Formulary limitations and the elderly: results from the Managed Care Outcomes Project.

OBJECTIVE: To examine whether restrictive formularies are associated with differences in healthcare resource utilization, including number of office visits, prescriptions, and hospitalizations, and whether this association varies by age. STUDY DESIGN: Cross-sectional, longitudinal study. PATIENTS AND METHODS: Patients enrolled in one of six health maintenance organizations in six different states, three in the eastern and three in the western United States, were eligible for the study. Data from between 1309 and 3938 patients were available for analysis for each of the five diseases studied, for a total of 12,997 patients across all study diseases. Healthcare utilization by patients in the study included more than 99,000 office visits, 1000 hospitalizations, and 240,000 prescriptions. We used severity-adjusted prescription counts, prescription costs, office visit counts, and measures of inpatient hospital utilization to assess the effects of formulary limitations. RESULTS: We found positive, significant associations between the independent variable formulary limitations in drug class and the dependent variables measuring resource utilization. These associations were sometimes significantly greater for elderly patients after controlling for severity of illness and other variables. CONCLUSIONS: Common strategies for decreasing drug expenditures may be associated with higher severity-adjusted resource utilization. In specific areas, this association is more pronounced in the elderly.

Case management: high-intensity care for frail patients with complex needs.

Case management has evolved beyond the functions of discharge planning and utilization review to a role of managing the delivery of services for populations across settings. The two forces driving this change are the growth of Medicare managed care and the increasing numbers of frail older patients with chronic disease. Necessary components of case management include a system of risk identification; an ability to link information, physicians and other providers; an interdisciplinary team approach; and the ability to follow identified older patients over time. In high intensity/low volume models, each case manager works directly with a small number of patients for a given episode of care or over time.

The integration of primary care and case management in chronic disease.

Case management historically has been facility based and has focused on discharge planning and utilization review. Integrated case management needs to include risk screening, disability prevention programs, linked information processes, and interdisciplinary teams that manage care over time and across settings. This article describes one such model that can change primary care into a process that involves the entire team, including the patient.

The acute and long-term care interface. Integrating the continuum.

Acute and long-term care traditionally have been distinctly different health care services, separated by reimbursement mechanisms, types and numbers of providers, and overall approach to the management of chronic illness. Considerable effort has been made of late, primarily due to financial incentives, to integrate these two levels of care into a "seamless" continuum. Barriers to such an integration process must first be identified. Physician and other health care providers will need to develop the tools and resources necessary to manage frail, chronically ill patients in settings other than the traditional acute care hospital, as well as to develop information systems that allow communication to flow easily between all levels of care. As subacute or transitional care becomes a central piece of a health care delivery system, those tools become critical to the provision of quality, integrated care.