A Study of Differences between Social/HMO and Other Medicare Beneficiaries Enrolled in Kaiser Permanente under Capitation Contracts Regarding Intermediate Care Facility Use Rates and Expenditures

摘要

The Social/HMO Demonstration evaluates the feasibility of expanding Medicare Supplemental Insurance benefits to cover a limited amount of ICF and community based long-term care (LTC) services provided under a comprehensive HMO benefit package for capitated Medicare beneficiaries. The policy research question addressed by this study is whether adding an Expanded Care Benefit (ECB) to the capitated HMO benefit package offered by Kaiser Permanente (KP) changes utilization patterns and costs of ICF services, and the probability of becoming Medicaid eligible. This study provides descriptive information regarding this policy research question. The research goal of this study is to measure the extent to which collective ICF use rates and expenditure patterns for S/HMO members are consistently the same, greater or less than baseline data of Risk HMO Medicare members who do not have the S/HMO ECB. The purpose of such measurement is to determine if an empirical basis exists for postulating an ICF utilization and expenditures outcome effect which is influenced by the S/HMO ECB. Utilization and financial data are collected from all SNF and ICF level nursing homes in Multnomah County for all Medicare beneficiaries enrolled in KP between June 1, 1986 and July 31, 1988. Eligibility data are assembled on all Medicare beneficiaries enrolled in KP during the same time period who were residents of Multnomah County. Nursing home use rates and rates for related expenditures are determined for all nursing home residents (1, 331) by their eligibility status in KP during the time of each nursing home stay. Days in an ICF are censored by transfers between Cost, Risk and S/HMO enrollment status. Rates are standardized by the age and gender distribution of research population members (19, 261) to adjust use rates for differences in age cohort distribution of Risk members and S/HMO members. Risk rates and S/HMO rates are compared and differences in utilization and expenditures are evaluated. Conclusions about such patterns are used to formulate hypotheses for testing and confirming descriptive observations. Findings show that overall S/HMO member rates are less than Risk member rates for five of the six Research Questions addressed in this study. Specifically, the probability of admission to an ICF is substantially greater for S/HMO members than for Risk members. However, S/HMO members remained in ICFs fewer days than Risk members, over the two year study period, as measured by age adjusted rates for ICF days per member year of eligibility during the study period. Difference in the mean length of ICF stay is statistically significant between Risk and S/HMO. The rate of total payments received by nursing homes for S/HMO ICF residents per 1000 S/HMO members was substantially less than that for Risk members. The rate of spend-down to welfare status was substantially lower for S/HMO members than for Risk members who became ICF residents. Higher proportions of S/HMO members were discharged from ICFs to home than were Risk members, which is consistent with S/HMO Expanded Care Benefit objectives.