Addressing the needs of chronically ill persons under Medicare

Are Managed Care Medicare Beneficiaries With Chronic Conditions Satisfied With Their Care?

OBJECTIVES

This article compares patient experiences of chronically ill older people in health maintenance organizations (HMOs) with other forms of Medicare supplemental coverage.

METHOD

Using data from the 1996 Medicare Current Beneficiaries Survey, the authors analyzed the experiences of chronically ill elderly with overall quality, access to care, and physicians' technical, interpersonal, and information-giving skills. Logistic models controlled for prevalent chronic conditions, functioning, perceived health status, sociodemographics, region of residence, and county-level Medicare HMO penetration.

RESULTS

Satisfaction with quality of overall care and physicians' skills was more likely for many conditions for those with private fee for service and Medicaid supplemental coverage, compared to Medicare HMO population. No insurance effects were found among elders who had none of the examined conditions.

DISCUSSION

Managed care may have negatively affected patients' perceptions of overall quality of care and doctor-patient interaction. Including additional and supplementary services to the delivery of care may improve satisfaction rates.

Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice

BACKGROUND

The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care.

OBJECTIVE

To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus.

DESIGN

Retrospective cohort study

SUBJECTS

Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice.

MEASUREMENTS

Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care.

MAIN RESULTS

Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls.

CONCLUSIONS

A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.

Effect of a Consumer-Directed Voucher and a Disease-Management-Health-Promotion Nurse Intervention on Home Care Use

PURPOSE

We describe the impact of two interventions, a consumer-directed voucher for in-home supportive services and a chronic disease self-management-health-promotion nurse intervention, on the probability of use of two types of home care-skilled home health care and personal assistance services-received by functionally impaired Medicare beneficiaries.

DESIGN AND METHODS

The Medicare Primary and Consumer-Directed Care Demonstration was a randomized controlled trial in 19 counties in New York, West Virginia, and Ohio with four groups: disease-management-health-promotion nurse, consumer-directed voucher, combination (nurse plus voucher), and control. We estimated a bivariate probit model for the 1,394 individuals aged 65 or older who had no private long-term-care insurance.

RESULTS

Whereas the nurse intervention alone had no effect on the probability of using either type of home care, the voucher alone increased the probability of personal assistance services use by 13% (p =.002) but not that of skilled home health care use. The combination of the two interventions increased the probability of personal assistance services use by 18% (p <.001).

IMPLICATIONS

The implementation of disease-management-health-promotion nurse interventions should not lead to a greater probability of skilled home health care or personal assistance services use, whereas the provision of consumer-directed vouchers should result in an increased probability of personal assistance services use, as intended.

Identification of risk for high hospital use: cost comparisons of four strategies and performance across subgroups

OBJECTIVES

To determine the relative costs of four risk-identification strategies and compare their performance in predicting hospital use by different subgroups of older persons based on age, sex, and prior hospital use.

DESIGN

Prospective validation study and cost-comparison analysis.

SETTING

Community-based.

PARTICIPANTS

Five thousand one hundred thirty-eight participants of the sixth wave of three sites of the Established Populations for Epidemiologic Studies of the Elderly.

MEASUREMENTS

Four strategies (prior hospitalization data only, a 10-item self-report screen alone, self-report combined with two laboratory tests, and sequential self-report plus as-needed use of laboratory tests when the self-report screen is inconclusive) and 3-year Medicare Part A hospital cost data.

RESULTS

Assuming that interventions based on screening would yield a total benefit of $1,000 per true-positive case and a cost of $400 for each false-positive case, the sequential strategy was slightly less expensive than the self-report only strategy; both were considerably less expensive than the combined or hospitalization-only strategies. Accuracy as measured by the area under the receiver operating characteristic curve for the sequential strategy was comparable for all subgroups (between 0.62 and 0.70) but was least accurate for those who had high prior use and for those aged 85 and older.

CONCLUSION

A sequential screening strategy that administers laboratory tests selectively is slightly less expensive than one that uses only self-report items. This strategy is also accurate in both sexes, in those with various degrees of prior use, and in the oldest old.

Development of a method to identify seniors at high risk for high hospital utilization

BACKGROUND

A small percentage of older persons account for most Medicare costs. If persons at high risk for high health care utilization can be identified, resources can be directed to improve their health care and reduce utilization.

OBJECTIVE

To develop an efficient and economical approach to identifying older persons at risk for high future health care utilization.

DESIGN

Validation cohort.

SETTING

Three communities.

SUBJECTS

Five thousand one hundred thirty-eight community-dwelling persons aged 71 years or older.

MAIN OUTCOME MEASURES

High utilization (defined as >or=11 hospital days during 3 years) and overall Part A Medicare hospital costs during 3 years.

RESULTS

Predictive multivariable models were created that relied on prior hospitalization only, self-report only, and combined self-report and physical examination/lab data. Ten self-report items (hospitalizations in prior year and year before that, male gender, fair/poor health, not working, infrequent religious participation, needing help bathing, unable to walk 1/2 mile, diabetes, and taking loop diuretics) and two lab tests (low serum albumin and iron) remained as independent predictors of high utilization. Based upon these variables, approximately 1/4 of the population was identified as being at high risk (>or=0.28 probability) for high health care utilization and those identified accounted for approximately half of all Medicare Part A costs for the entire population. Finally, a two-phase strategy was developed in which tests are only administered to individuals whose risk cannot be adequately determined by self-report variables (approximately 1/4 of subjects).

CONCLUSIONS

Simple questions and laboratory tests can accurately and efficiently identify seniors at high risk for high health care utilization.

Chronic illness and plan satisfaction under managed care

This DataWatch uses data from the 1993 Employee Health Care Value Survey (EHCVS) to compare the experiences of respondents with and without chronic illnesses under managed care. After controlling for potential confounders, we found that chronic illness was associated with increased odds of dissatisfaction in both independent practice association plans and prepaid group practices, but not under fee-for-service coverage. Chronic illness appeared to exacerbate difficulties and to attenuate the benefits experienced by healthy persons under managed care. We conclude that persons with chronic illnesses may be at particular risk under managed care; their experiences may warrant particular attention when health plan performance is being monitored.

Purchasing Medicare prescription drug benefits: a new proposal

Medicare policymakers are considering using private-sector firms to offer and manage a prescription drug benefit. In such arrangements Medicare and its potential contractors will need to consider four major areas of risk: selection risk, cost management risk, risks of government as a business partner, and risks that new Medicare benefits will change competitive advantages. This paper considers these risk factors and suggests a model for Medicare prescription drug coverage. By adapting private-sector purchasing practices and using competitive markets, Medicare could offer prescription drug benefits--at affordable premiums for beneficiaries--without resorting to national price controls for pharmaceutical products.