ABSTRACT
OBJECTIVE: To determine the validity of the Pra instrument in predicting the use of health-related services by older enrollees in a managed care plan. DESIGN: Cohort study. At baseline, a survey was administered by mail. Responses were entered into the Pra formula to estimate each person's probability of using health-related services heavily in the future. The subjects' use of services during the following year was monitored through claims submitted to their managed care organization. SETTING: Urban and suburban areas of Southern California. PARTICIPANTS: Persons aged 65 years and older enrolled in a Medicare risk health plan (n = 6802). MEASUREMENTS: Baseline data included demographic, health-related, social, functional, and previous-use-of-service characteristics. Follow-up data included the use of and claims for payment for inpatient hospital care, emergency room services, nursing home services, home care, ambulance services, outpatient surgery, and durable medical equipment. RESULTS: High-risk subjects (highest quartile of Pra values) incurred hospital admissions and claims that were 2.5 and 2.7 times greater than those of low-risk subjects (lower three quartiles). CONCLUSIONS: The Pra formula is recommended for screening older adults enrolled in managed care organizations (as well as for screening those in the fee-for-service environment). It identifies older people who may benefit from interventions designed to avert health crises and the need for expensive care.
Subject(s)
Health Services Research/methods , Health Services for the Aged/statistics & numerical data , Managed Care Programs/statistics & numerical data , Patient Readmission , Aged , Aged, 80 and over , California , Female , Humans , Male , Medicare/statistics & numerical data , Predictive Value of Tests , Reproducibility of Results , Risk Factors , Surveys and Questionnaires , United States , Utilization Review/methodsABSTRACT
With membership in Medicare-risk HMOs increasing, health plans are attempting to develop mechanisms to identify seniors who are "at risk" for high utilization and therefore increased costs. Developed in 1991, the Secure Horizons Health Inventory is a self-administered survey that questions new HMO members on self-perceptions of health, the presence of chronic conditions, functional limitations, prior health care utilization, and the availability of social support. Early identification will enable HMOs to develop appropriate interventions to manage the care of these members.
