Medicare HMO disenrollment and selective use of medical care: osteoarthritis-related joint replacement.

OBJECTIVE: Recent Medicare health maintenance organization (HMO) disenrollees use a high level of medical services. This study examined admissions for total hip arthroplasty (THA) and osteoarthritis-related knee replacements (OKR) among Medicare HMO disenrollees and continuously enrolled fee-for-service (FFS) beneficiaries to determine whether Medicare beneficiaries are returning to the FFS system to receive quality-of-life enhancing elective care. STUDY DESIGN: Retrospective analysis of Medicare inpatient claims for elderly Medicare beneficiaries residing in South Florida between 1990 and 1993. METHODS: Inpatient admission rates for THA, OKR, and for 2 acute conditions--total hip replacements related to fracture of the hip (HRF) and acute myocardial infarction (AMI)--were estimated for Medicare HMO disenrollees over the 3-month period immediately following their disenrollment. These rates were compared with standardized rates for Medicare FFS enrollees. RESULTS: The annualized adjusted rates of both THA and OKR were 3.5 to 4 times higher among Medicare HMO disenrollees than among FFS beneficiaries (P < or = .0001 for both procedures); substantially smaller differences were noted for HRF (P < or = .05), and no difference was present for AMI. HMO disenrollees and FFS enrollees did not differ in their levels of comorbidity at the time of admission. CONCLUSIONS: These data provide indirect evidence that Medicare HMOs in South Florida are rationing THA and OKR and that beneficiaries respond by returning to the FFS system to seek care. This apparent rationing has important implications regarding for the management of serious, but nonemergent, medical conditions within the evolving Medicare system.

Structuring effective IDS-AMC affiliations.

IDSs able to incorporate academic medical centers (AMCs) into their organizations can realize several benefits, including access to a broad spectrum of specialty services and clinical resources that can be used to develop clinical protocols and reduce variations in care delivery practices across the system. Before pursuing such a strategy, however, IDSs also must be ready to assume the challenges associated with managing AMCs. To effectively incorporate an AMC, an IDS will need to undertake cost-control initiatives within the AMC, implement an enterprisewide information system, and transform the AMC's culture to reflect a team-oriented, community-focused approach. Most importantly, the enterprisewide information system should provide a means to seamlessly integrate the AMC into the larger organization.

Do Medicare HMOs and Medicare FFS differ in their use of the Medicare hospice benefit?

This study compares use of the hospice benefit in Medicare fee-for-service (FFS) and Medicare risk-health maintenance organization (HMO) options in South Florida in 1992. A higher percentage of deaths occurred in hospice in the HMO option than in the FFS option. Compared to individuals in the FFS option, HMO-enrolled hospice users had longer lengths of hospice stay, lower 7-day mortality and higher 180-day (6 month) survival. These differences are consistent with the physician's financial incentives associated with the two programs.

Racial and income differences in use of the hospice benefit between the medicare managed care and medicare fee-for-service.

OBJECTIVE: To examine whether use of the Medicare Hospice Benefit between health maintenance organization (HMO) and Fee-For-Service (FFS)-enrolled beneficiaries varies by income or race. DATA SOURCE: Medicare enrollment and claims data for South Florida. RESULTS: In the FFS system, rate of death in hospice varied by income. In the HMO system, it did not. Time spent in hospice varied by income in the HMO system and not in the FFS system. There was little evidence that racial differences in hospice use differed between FFS and HMO options. CONCLUSIONS: These differences raise questions about whether some hospice use may be in response to system-level incentives.

Medicare HMOs: who joins and who leaves?

Medicare risk health maintenance organizations (HMOs) are an increasingly common alternative to fee-for-service Medicare. To date, there has been no examination of whether the HMO program is preferentially used by blacks or by persons living in lower-income areas or whether race and income are associated with reversing Medicare HMO selection. This question is important because evidence suggests that these beneficiaries receive poorer care under the fee-for-service-system than do whites and persons from wealthier areas. Medicare enrollment data from South Florida were examined for 1990 to 1993. Four overlapping groups of enrollees were examined: all age-eligible (age 65 and over) beneficiaries in 1990; all age-eligible beneficiaries in 1993; all age-eligible beneficiaries residing in South Florida during the period 1990 to 1993; and all beneficiaries who became age-eligible for Medicare benefits between 1990 and 1993. The associations between race or income and choice of Medicare option were examined by logistic regression. The association between the demographic characteristics and time staying with a particular option was examined with Kaplan-Meier methods and Cox Proportional Hazards modeling. Enrollment in Medicare risk HMOs steadily increased over the 4-year study period. In the overall Medicare population, the following statistically significant patterns of enrollment in Medicare HMOs were seen: enrollment of blacks was two times higher than that of non-blacks; enrollment decreased with age; and enrollment decreased as income level increased. For the newly eligible population, initial selection of Medicare option was strongly linked to income; race effects were weak but statistically significant. The data for disenrollment from an HMO revealed a similar demographic pattern. At 6 months, higher percentages of blacks, older beneficiaries (older than 85), and individuals from the lowest income area (less than $15,000 per year) had disenrolled. A small percentage of beneficiaries moved between HMOs and FFS plans multiple times. These data on Medicare HMO populations in South Florida, an area with a high concentration of elderly individuals and with one of the highest HMO enrollment rates in the country, indicate that enrollment into and disenrollment from Medicare risk HMOs are associated with certain demographic characteristics, specifically, black race or residence in a low-income area.

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.

Anatomy of the Alzheimer's Respite Care Program (ARCP).

The Alzheimer's Respite Care Program is an innovative project designed to serve caregivers of Alzheimer's clients. This unique model offers both in-home and institutionally based respite care. Two community organizations which offer Adult Day Care respite forged a partnership to coordinate and expand their continuum of care, bringing many of the benefits of a day care setting into the home. This paper compares the original project conceptualization with its current design today. Factors affecting this evolution are explored together with program modifications incorporated to more appropriately respond to local needs. Key marketing strategies are discussed coupled with a presentation of program successes and recommendations for the future.