Effect of a gatekeeper plan on health services use and charges: a randomized trial.

A randomized trial was conducted to determine the effectiveness of a health care plan which uses physicians as gatekeepers to control health services use and charges. New enrollees in United Healthcare (UHC), an independent practice association, were randomly assigned to the standard UHC plan requiring a gatekeeper, or to an alternate plan with equal benefits but without a gatekeeper. Individuals in both plans were similar in demographic characteristics, perceived health status, and other health insurance coverage. The gatekeeper plan had 6 percent lower total charges per enrollee than the plan without a gatekeeper. There were minor differences in hospital use and charges. Ambulatory charges were $21 lower per person per year in the plan with a gatekeeper (95% CI = -39.9, -2.1) and these were due to .3 fewer visits to specialists (95% CI = -0.50, -0.10). We conclude that a health plan which incorporates incentives and penalties for physicians to act as gatekeepers can reduce the cost of ambulatory services by limiting specialist visits.

Pricing Medicare's diagnosis-related groups: charges versus estimated costs.

Hospital payments under Medicare's prospective payment system (PPS) are based on prices established for 474 diagnosis-related groups (DRG's). Previous analyses using 1981 data demonstrated that DRG prices based on charges alone were not that different from prices calculated from estimated costs. Data for 1986 were used in this study to show that the differences between the two sets of DRG prices are much larger than previously reported. If DRG prices were once again based on estimated costs instead of the current charge-based prices, payments would be significantly redistributed.

Using patient age in defining DRGs for Medicare payment.

Major changes were recently implemented in the diagnosis related groups (DRGs) used for payment under Medicare's prospective payment system (PPS). As of October 1987, patient age was no longer used in combination with the presence of a complication or comorbidity (CC) to define DRGs. We present the results of one of the studies that led to this change. We analyzed inpatient charges for 1984 and found that the use of age in combination with CC is inappropriate for grouping Medicare patients. The original DRGs resulted in an underpayment for CC patients and an overpayment for patients 70 years or older without a CC.

Use of ambulatory care services in three provider plans: interactions between patient characteristics and plans.

A previous study of low-income enrollees in a closed-panel health maintenance organization (HMO) and a Blue Cross/Blue Shield (BC/BS) plan showed that the effect on the use of health services of the age, sex, health status, previous health care use, race, and family size of the enrollees was different in the two plans. We have replicated this study using the same two provider plans but studying a different group of white collar, middle class enrollees. A third plan, an experimental independent practice association (IPA), was also available for analysis. Utilization was defined as use (yes/no) and the quantity of use for those who used services (in standardized dollars). Significant interactions were detected between plan and all of the independent variables but race. The use of services in the HMO was least affected by enrollees' characteristics (age, sex, race, health status, prior use, family size) and use was most sensitive to patient characteristics in BC. In some respects, the IPA was more like the HMO and in other respects more like the BC/BS plan.

Retirement style and retirement satisfaction: retirees aren't all alike.

Postretirement patterns of work--employment for pay, voluntary activities, or no work-like activities--were examined for 1511 recent retirees from major corporations. A related typology of retirement style--reorganizer, rocking chair, holding on, and dissatisfied patterns--was also used. These patterns were examined in terms of preretirement characteristics of the respondents, postretirement attitudes about retirement, and retirement satisfaction. Multivariate analyses comparing the salience of retirement style with health, income, occupation, and preretirement feelings about retiring for predicting retirement satisfaction indicated that retirement style was a significant predictor of overall retirement satisfaction, and the subscales of satisfaction with activities and satisfaction with finances. Implications of these findings for preretirement counseling and retirement policies are discussed.

Retirement choice and retirement satisfaction.

Retirees from major corporations who reported they retired voluntarily were compared with nonvoluntary retirees to determine the individual factors that led to a voluntary or nonvoluntary decision to retire and the impact of that voluntary/nonvoluntary decision on retirement attitudes and satisfaction. Seven firms provided mailing lists of recent retirees, and 1486 respondents completed questionnaires. Voluntary retirees tended to be persons with higher income, occupation, and health status, who had more positive feelings about retirement and more family support for their decision to retire, compared with nonvoluntary retirees. Voluntary retirees were significantly more likely to have positive attitudes and higher satisfaction in retirement than nonvoluntary retirees. However, health status and preretirement feelings about retirement were more significant predictors of retirement attitudes and satisfaction than the voluntary/nonvoluntary decision. Implications of these findings for preretirement counseling and retirement policies are discussed.