Medicaid managed care and childhood immunization delivery

Childhood immunization rates can be used as a barometer of the quality of care delivered to children. Medicaid managed care has the potential to improve childhood immunization delivery by implementing population-based medicine in primary care. Studies of immunization rates under Medicaid managed care have found mixed results; in some settings immunization rates were higher for children covered by Medicaid managed care than for children covered by fee-for-service Medicaid, but in other settings immunization rates were similar for children in the two types of Medicaid programs. In most studies, overall rates were well below national guidelines for all populations enrolled in Medicaid.

Study provides LOS benchmark data on 57 conditions, by ICD-9 and DRG codes

Data Library: Length-of-stay benchmarks by ICD-9, DRG codes, managed care vs. FFS. A new study comparing thousands of discharges within 57 different categories shows HMO lengths of stay similar to FFS. The data come from practicing surgeons' opinions and guidelines from actuarial firm Milliman & Robertson. See how your rates compare.

Health care utilization by the elderly in HMOs: comparing risk and cost contracts

Data are utilized collected from the American Association of Health Plans, a trade association representing HMOs, to study differences in utilization patterns between medicare beneficiaries enrolled in Medicare risk and cost contracts with health plans. Utilization is measured by the number of ambulatory procedures performed, outpatient and emergency room visits, and acute and nonacute discharges. Compared to elders enrolled in risk plans, those in cost arrangements appear to exhibit higher inpatient and outpatient use. Members of for-profit plans experienced greater outpatient visits, accreditation did not appear to influence utilization, and IPA arrangements resulted in a decrease in outpatient utilization. Financial and policy issues are discussed.

Report finds Medicare HMO members are younger, healthier and lower cost than FFS seniors

Data File: Are managed seniors healthier than those in fee for service? A recent study by the U.S. General Accounting Office looks at disenrollment rates and costs of chronically ill Medicare HMO members in California. The findings support the much-disputed theory that seniors enrolled in HMOs are younger, healthier, and lower cost.

Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients

CONTEXT

The worst outcome of critical care may not be death itself; rather, the worst may be an extended death process in which a patient's and his or her family's suffering has been prolonged by services that are ultimately impotent. We have previously used potentially ineffective care (PIC) as a proxy measure for this type of care.

OBJECTIVE

To determine if PIC is delivered less often to Medicare patients enrolled in health maintenance organizations (HMOs) than those in traditional fee-for-service health plans.

PATIENTS

All Medicare patients hospitalized in intensive care units in California during fiscal year 1994.

OUTCOME

Potentially ineffective care was defined as the concurrence of in-hospital death or death within 100 days of hospital discharge and resource use (total hospital costs) above the 90th percentile.

METHODS

Hospital costs were adjusted for institution-specific cost-to-charge ratios and local wage indices derived from Health Care Financing Administration cost reports. A multivariate regression model adjusted PIC rates for age, sex, race, elective admission to the hospital, Charlson index diseases, the 15 most common diagnosis related groups for death by 100 days, intensive care unit size, and number of residents at the hospital.

RESULTS

A total of 3914 (4.8%) of 81 494 patients experienced PIC and used 21.6% of total intensive care unit resources. The occurrence of PIC was less common among HMO members (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87). However, HMO members were not more likely to experience in-hospital death (adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.07) and only slightly more likely to experience death by 100 days after hospital discharge (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.15).

CONCLUSIONS

Patients who experience PIC outcomes are not uncommon in the Medicare population, and patients experiencing this outcome consume a disproportionate amount of medical resources. Medicare beneficiaries in HMO practice settings had a lower risk of experiencing PIC outcomes after adjusting for age, sex, diagnosis, comorbid conditions, and characteristics of the treating hospital. This suggests that HMO practices may be better at limiting or avoiding injudicious use of critical care near the end of life.

Biased selection and Medicare HMOs: analysis of the 1989-1994 experience

This article presents the results of an analysis of the preenrollment and postdisenrollment experiences of Medicare-risk HMO enrollees. The results indicate that in the 6 months prior to their enrollment, new HMO enrollees use on average 37 percent fewer services than do beneficiaries in traditional fee-for-service Medicare. Furthermore, HMO disenrollees use 60 percent more services in the six months after disenrollment than do fee-for-service beneficiaries. Finally, new enrollees had relatively lower chronic-condition expenditures and mortality rates, whereas disenrollees had higher values for both. These findings suggest that the overall results, in part, reflect permanent differences between the HMO and fee-for-service Medicare populations. Moving to an annual enrollment with a 90-day cooling-off period appears to be a reasonable approach to addressing these differences in enrollees.

The Medicare-HMO revolving door--the healthy go in and the sick go out

BACKGROUND

Enrollment in Medicare health maintenance organizations (HMOs) is encouraged because of the expectation that HMOs can help slow the growth of Medicare costs. However, Medicare HMOs, which are paid 95 percent of average yearly fee-for-service Medicare expenditures, are increasingly believed to benefit from the selective enrollment of healthier Medicare recipients. Furthermore, whether sicker patients are more likely to disenroll from Medicare HMOs, thus raising average fee-for-service costs, is not clear.

METHODS

We used Medicare enrollment and inpatient billing records for southern Florida from 1990 through 1993 to examine differences in the use of inpatient medical services by 375,406 beneficiaries in the Medicare fee-for-service system, 48,380 HMO enrollees before enrollment, and 23,870 HMO enrollees after disenrollment. We also determined whether these differences were related to demographic characteristics and whether the pattern of use after disenrollment persisted over time.

RESULTS

The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group. Beneficiaries who disenrolled from HMOs re-enrolled at about the time that their level of use dropped to that in the fee-for-service group.

CONCLUSIONS

These data show marked selection biases with respect to HMO enrollment and disenrollment. These biases undermine the effectiveness of the Medicare managed-care system and highlight the need for longitudinal and population-based studies.

Variations in cataract extraction rates in Medicare prepaid and fee-for-service settings

OBJECTIVE

To compare rates of cataract extraction in 2 prepaid health settings and in traditional fee-for-service (FFS) settings.

DESIGN

A cross-sectional analysis using 1993 health maintenance organization (HMO) Medicare claims and encounter files, the Health Care Financing Administration (HCFA) 5% Medicare Part B provider/supplier file, and the HCFA October 1992 100% Medicare population file.

SETTING

Southern California Medicare FFS settings and the staff-model and independent practice association (IPA) plans of a large California HMO.

PATIENTS

1993 Medicare beneficiaries aged 65 years and older. The study included 43387 staff-model HMO enrollees, 19050 IPA enrollees, and 47 150 FFS beneficiaries (a 5% sample of all Southern California FFS beneficiaries).

MAIN OUTCOME MEASURE

Age and risk-factor adjusted rates of cataract extraction per 1000 beneficiary-years.

RESULTS

After controlling for age, sex, and diabetes mellitus status, FFS beneficiaries were twice as likely to undergo cataract extraction as were prepaid beneficiaries (P<.01). Female FFS beneficiaries were nearly twice as likely to undergo the procedure as were male FFS beneficiaries (P<.001); there were no extraction rate differences by sex in the prepaid settings.

CONCLUSION

Because of the potential implications for vision care in the elderly, the significantly different rates of cataract extraction in FFS and prepaid settings warrant further clinical investigation to determine whether there is overuse in FFS vs underuse in prepaid settings. Such investigations must assess the appropriateness of cataract surgery by evaluating its use relative to clinical need.

Ambulatory care visits of physician offices, hospital outpatient departments, and emergency departments: United States, 1995

OBJECTIVES

This report describes ambulatory care visits in the United States across three ambulatory care settings-physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for aggregated ambulatory care visits and for each setting.

METHODS

The data presented in this report were collected by means of the 1995 National Ambulatory Medical Care Survey (NAMCS) and the 1995 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of providers. The NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates.

RESULTS

During 1995 an estimated 860.9 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.3 visits per person. Visits to office-based physicians accounted for 81.0 percent of ambulatory care utilization, followed by visits to emergency departments (11.2 percent) and outpatient departments (7.8 percent). Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. Less than two-thirds of ambulatory care visits by black persons were to physician offices. There were an estimated 126.1 million injury-related ambulatory care visits during 1995, or 48.2 visits per 100 persons.