies $11.12.19 Wages have been stagnant during the past 10 years often struggle to maintain an adequate supply of personal with a mere 10 cents per hour gain in real terms. One-third protective equipment (PPE), which is essential to protect of home care workers live below 138 percent of the federal both providers and consumers from the spread of poverty level, and 18 percent are uninsured. Paid sick leave infection. These challenges have received far less national and other employment benefits are uncommon. attention than the shortages experienced in other settings, such as SNFs and hospitals. Little formal training is required of the home health workforce, although for providers certified by Medicare Rural agencies also lack skilled respiratory services and Medicaid, home health aides must have 75 hours of compared with urban agencies.23 This could be a training and pass a competency exam. significant problem during COVID-19 because these providers facilitate patient lung function recovery. Providers of skilled rehabilitation services in home health, such as occupational or physical therapy, receive COVID-19 POLICY AND REGULATORY CHANGES much higher wages, reflecting their formal training and licensure. CARES Act HOME HEALTH DURING COVID-19 The Coronavirus Aid, Relief, and Economic Security (CARES) Act, the $3 trillion COVID-19 stimulus plan Initial Reductions in Demand and Access to passed by Congress on March 23, 2020, allocated $100 Patients billion to health care providers. Of this, $50 billion Medicare home health beneficiaries are particularly has been distributed to hospitals and LTSS providers, vulnerable to COVID-19 because of advanced age, including home health agencies that bill Medicare, but prevalence of chronic conditions, and recovery there is little reporting on the proportion allocated to posthospitalization. Two COVID-19 phenomena have these agencies.24 significantly reduced use of home health care: substantial The CARES Act allows nurse practitioners, clinical nurse decreases in elective surgeries and reluctance of Medicare specialists, and physician assistants to certify and recertify beneficiaries to allow providers into their home out of fear a Medicare beneficiary’s eligibility for home health of infection.20 commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 6 services.25 Prior to the CARES Act, only physicians were POLICY IMPLICATIONS allowed to make this determination. This temporary policy Several policy changes could potentially increase the value change may be particularly helpful in areas with limited of the Medicare home health benefit in the COVID-19 era. provider availability, including many rural communities. However, the change also may increase the risk of Expand Opportunities to Provide Care at Home overutilization and open the door for potential fraud. • Better integrate home health, health care, and social care. Including social care programs and nonmedical Telehealth benefits in traditional Medicare is important for Effective March 1, 2020, Medicare beneficiaries were addressing all of an individual’s needs and could help provided sweeping expanded access to telehealth services. integrate LTSS (including home health) into the health However, the ability for home health agencies to bill care system and particularly benefit individuals Medicare for telehealth remains limited, as only in-person recovering from COVID-19.29 visits can be reported on the claim.26 • Create a more robust benefit for postacute care Limiting the ability to bill for telehealth may reduce the at home. As structured, Medicare’s coverage of potential for fraud and overbilling of Medicare. However, postacute care at home is inadequate to meet the strengthening telehealth access could enable critical needs of many patients returning home from the monitoring of patient status at a time when beneficiaries hospital. If Medicare were to cover more than one are not eager to have providers visit their homes. Overall, home health visit per day, it could help close the expanded telehealth billing authority could reduce unmet quality gap between SNF and home health care, needs for home health users. avoid unnecessary institutional postacute care, and reduce costs.30 Expanding the coverage conditions for telehealth home health visits also could help address Medicare Advantage the postacute care needs of patients recovering from CMS gave Medicare Advantage (MA) plans more COVID-19. regulatory flexibility so they could avoid disruptions in • Pay family caregivers supporting COVID-19 patients’ care and offer more nonmedical benefits.27 This builds recovery. Training and paying family caregivers on CMS’ changes in 2019 allowing MA plans to provide to care for patients during the postacute period non-health-related benefits and cover in-home care could accelerate patients’ recovery from COVID-19 services, caregiver supports, and palliative care.28 Such and prevent costly, negative outcomes for both supplemental benefits may be particularly useful for beneficiaries and caregivers.31 Medicare also could beneficiaries who require home health care and could help support family caregivers by providing PPE to complement the care Medicare fee-for-service covers, protect them from infection while they care for family including meal delivery, nonmedical transportation, members recovering from COVID-19 at home. home modifications to support home living, and other social supports. Bolster the Home Health Workforce • Increase pay of home health aides to improve the quality of care. Although home health agency reimbursement is already tied to regional wages, CMS could add a wage and benefit increase to payments for home health aides. Such a wage premium could help address the extra hazards involved in providing commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 7 direct care during a pandemic. Increased benefits such • Report COVID-19 data. Given the lack of publicly as paid sick leave also could promote safety during the available information about COVID-19 infections pandemic and beyond by reducing the need for aides to among Medicare home health beneficiaries and the work and earn when they are sick. These changes also workforce, the government could require that agencies could help address worker shortages (already a problem report these data, as nursing homes are required to do. before COVID-19), increase retention, and lead to higher Ideally, these reports would be distinct from general quality of care in the long term.32 population case reporting and could establish greater parity of COVID-19 data between home health agencies • Expand scope of practice. As previously discussed, the and skilled nursing facilities. CARES Act allows nurse practitioners, clinical nurse specialists, and physician assistants to certify a person’s need for home health. Yet their scope of practice CONCLUSION beyond this remains limited. Making these expansions The impact of COVID-19 on Medicare home health services permanent and evaluating other expansions in scope of is not fully understood. More research is needed on practice could help support and enhance the quality of how COVID-19 affects home health use, particularly for the home health workforce. populations experiencing disparities in accessing care. Home health is well positioned to offer services to Enhance Quality and Oversight individuals in their own homes, which is an increasingly • Expand regulatory oversight of home health agencies important care option during the pandemic. However, the to motivate adoption of best practices. Increasing current design of the Medicare home health benefit is not oversight, which is currently limited, and allowing sufficient to meet the needs of postacute beneficiaries. public access to agencies’ emergency preparedness plans could improve their responses in future Policy options for addressing this problem include pandemics. increasing pay for home health aides; bolstering allowable visits (including telehealth) for rehabilitation and • Reduce knowledge gaps. Data on use of home health by monitoring; providing enhanced regulatory oversight; and Medicare Advantage enrollees are limited, and the data expanding providers’ scope of practice beyond the changes that do exist appear to show that home health agencies in the CARES Act. Careful evaluation of rule and policy included in MA plans are of poorer quality compared changes could help identify any unintended consequences with those in traditional Medicare.33 Expanding MA and elucidate whether the benefits of such initiatives exceed plans to cover non-health-related benefits, such as the costs. palliative care or in-home support services, could change the quality of home health care overall for MA enrollees. Evaluating home health quality and outcomes by MA status could determine the relative benefit of these added services, especially during the COVID-19 pandemic. commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 8 NOTES 1.“People at Increased Risk for Severe Illness,” Centers 13. Lauren Harris-Kojetin et al., Long-Term Care Providers for Disease Control and Prevention, June 25, 2020. and Services Users in the United States, 2015–2016, series 3, no. 43 (National Center for Health Statistics, 2. Centers for Medicare and Medicaid Services, Jimmo v. Feb. 2019). Sebelius Settlement Agreement Fact Sheet (CMS, Feb. 20, 2014). 14. Harris-Kojetin et al., Long-Term Care Providers, 2019. 3. Medicare Payment Advisory Commission, Report to 15. Jo-Ana Chase et al., “Relationships Between Race/ the Congress: Medicare Payment Policy (MEDPAC, Mar. Ethnicity and Health Care Utilization Among Older 2020). Post-Acute Home Health Care Patients,” Journal of Applied Gerontology 39, no. 2 (Feb. 2020): 201–13. 4. Rachel M. Werner et al., “Patient Outcomes After Hospital Discharge to Home with Home Health 16. Matthew A. Raifman and Julia R. Raifman, Care vs. to a Skilled Nursing Facility,” JAMA Internal “Disparities in the Population at Risk of Severe Illness Medicine 179, no. 5 (May 1, 2019): 617–23. from COVID-19 by Race/Ethnicity and Income,” American Journal of Preventive Medicine 59, no. 1 5. Centers for Medicare and Medicaid Services, Medicare (July 2020): 137–39. Benefit Policy Manual Chapter 7 — Home Health Services (CMS, Jan. 10, 2020). 17. Leighton Chan et al., “Disparities in Outpatient and Home Health Service Utilization Following 6. Guy David and Kunhee L. Kim, “The Effect of Stroke: Results of a 9-Year Cohort Study in Northern Workforce Assignment on Performance: Evidence California,” PM&R 1, no. 11 (Nov. 2009): 997–1003. from Home Health Care,” Journal of Health Economics 59 (May 2018): 26–45. 18. Joanne Spetz et al., “Home and Community-Based Workforce for Patients with Serious Illness Requires 7. Centers for Medicare and Medicaid Services, National Support to Meet Growing Needs,” Health Affairs 38, Health Expenditure Data (CMS, Dec. 17, 2019). no. 6 (June 2019): 902–09. 8.MEDPAC, Report to the Congress, 2020. 19. Spetz et al., “Home and Community-Based,” 2019. 9.MEDPAC, Report to the Congress, 2020. 20. Reed Abelson, “Hospitals Struggle to Restart Lucrative Elective Care After Coronavirus Shutdowns,” New 10. Hsueh-Fen Chen et al., “Quality Performance of Rural York Times, May 9, 2020; and Phil Galewitz, “Are Vital and Urban Home Health Agencies: Implications for Home Health Workers Now a Safety Threat?” Kaiser Rural Add-On Payment Policies,” Journal of Rural Health News, Mar. 25, 2020. Health 36, no. 3 (Summer 2020): 423–32. 21. Robert Holly, “HHCN Survey: 92% of Home Health 11. Alyssa Pozniak et al., Evaluation of the Home Health Agencies Have Lost Revenue Due to Coronavirus,” Value-Based Purchasing (HHVBP) Model (Centers for Home Health Care News, June 1, 2020. Medicare and Medicaid Services and Arbor Research Collaborative for Health, Dec. 2019). 22.“COVID-19 Nursing Home Data,” Centers for Medicare and Medicaid Services, June 21, 2020. 12. Centers for Medicare and Medicaid Services, “Value- Based Programs,” last updated Jan. 6, 2020. 23. Chen et al., “Quality Performance,” 2020. commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 9 24. Centers for Disease Control and Prevention, HHS Provider Relief Fund (CDC, June 16, 2020). 25.“Medicare Telemedicine Health Care Provider Fact Sheet,” Centers for Medicare and Medicaid Services, March 17, 2020; and “Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic,” Centers for Medicare and Medicaid Services, Apr. 30, 2020. 26. CMS, “Medicare Telemedicine,” 2020; and CMS, “Trump Administration Issues,” 2020. 27.“Information Related to Coronavirus Disease 2019 — COVID-19,” Centers for Medicare and Medicaid Services, Apr. 21, 2020. 28. Long-Term Quality Alliance and ATI Advisory, Meeting Medicare Beneficiary Needs During COVID-19: Using Medicare Advantage Supplemental Benefits to Respond to the Pandemic (LTQA and ATI Advisory, May 26, 2020). 29. Rachel S. Bergmans, Briana Mezuk, and Kara Zivin, “Food Insecurity and Geriatric Hospitalization,” International Journal of Environmental Research and Public Health 16, no. 13 (July 2019): 2294. 30. Rachel M. Werner and Courtney H. Van Houtven, “In the Time of Covid-19, We Should Move High-Intensity Postacute Care Home,” Health Affairs Blog, Apr. 22, 2020. 31. Werner and Van Houtven, “In the Time of Covid-19,” 2020. 32. Jennifer M. Reckrey et al., “Beyond Functional Support: The Range of Health-Related Tasks Performed in the Home by Paid Caregivers in New York,” Health Affairs 38, no. 6 (June 2019): 927–33. 33. Margot L. Schwartz et al., “Quality of Home Health Agencies Serving Traditional Medicare vs. Medicare Advantage Beneficiaries,” JAMA Network Open 2, no. 9 (Sept. 4, 2019): e1910622. commonwealthfund.org Issue Brief, October 2020 Medicare and Home Health: Taking Stock in the COVID-19 Era 10 ABOUT THE AUTHORS ACKNOWLEDGMENTS Courtney Harold Van Houtven, Ph.D., is a professor in The authors would like to thank Bob Thomas and Mary the Department of Population Health Science at Duke Kofstad for providing background and experience during University School of Medicine and Duke–Margolis Center the COVID-19 pandemic. In addition, recent collaborations for Health Policy. She also is a research scientist in the with Dr. Nathan Boucher and Dr. Rachel Werner have Center of Innovation to Accelerate Discovery and Practice informed our writing. Transformation at Durham Veterans Affairs Health Care System. Dr. Van Houtven’s aging and economics research interests encompass long-term-care financing, structure, Editorial support was provided by Laura Hegwer. and informal care. She examines how family caregiving affects health care use, expenditures, and health and work outcomes of care recipients and caregivers. Dr. Van For more information about this brief, please contact: Houtven is also interested in understanding how best to Courtney Harold Van Houtven, Ph.D. support family caregivers to optimize caregiver and care Professor recipient outcomes and in designing and evaluating care Department of Population Health Science models that heighten the ability for disabled older adults Duke University School of Medicine to remain at home to meet their preferences. She received courtney.vanhoutvenduke.edu her doctorate in health policy and administration from the University of North Carolina at Chapel Hill. Walter D. Dawson, D.Phil., is an assistant professor in the Department of Neurology, Layton Aging and Alzheimer’s Research Center at the Oregon Health & Science University (OHSU) School of Medicine. His research focuses on long-term-care financing and interventions to better support people living with Alzheimer’s disease and other dementias as well as their family care partners. In addition to an appointment at the OHSU School of Medicine, he is a Senior Atlantic Fellow for Equity in Brain Health with the Global Brain Health Institute at the University of California, San Francisco, and a faculty member at Portland State University’s Institute on Aging. Dr. Dawson also has direct experience working on national and state- level public policy including at the U.S. Senate Special Committee on Aging. He received his doctorate in social policy from the University of Oxford. commonwealthfund.org Issue Brief, October 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.