CHAPTER I DEFINITION OF THE PROBLEM INTRODUCTION Entitlement program reform has been an ongoing discussion in the past years because of the rapid increase in beneficiaries along with changes in available government funds to support these programs. With an increasing number of baby boomers and healthcare costs rising, spending on Medicare has been a topic of interest due to the financial impacts on the entire healthcare system. Advancements in medical technology along with more awareness to healthy lifestyles, people are living longer and healthier lives, which ironically puts a strain on the current healthcare system.Per patient spending is fluctuating for a variety of reasons, one being rapid changes in the market place as well as implementation of new programs. Furthermore, physician and hospital reimbursements continue to decrease while the number of chronically ill patients is on the rise. One key question that must be raised in regards to dollar amounts being spent along with areas of coverage and physician reimbursements is; how have the spending trends on Medicare impacted health outcomes for patients?In medicine, positive health outcomes is what the system is designed to improve and should be constantly evaluated and redesigned in efforts to capitalize on available funding. With different areas of coverage such as hospital spending, private office reimbursements, and prescription drug coverage, allocations to each area need to be assessed in efforts to find which area has the most influence on patient care.

With recent changes in per patient spending, health outcomes and improved health status with chronic conditions must be looked at in order to see how the adjustments in spending have impacted patient outcomes and overall health status.BACKGROUND Historical trends of funding for the Medicare program is readily available through The Center of Medicare and Medicaid Services (CMS) and current projection models are also available, but health outcomes become more complex when evaluating different chronic conditions. Some limitations to the funding trends are both external and internal events that have caused spending too rapidly increase or decrease. One example of this would be the introduction of the Medicare Part D program, which gave participants rescription drug coverage, but also increased allocated funds by 18%. The amount of money spent on healthcare fluctuates as technology and treatment improves, along with increased competition in the market place. By using per patient spending as well as evaluated changes in budget allocations, one can assume that some programs will show more benefits than others.

This would be a key finding when assessing how changes in government resources can contribute to the improvement of health outcomes with certain chronic diseases or how they could lead to digressions in patient care.In regards to evaluating health outcomes, many patients have four or more chronic conditions. As a result, health evaluations are broken down by disease state, patient demographics and are also classified by either mental or physical health. A disproportionate amount of spending is used to treat patients with multiple conditions, which is a large issue that most people coming into the Medicare program are worried about. As of 1996, CMS implemented a program called the Health Outcomes Survey (HOS), which tracks Medicare patients’ subjective health measures throughout their time in the program.The program not only evaluates physical well-being, but it also evaluates mental health which is a key outcome when attempting to improve overall quality of life.

This program has been criticized by some, but due to lack of access of health records on an individual basis, the HOS will be used to evaluate the trends in mental and physical health outcomes in comparison to national trends. HOS is the first health outcomes survey that measures outcomes from Medicare patient groups in a managed care setting.The patients selected to participate in the HOS are gathered from a number of different Medicare + Choice Organizations, also known as M +CO.

The objective of the program is to evaluate how well the plans are managing, maintaining and improving patient care. To measure the quality of care given over time, patients from select plans are randomly chosen to take surveys evaluating physical and mental health status in a given year and are then followed up in two years to monitor any changes in health status. The surveys ask a number of subjective questions with a focus on many different areas of the patients’ current and historical lifestyle.

The questions are also very simply stated with a limited number of basic answers to choose from, making the process of survey taking and follow up very straightforward for the participants. These data are used to help Medicare make informed decisions on how to improve the care given to individuals in all participating health plans. Once data from surveyed participants is received and broken down by each specific Choice Organization plan at State and local levels, researches attempt to find disparities in how each plan effectively delivers care.Patient demographics are also broken down by age, gender, educational level, ethnicity and other variables to find potential reasons for health improvement measure. Medicare hopes to find more individual methods of improving health and well being based on all the different components of each patient’s personal lifestyle and medical history. PURPOSE OF THE PROJECT The purpose of this research is to find a relationship between the changes in Medicare funding and the outcomes that the program produces for its patients.

RESEARCH QUESTIONSThis research paper will answer the following questions about overall trends in Medicare spending as well as outcomes for physical and mental improvements in the medical care provided by CMS. 1. How much has spending on the Medicare program increased or decreased in the last ten years? 2. What are some reasons for the fluctuations in spending? 3.

How have outcomes improved or worsened with regards to physical and mental health in the past ten years? 4. Is there a relationship between Medicare spending and health outcomes? ASSUMPTIONS/LIMITATIONSAssumptions incorporated into this research project were the following: -The spending data from CMS is completely accurate -All outcomes listed on HOS are valid and achieved with medical expertise. -Outcomes are going to be defined using current therapeutic recommendations and protocols. -The main limitation being faced is having access only to secondary data. Conclusions will be drawn from this data due to limited access and cannot account for external variables.

DEFINITIONS CMS- Center for Medicare and Medicaid Services HOS- Health Outcomes SurveyM + CO- Medicare + Choice Organizations GDP- Gross Domestic Product CHAPTER II LITERATURE REVIEW In 1965, Title XVIII of Medicare of the Social Security Amendment provided publicly financed health insurance to the elderly (Shi, 2008). Participants must be 65 years of age to meet the eligibility criteria. The program is considered an entitlement program because people contribute through taxes during working years, which also grants admission despite income level (Shi, 2008). One main benefit seen since the programs’ inception has been the reduction in racial and health disparities.Since anyone at least 65 years of age can enroll, patients have been treated despite race and disabilities, which is now being viewed as a model for treatment methods for the rest of the nation (Eicher, 2005). Enrollment numbers continue to rise each year with nearly 1 million new patients being added as beneficiaries of Medicare (CMS 2007).

Although spending figures usually focus on the elderly and those enrolled in Medicare, spending has also increased in all age groups from 1963 to 2000 (Meara, 2004).It is clear that spending is on the rise, but finding uniform quality measure reports can be difficult due to the lack of consistent quality measures used by hospitals. Funding for the program clearly comes from taxpayers, but the system still operates as a third-party system where payments are made to private insurers, such as managed care plans that provide care for specific populations (CMS, 2005). Using a private managed system to run the program has had scrutiny due to rising costs, and much attention has been given to a nationalized program such as those implemented in other industrialized countries (Benjamin, 2000).

Recent limitations on data regarding effectiveness of HMO’s suggest that they neither deliver the promised cost savings nor reduce regulatory burdens on government, which is a current argument regarding the efficiency of how the Medicare program is designed (Oberlander, 1997). Disparities in health outcomes produced from different plans in participating states is also an issue that some would argue in favor of due to the competition created by the released trends in outcomes. However, the program still has to maintain the role of providing and maintaining the best possible care for the patients.Spending for the program has grown significantly since the beginning of the 1960’s and has consumed an increasing percentage of the United State’s gross domestic product (GDP) as healthcare costs continue to rise. Since 1970, Medicare spending as a percent of GDP has risen consistently with spikes occurring in the early 90’s and 2000’s, with a total percentage of 10% as of 2006 (Hartman 2006).

An increase in Medicare spending came in 2006 when Part D was approved by President Bush. Part D gave Medicare recipients prescription drug coverage and increased spending to 1 trillion dollars or $7,026 per person (Catlin, 2008).This program was desperately needed because studies found that many Medicare patients with chronic illnesses decided not to take certain prescription drugs because out-of-pocket costs became too high making it unaffordable (Rector, 2004).

However, much criticism has been given to the program. Furthermore, many patients are being prescribed expensive medicines that their coverage cannot sustain for the entire year, causing those patients to fall into a doughnut hole where only out of pocket pay will get them out of it (Journal of Health Care Finance 2008).Along with the same notion of chronic illnesses, current studies are also showing that most of the spending growth being seen in recent years is contributed from patients with five or more conditions being treated (Thorpe, 2006). Some of this can be due to the rise in disease prevalence along with improved clinical treatment thresholds (Thorpe, 2006). Around one third of the Medicare spending comes from chronic illnesses with 60 percent of patients having five or more conditions (Health Business, 2008).This issue of spending raises questions on whether the one-third spent is effective treatment in creating improved outcomes and also begs the question of which conditions should more money be allocated to? (Meara, 2008).

Because the funding is public, some are wondering how taxpayers feel about where and how much of the Medicare dollars are being spent wisely (Gold, 2007). Spending for the program has slowed down in certain years due to changes in payment policy, regulations, and physician reimbursement reductions (White, 2008).In 2003, health care spending rose 7. 7 percent, which was less of an increase from previous years because of deceleration in Medicaid spending and supplemental funding provisions to Medicare (Smith, 2005). Projections for future spending suggest that it will outpace the GDP growth and by 2015 healthcare costs will be 20% of the GDP (Borger, 2006).

With an increase in enrollees along with spending, questions have been raised regarding the benefits of the Medicare program to its participants.Several survey methods have been created since the mid 1990’s and the current Health Outcomes Survey (HOS) is conducted every spring through CMS in order to measure patient outcomes and satisfaction with the program (hosonline. com). The goal of the survey is to gather valid, reliable, and clinically meaningful health status data from M + CO’s for use in quality improvement activities and public reporting (CMS 2008). Current reports on the HOS program have shown effectiveness in the surveys, but some improvements are still currently being made (HOSonline, 2004).By breaking down the available outcomes data provided by HOS, researchers can gain a better understanding of where and how future improvements can be made.

Other programs such as pay-for-performance and voucher benefit are being looked at as potential ways to increase health outcomes of Medicare beneficiaries (Ramos, 2007; Meng, 2006). One other measure being looked at is whether or not new technologies are appropriately being used for Medicare patients and whether the cost of the technologies is really worth the spending (Neumann, 2005).The government conducted processes discussed above are also being compared to the methods used by the Joint Commissions in hospitals across the nation to see if there is a difference between the two procedures (Griffith, 2002). Since patient populations of elderly vary across the nation, some physicians are looking at spending in different regions and relating them to certain outcomes for specific diseases in attempt to find a regional relationship (Fisher, 2003).

It is clear that one challenge being faced with current outcome evaluation methods is that there are many variables that effect how the data can be interpreted.As hospital payment procedures are becoming more performance based and consumers are asking for more transparency and competition, it would be in the best interest of the government to fully implement and improve the current methods of health outcomes. The current subjective program conducting research through the HOS is the only nationalized system available to date. Although lacking in the objective measure of health status, the HOS findings can still be beneficial in regards to evaluating the effectiveness of the Medicare program. CHAPTER III METHODOLOGYThe research study will consist of a policy analysis approach in order to compare past spending trends of the Medicare program with the outcomes recently documented based on the Health Outcomes Survey provided by CMS. There is sufficient data already available looking at spending allocations and epidemiology data in regards to where future spending will most likely occur.

The data will be viewed as overall trends of dollar amounts spent as well as percent increase in change from previous years. This data will be used in efforts to chart increases and decreases in spending for the last ten years.The effectiveness of the HOS will be used to compare the spending trends with outcomes. Data gathered from changes in both physical and mental health in each given cohort will be used to establish the success of the Medicare program.

As the surveys are recorded, answers to each question are categorized to ascertain how physical and mental health has changed over time. The results are given as a percent of which patients improved, remained the same or became better. Potential flaws and shortcomings of the HOS will also be researched in efforts to find a more effective and uniform way of measuring health outcomes among Medicare patients.

PROCEDURE Data Collection The current CMS website will mainly be used as the sole resource for past spending and allocation trends. Yearly total spending and per patient expenditures will be used to determine if a variance in spending or allocation could potentially have had an effect on the outcomes produced in the given time frame. As noted before, having a uniform method of evaluating health outcomes has been a challenge for both CMS and hospital systems in general, which is why the HOS system will be utilized at this time to evaluate the outcomes currently and historically produced by Medicare services.The first step will be to chart yearly spending trends looking back at the last ten years (since HOS started in 1998) and determine how many enrollees entered the program within those years. Since every year will have an increase in actual dollar amounts spent because of overall increased costs of healthcare and increased number of enrollees, differences in the percentage change will be used to verify fluctuations. An example would be if dollars spent increased from the previous year as a certain percent, but was less on an increase percent from the previous.In this scenario, the year would be considered a decrease in spending.

Per patient spending will also be used in efforts to provide an alternative way of viewing spending trends. The next step will be to view all outcome records from HOS and document whether the overall physical and mental health improvement rates increased or decreased in the given years of each cohort. The way the HOS determines their outcomes is by means of surveys given to specific cohorts or groups of M + CO enrollees every two years. A baseline survey was given in 1998 to a large sample, which was labeled as “Cohort 1. In 2000, the same available cohort members were given the same survey to determine whether their physical and mental health status stayed the same, improved or became worse. Each year new cohorts are sampled and a health follow up occurs two years later. The survey breaks down health status into two areas which are physical and mental health, creating an overall percentage of how these areas have improved or became worse. These data will be looked at to determine if the majority of patients became healthier mentally or physically or became worse.

Majority will be defined as greater than 50 % of the sampled patients becoming worse or getting better. The third step will be to look at whether the difference in spending and allocations could have had an impact on the outcomes produced and evaluated by the HOS. To keep things simple, each cohort follow up will be grouped as success or failure when compared to the spending trends in the given year. Sources of the Data The policy analysis will be using secondary historical data provided by CMS and HOS.

CMS will have spending data available for reporting as well as enrollment data.HOS has cohort data from 1998 until 2005 looking at subjective results in regards to patients currently enrolled in Medicare. More recent cohort will not be available until later years, which limits the number of actual data sets available for analysis.

Some hospital performance measure will be discussed in efforts to seek out alternative methods of evaluations but will not be taken into account when making a final conclusion. Most of the research will be done on-line, using the available outcome reports publicly available through HOS. DECISION CRITERIAHow Will the Data be Analyzed? In this specific policy analysis, the research will attempt to find a direct or indirect effect on the spending and allocation of dollars with the health outcomes produced for patients. Differences in skill and facility resources is an area in which HOS and other outcome measures fail to take into account, which is a challenge the program faces. With current guidelines establishing a standard of care, as well as uniform reimbursement amounts for Medicare patients, this has been an area that HOS cannot factor in when evaluating health outcomes.From the perspective of HOS, the purpose is to only look at outcomes on a case by case basis taken as one data pool in efforts to find out how well patients are doing under the blanket of Medicare services. This is why spending is going to be used as a comparator (independent variable), because it seems that recent policies in healthcare evolve around the notion that more taxpayer money can equate to better programs and in this case, patient care. Each year of spending will be compared to the overall outcome from the cohort and will be determined as either improved, stayed the same, or became worse.

If the majority of the patients in the cohort became healthier mentally and physically in the given time frame, this will be considered a success in the program, where if the majority became worse overall or died, it would be labeled as a failure. Those that remained the same will be grouped with those that felt better, because the role of medicine is to do no harm. Each success or failure will be correlated to the spending increase or decrease to find what percent of the ten years being analyzed produced positive outcomes.

The basis of the story being told will be very general, but due to the complexity of how the outcomes are reached and sampled, this will be the most accurate way of determining whether the Medicare program is successful or is in need of more work in particular areas. Since data from HOS is derived from a number of different Medicare + Choice Organizations in diverse States, the final result report is created from aggregate data recorded by each specific plan.The program evaluators use national trend data to compare the cohort data collected, which is used by CMS to compare the efficiency of the different M + CO plans, but for the purpose of this analysis, only national level data will be used. With both mental and physical health outcomes being used, an improvement in one or the other or both will be evaluated in efforts to find variances in how either measure is affected by the care given. The objective of the research is to find whether more money and changes in allocation equate to better patient care and outcomes.This will be evaluated without taking into account the many differences that exist in the process of actually delivering the care. Scope and Limitations Spending for Medicare and how many people who are enrolled may seem like easy variables to find and assess, but due to the complexity of the large bureaucratic system involved, these numbers can be challenging to find. CMS has a lot of figures and lists posted on the website, so the process may be easier than anticipated but some limitations of interpretation still exist.

The largest limitation involves not being able to evaluate differences in the delivery of care from different hospitals and physicians. Most hospitals have a quality measure program already implemented in their system, which may not be inline with how Medicare services views outcomes. This has been an ongoing problem within hospital systems but for the purpose of this research, specific hospital measures may have an impact on how the data is communicated, but will not be taken into account.With data being gathered from different M + CO’s, variances in plans is another limiting factor that becomes too complicated to asses, which is part of the reason why the HOS was designed. By breaking down outcomes specific to a particular M + CO plan, administrators can better asses where changes in the program can be made. The data is reported at a national level, then a state level and finally the specific plan data is analyzed.

By using national level data, limitations found in each individual plan are eliminated. One other limitation being faced is the dependency on the tatistics and figures used by the HOS. This will be the main source for evaluating outcomes which limits the data pool and data collection methods currently available. Because of the vast number of patients and high dropout rates, another limitation is not having consistent objective data that looks at scientific evidence of actual health measures. This is the number one area of criticism the program faces, but due to limited access to actual charts and follow up, subjective survey results will be the best method of evaluation available today. CHAPTER IV DATA ANALYSISThe first step in viewing spending trends is to look at the number of enrollees into the Medicare program since 1998. The following table lists those numbers according to CMS. Table 1 Number of enrollees entered into the Medicare program per year.

YearNumber of Enrollees 199838,432,477 199938,727,108 200039,199,460 200139,606,975 200240,066,786 200340,656,995 200441,674,955 200542,266,708 200642,950,586 200743,851,973 200844,960,543 It can be noted that the rise in actual patients entered into the program has been somewhat consistent with higher rises occurring between the years 2003 and 2004, along with a near 1. million increase from 2007 to 2008. Another important note to make regarding these data is that only a few years had less of an increase in patients as the previous year. An example would be the rise from 2004 to 2005 being only about half of the increase seen from 2003 to 2004. Although all numbers seem to increase, the overall percentage of increase fluctuates throughout the last ten years. One item that the figures do not address is the actual number of patients eligible for the Medicare program, which would be an interesting finding since some patients could have reached the age of 65, but chose not to enroll.Nonetheless, the numbers are quite large and one can see why the Medicare program is becoming so costly when patient enrollees never seem to remain the same or decrease. The increase in enrollees is one variable that most researchers fear due to the rising costs of healthcare along with the years of healthy living improving as well.

Projections for years to follow, only predict a continued increase in the number of enrollees into the Medicare program. The next table illustrates the amount of spending that has gone into Medicare since 1998. Table 2Amount spent in dollars and the percent change from the previous years. Difference in increase or decrease percent from previous year (1998-2008). YearDollars Spent in BillionsPercent Change from Previous Year Difference in Percent Change from Previous Year 1998209. 2 1999212. 81. 7 % 2000224.

45. 4 %+ 3. 7 2001247. 410.

2 %+ 4. 8 2002264. 87.

1 %-3. 1 2003282. 76. 8 %-0. 3 2004311. 210.

1 %+ 3. 3 2005339. 49. 1 %- 1.

0 2006402. 318. 5 %+ 9. 4 2007431.

27. 2 %- 11. 3 2008465. 17. 8 %+ 0. 5 It looks as if spending for the Medicare program has consistently risen in the past ten years.From 1998 to 2008, spending has gone up 255. 9 billion dollars (122%) with noticeable changes in 2001, 2004 and of course 2006.

The rapid increase in 2006 was due to the Medicare D prescription drug program discussed in previous sections and remains the largest percent increase in the last ten years. It is also noteworthy to find that in some years spending did not rise as much as the previous year, which would still be considered an increase due to the actual dollars having gone up, but a decrease as an overall percentage. An illustration of this occurrence would be from 2001 to 2002, where 17. billion dollars were spent which was an actual decrease of 3. 1% from the previous year. For the purpose of the current analysis, any year of spending which was not increased by the same percent as the previous year will be considered a decrease even though actual dollars did happen to rise.

With that being said, four years experienced a decrease in the amount spent compared to the previous year (2002, 2003, 2005, and 2007). By looking at both patient enrollees and the amount spent, per enrollee expenditures can be viewed in Table 3 along with the percent changes from the previous year.Table 3 Per patient expenditures from 1998 to 2008 in dollars and percent change from previous year. YearPer Patient ExpendituresPercent Change from Previous Year 19985,497 19995,550. 9 % 20005,7794 % 20016,3079 % 20026,6855 % 20037,0205 % 20047,5968 % 20058,1527 % 20069,48916 % 200710,0035 % 200810,3423 % To analyze these figures after evaluating the individual components of the number of overall enrollees and total spending independently is noteworthy to potentially discover a trend that is unique to what the previous charts have shown.Interestingly, the trends seen in Table 3 are consistent with the trends observed in the Tables 1 and 2, highlighting the same increases and differences of both tables.

The spike in 2006 caused by the implementation of Medicare part D is also highlighted in the graph along with demonstrating only two years in which the increase in amount of expenditures stayed the same, those years being that of 2002 and 2003. To be consistent with the evaluation of the actual dollars spent, years in which increases were not as high as the increases of the previous year will still be considered a decrease in spending.The years that would be considered a decrease from the year before based on Table 3 would be 2001, 2002, 2005, 2007 and 2008. The actual health performance measurement results from every cohort starting since 1998 are a key component to how Medicare assesses the success of how each M + CO delivers healthcare. Each cohort starts out with a high number of participants to be surveyed, but due to poor follow up and deaths, sometimes only 80% of the participants respond. Some examples of questions given to patients used to evaluate physical health status are as follows: -Does your health now limit you in climbing several flights of stairs? During the past 4 weeks, have you accomplished less than you would like with your work or other regular activities as a result of your physical health? -During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? -How much of the time during the past 4 weeks: Did you have a lot of energy? -Compared to one year ago, how would you rate your physical health in general now? -In general, would you say your health is:The choices patients have available to answer the above questions usually consist of options such as, excellent, very good, fair, poor, yes all the time, yes some of the time etc. Each answer is grouped into a category that would describe the patient as either feeling better, worse are staying the same.

Based on these types of questions regarding physical health, the following chart shows the performance measurement results for physical health. Table 4 Physical performance measurement results. Cohort Number and Corresponding YearsNumber of RespondentsPercentBetterPercent SamePercent Worse 1 (1998-2000)122,44414. 0%52.

1%33. 9% 2 (1999-2001)124,83514. 7%51. 5%33. 8% 3 (2000-2002)122,31715. 0%52. 2%32. 9% 4 (2001-2003)95,56514.

9%52. 5%32. 6% 5 (2002-2004)92,43414. 7%52. 6%32.

7% 6 (2003-2005)90,15414. 2%52. 2%33. 6% 7 (2004-2006)95,40215. 9%48. 8%35. 3% 8 (2005-2007)96,90515.

5%44. 6%39. 9% It is remarkable to find that each cohort produced pretty similar results when evaluating physical health.

The smallest percent of patients with improved physical health status was 14 % and the largest being 15. 9 %, which is pretty minimal.The consistency in this type of trend also holds true for those that felt the same as well as those that became worse. The largest percent of patients feeling the same being 52. 6 % and the smallest percent being 44. 6 %, with regards to those who felt worse the max percent was 39. 9 % and the minimum was 32.

6 %. Small variances were seen in each category, which could be contributed to the consistency of the questions being asked each year as well. There was also never a cohort in which the majority of patients felt worse than when originally assessed two years prior at baseline.The max percentage of patients that felt worse over time was 39. 9 % in Cohort 8, which is pretty impressive when taking into account that the data is evaluating trend from ten years ago.

The number of actual respondents decreasing towards the more recent years is an interesting finding as well, considering that the number of enrollees and eligible participants increased significantly in the last ten years. Many variables can contribute to this downward trend of actual participants, but one can only assume that CMS is making every effort to improve the response rates for future cohorts.In regards to many of the patients stating they feel the same as the previous two years, raises questions on how effective treatments are becoming as technologies continue to improve. Cohort 8 had the least percent of people claim they feel the same, which was also one of the cohorts with highest percentage claiming they felt better, which would counter the previous argument regarding newer treatment methods. Many interpretations can be made of the above physical measurements, but one must look at the entire data set including mental health performance measures before drawing any conclusions thus far.Mental health is an important health measure to evaluate especially in the elderly population. Many life changing events can occur in the years past the age of 65 and physical health can have a direct effect on mental health as well.

Some examples of the questions asked on the survey to evaluate mental health status are as follows: -How much of the time during the past 4 weeks: Have you felt calm and peaceful? -How much of the time during the past 4 weeks: Have you felt downhearted and blue? During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc. )? -Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now? -Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? -In the past year, have you felt depressed or sad much of the time?As seen in the questions asked to evaluate physical health, potential answers for mental health measurements included, yes or no, yes frequently, etc. The results from the questions regarding mental health are listed in the table below. Table 5 Mental performance measurement results. Cohort Number and Corresponding YearsNumber of RespondentsPercent BetterPercent SamePercent Worse 1 (1998-2000)122,44415. 3%63. 1%21. 6% 2 (1999-2001)124,83516.

1%62. 7%21. 2% 3 (2000-2002)122,31716. 1%62. 9%32. 9% 4 (2001-2003)95,56515. 7%64. 0%20.

3% 5 (2002-2004)92,43415. 9%63. 8%20. 3% 6 (2003-2005)90,15416.

%62. 8%21. 0% 7 (2004-2006)95,40222. 5%56. 3%21. 2% 8 (2005-2007)96,90523. 5%55.

9%20. 6% Trends seen in the mental health category are somewhat comparable to those recorded with the physical health measures. A few differences to be noted are that only Cohort 3 had over 30 % of respondents say they became worse over time, which was the case with all cohorts when looking at physical health. The difference in physical and mental health status becoming worse varied consistently by about 10 % for each cohort, illustrating that more people became worse overall in the physical health category.In regards to those patients that felt the same mentally, most cohorts had over 60 % make this claim, with the most recent two cohorts (Cohorts 7 & 8) being below 60 %. However, these two cohorts also experienced increases in the percentages for those that became better.

This trend was seen in the physical health measurements as well, which once again creates an interesting discussion on the effects of new advancements in medical treatments and technologies.The data trends for mental health performance are very positive and it appears that the majority of patients in each cohort are improving or feeling the same. A new patient starting out in the Medicare program would feel confident with the future of their healthcare if this data was available to them prior to enrollment. As described before, the criteria used to determine whether each cohort was considered a success of failure was to group those that felt the same or better into one category and compare those percentages to the participants that became worse.If over 50 % of participants experienced an improvement, the cohort would be considered a success, if less than fifty percent experienced progress, the cohort would be determined a failure. Tables 6 and 7 illustrate those figures for both physical and mental performance. Table 6 Final determination for physical performance measurements. Cohort Remained Same or BetterBecame WorseSuccess >50% or Failure 50% or Failure