Research ArticlesHow does managed care manage the frail elderly? : The case of hospital readmissions in fee-for-service versus HMO systems
Section snippets
Introduction and background
Many believe that encouraging Medicare beneficiaries to enroll in managed care plans is the most viable option for controlling health care costs incurred by the elderly1; however, whether managed care can contain costs for the elderly remains largely untested.2 Some studies have demonstrated that health maintenance organizations (HMOs) provide comparable or better access and quality of care than fee-for-service (FFS) systems to general samples of elderly patients,3 patients with chronic,
Setting and sample
The setting and sample for this research are described in more detail elsewhere11, 25; a brief description follows. The study was conducted at Sharp HealthCare (SHC), a nonprofit 501(c)(3) corporation and the largest health care organization in San Diego County, California. At the time of the study, SHC owned and operated 6 acute care hospitals, 4 skilled nursing centers, 15 ambulatory clinics, 1 rehabilitation center, and a large home health agency. With a network of over 1,000 affiliated
Results
Table 1 presents selected characteristics of the 190 inpatient hospital users in the sample, by payer/provider type, for the covariates used in the logistic regression analyses. Generally, the dually enrolled had different characteristics than the Medicare HMO and Medicare FFS beneficiaries, including poorer self-assessed health status.
With regard to sociodemographics, the HMO and Medicare FFS beneficiaries differed somewhat in terms of age and gender. The HMO enrollees were slightly less
Discussion
This study analyzed data from a random sample of a frail elderly population served by the largest health care organization in San Diego county and one of the largest integrated health care systems in the United States. The purpose of the study was to determine whether the adverse outcomes of hospital readmissions and preventable hospital readmissions varied by payer/provider type for a sample of 190 inpatient hospital users. After controlling for baseline differences between payer/provider
Policy implications
Managed care will continue to be a major vehicle for the provision of medical care to Medicare and Medicaid beneficiaries as well as other populations. The results of this study and others indicate that a stringent approach to utilization control may work to the detriment of frail elderly HMO enrollees. While managed care may encourage a more judicious use of services for younger and/or healthier populations, it may limit beneficial care for the frail elderly population. Managed care strategies
Acknowledgements
We gratefully acknowledge the contribution of Kwi Bulow, MD and Julie Prazich, MD in the conduct of this study, and the assistance of Susan Hoekenga, MSG, in the preparation of this manuscript. We would also like to thank Rodney Dunn, MS, for assistance with the statistical analyses.
This study was supported by grant numbers 89130-G and 93339-G from the John A. Hartford Foundation, Inc., New York, NY. We thank them for that support.
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