Enrollment duration, service use, and costs of care for severely mentally ill members of a health maintenance organization.

BACKGROUND: The rapid growth of prepaid health care and the increasing enrollment of Medicaid clients in health maintenance organizations (HMOs) raise concerns about the adequacy of services for persons with severe mental illness in capitated health plans. Uncontrolled studies have suggested that enrollment of HMO members with mental illness may be prematurely terminated. METHODS: We identified 250 adult Kaiser Permanente Northwest Region (Portland, Ore) members who were enrolled during 1986 or 1987 and had chart diagnoses of schizophrenia or bipolar disorder. Severely mentally ill subjects were matched by age and sex with control HMO members with and without diabetes mellitus. Records of the HMO and the state mental health agency were reviewed to determine HMO enrollment duration, private and public service utilization, and HMO costs of care during the 4-year follow-up period. RESULTS: The severely mentally ill subjects had 42 months of HMO enrollment during the follow-up period compared with 37 months for the controls without diabetes mellitus and 47 months for the patients with diabetes mellitus (P < .001). When HMO enrollment prior to the study was taken into account, the severely mentally ill subjects and those with diabetes mellitus had similar membership duration. Among the severely mentally ill subjects, community mental health service use was related to longer duration of HMO enrollment (P < .05) but HMO costs of care per member per month were not related to retention. The severely mentally ill subjects were high users of mental health services but their use of general medical care was similar to that of the controls without diabetes mellitus. CONCLUSIONS: This controlled study found no evidence for early termination of HMO members with costly mental illness. Use of community mental health care was associated with longer duration of HMO enrollment.

Replicating the chronic disease score (CDS) from automated pharmacy data.

Michael Von Korff and colleagues at the Center for Health Studies, Group Health Cooperative (GHC) of Puget Sound created a measure of chronic disease status (CDS) using automated outpatient pharmacy data. They reported the measure appeared to provide a stable and valid measure of health status. The availability of such a measure could become a new tool for a variety of applications, including screening, resource allocation, and quality assurance. The measure was replicated for its reliability and construct and predictive validity in the KPNW membership using automated pharmacy data. Reliability and validity were tested using correlation and regression techniques. The CDS showed test-retest reliability over time. It showed construct validity with the RAND-36 instrument and the BSI-8 depression screener. It showed predictive validity with health care visits and hospitalizations. The results were similar to those at GHC. The findings indicated that the CDS can serve, with certain precautions, as a readily accessible low cost measure of health status.

Seniors' Program for Injury Control and Education.

The Seniors' Program for Injury Control and Education (SPICE) examines the effects of exercise and physical fitness on falls and related injuries among older persons. The design is a two-group, randomized trial with 2 years of follow-up. The study is at Northwest Region of Kaiser Permanente (NWKP), a large hospital-based prepaid group practice HMO in Portland, OR. The participants are 1,323 community-living persons 65 years or older who are enrolled in NWKP and are at moderate risk of falling. A multifaceted intervention strategy uses a group approach to falls and injury prevention which includes moderate intensity endurance-building exercise (walking), strength and balance training, home safety improvements, and mental practice. Sessions of 20-25 participants are led by two nurses. Participants set their own realistic goals for exercising to accommodate to differing functional abilities and baseline conditioning. The control group receives usual care from the HMO. Participants report all falls for 2 years after randomization. Outcome measures include health status, physical functioning, falls, and fall-related medical care use and cost. If SPICE is effective, cost-effectiveness analysis will examine the relative efficiency of SPICE versus other successful FICSIT interventions. Thus far, recruitment and intervention compliance goals have been met from a population of frail elderly HMO members.

Development of the common data base for the FICSIT trials.

The eight FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) sites test different intervention strategies in selected target groups of older adults. To compare the relative potential of these interventions to reduce frailty and fall-related injuries, all sites share certain descriptive (risk-adjustment) measures and outcome measures. This article describes the shared measures, which are referred to as the FICSIT Common Data Base (CDB). The description is divided into four sections according to the four FICSIT committees responsible for the CDB: (1) psychosocial health and demographic measures; (2) physical health measures; (3) fall-related measures; and (4) cost and cost-effectiveness measures. Because the structure of the FICSIT trial is unusual, the CDB should expedite secondary analyses of various research questions dealing with frailty and falls.

A capitated payment system for involuntary mental health clients.

This DataWatch examines an outpatient capitated payment system, in the state of Oregon, designed to enhance community services for persons with chronic mental illness who had repeatedly been hospitalized involuntarily. Special state funds and Medicaid dollars were used to pay providers prospectively on a risk-adjusted basis for the delivery of outpatient mental health services. During the three-year study period clients were able to be discharged from the state hospital. Although the data are not straightforward, capitated clients' use of the state mental hospital seems to have declined somewhat more than that of comparison subjects. Outpatient service use was modest and appeared to have little relationship to a client's level of illness severity. Indeed, it was not possible to predict prospectively these clients' outpatient mental health services expenditures.

Modeling risk using generalized linear models.

Traditionally, linear regression has been the technique of choice for predicting medical risk. This paper presents a new approach to modeling the second part of two-part models utilizing extensions of the generalized linear model. The primary method of estimation for this model is maximum likelihood. This method as well as the generalizations quasi-likelihood and extended quasi-likelihood are discussed. An example using medical expense data from Washington State employees is used to illustrate the methods. The model includes demographic variables as well as an Ambulatory. Care Group variable to account for prior health status.

Chronic disease, functional health status, and demographics: a multi-dimensional approach to risk adjustment.

OBJECTIVE: The goal of this study was to develop unbiased risk-assessment models to be used for paying health plans on the basis of enrollee health status and use propensity. We explored the risk structure of adult employed HMO members using self-reported morbidities, functional status, perceived health status, and demographic characteristics. DATA SOURCES/STUDY SETTING: Data were collected on a random sample of members of a large, federally qualified, prepaid group practice, hospital-based HMO located in the Pacific Northwest. STUDY DESIGN: Multivariate linear nonparametric techniques were used to estimate risk weights on demographic, morbidity, and health status factors at the individual level. The dependent variable was annual real total health plan expense for covered services for the year following the survey. Repeated random split-sample validation techniques minimized outlier influences and avoided inappropriate distributional assumptions required by parametric techniques. DATA COLLECTION/EXTRACTION METHODS: A mail questionnaire containing an abbreviated medical history and the RAND-36 Health Survey was administered to a 5 percent sample of adult subscribers and their spouses in 1990 and 1991, with an overall 44 percent response rate. Utilization data were extracted from HMO automated information systems. Annual expenses were computed by weighting all utilization elements by standard unit costs for the HMO. PRINCIPAL FINDINGS: Prevalence of such major chronic diseases as heart disease, diabetes, depression, and asthma improve prediction of future medical expense; functional health status and morbidities are each better than simple demographic factors alone; functional and perceived health status as well as demographic characteristics and diagnoses together yield the best prediction performance and reduce opportunities for selection bias. We also found evidence of important interaction effects between functional/perceived health status scales and disease classes. CONCLUSIONS: Self-reported morbidities and functional health status are useful risk measures for adults. Risk-assessment research should focus on combining clinical information with social survey techniques to capitalize on the strengths of both approaches. Disease-specific functional health status scales should be developed and tested to capture the most information for prediction.

The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members.

OBJECTIVE: To assess the impact of increased prescription drug copayments on the therapeutic classes of drugs received and health status of the elderly. HYPOTHESES TESTED: Increased prescription drug copayments will reduce the relative exposure to, annual days use of, and prescription drug costs for drugs used in self-limiting conditions, but will not affect drugs used in progressive chronic conditions and will not reduce health status. STUDY DESIGN: Each year over a three-year period, one or the other of two well-insured Medicare risk groups in an HMO setting had their copayments per dispensing increased. Sample sizes ranged from 6,704 to 7,962. DATA SOURCES/DATA COLLECTION: Automated administrative data systems of the HMO were used to determine HMO eligibility, prescription drug utilization, and health status. ANALYSIS DESIGN: Analysis of variance or covariance was employed to measure change in dependent variables. FINDINGS: Relative exposure, annual days of use, and prescription drug costs for drugs used in self-limiting conditions and in progressive chronic conditions were not affected in a consistent manner across years by increases in prescription drug copayment. Health status may have been adversely affected. Larger increases in copayments appeared to generate more changes. CONCLUSIONS: Small changes in copayments did not appear to substantially affect outcomes. Large changes in copayments need further examination.

Improving the AAPCC (adjusted average per capita cost) with health-status measures from the MCBS (Medicare Current Beneficiary Survey).

Using data from the 1991 Medicare Current Beneficiary Survey (MCBS), multiple regression-based models predicting 1992 Medicare costs are developed and compared. A comprehensive model incorporating demographic, diagnostic, perceived health, and disability variables is shown to be stable and to fit the data well over the full range of Medicare-covered annual per capita expenses and for a variety of beneficiary subgroups defined by their health and functional status. This model produces stable unbiased estimates of expenditures on validation samples. A variant of this model is being considered for use in setting Medicare capitation payments for the second phase of the social/health maintenance organization (S/HMO) demonstration.

Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation.

Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients.

A partial test of a hospital behavioral model.

The influence of hospital and community characteristics on the behavior of five dimensions of hospital output is examined in this article. These dimensions are the level of emergency stand-by capacity, total admissions, the diagnosis-mix of admissions and the hospital's 'style of practice' with regard to ancillary services and length of stay. A simultaneous equations model is estimated with data from a sample of 63 New England short-term general hospitals for 1970. The findings suggest that various types of short-term general hospitals have distinctive preferences for emergency capacity, volume, case mix and style of practice, and that style of practice may be more appropriately viewed as a rate of resource use per day. Specific findings of interest include the positive interdependence between protection against running out of emergency beds and length of stay, and between length of stay and ancillary service use. Hospitals that admit greater numbers of patients tend to treat more severely ill patients, and sicker patients tend to go to larger hospitals. Hospitals that provide more ancillary services tend to attract the more acutely ill patients. Relationships among other elements of the hospital's utility function represent trade-offs, i.e. substitution, in a constrained world. Among the exogenous factors, patient preferences and ability to pay have strong associations with the types of care provided by hospitals. Highly educated, high income communities, for example, tend to prefer risk averse, service intensive hospital output. Teaching hospitals are shown to prefer higher protection levels, service-intensive patterns of care, and higher admissions levels. Self-paying patients tend to be admitted for more discretionary types of diagnoses and to receive longer diagnosis-specific lengths of stay. A relatively greater supply of physician specialists in the market area is associated with increased use of ancillary services in the hospital. If replicated, these results have significant policy implications for reimbursing teaching hospitals; for defining accessibility of hospital care for the uninsured; for identifying the practice of 'skimming' by proprietary hospitals; and for specifying the role of community preferences in determining hospital performance, especially with respect to quality of care and level of emergency stand-by capacity.

Preventing falls among community-dwelling older persons: results from a randomized trial.

A randomized trial of falls prevention program that addressed home safety, exercise, and behavioral risks was conducted with 3,182 independently living HMO members age 65 and older. The intervention decreased the odds of falling by 0.85, but only reduced the average number of falls among those who fell by 7%. The effect was strongest among men age 75 and older. The likelihood of avoiding falls requiring medical treatment was not significantly affected by the intervention. We conclude that the intervention dose was not of sufficient intensity or duration to have a marked protective effect on older persons. Future research should focus on more intensive intervention approaches because serious falls do not appear to be amendable to low-intensity environment/behavioral efforts.

Measuring the quality of life of the elderly in health promotion intervention clinical trials.

The Multicenter Trials of Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) is a series of clinical trials of biomedical, behavioral, and environmental interventions to reduce the risks of frailty and injury among the elderly. Reliable assessment of the quality of life reported by the subjects is a central issue in evaluating the interventions. An intervention may have a significant impact on an elderly person's sense of well-being, even though significant improvement is not observed in selected physical outcome measures. Elderly persons' compliance with particular intervention regimens may be influenced by the quality of life effects that they perceive in relation to the intervention. The researchers review the definition and measurement of quality of life in the trials, with particular attention to issues in determining common measures used at all study locations. Practical considerations in the selection and use of quality of life measures in both community and institutional populations are addressed. Topics discussed include the interrelation of aging, functional capacities, and quality of life; the multi-dimensionality of quality of life in relation to differential intervention effects; and age-related issues in the collection of quality of life data. Preliminary observations are reviewed, and potential contributions of FICSIT to intervention-sensitive quality of life assessments among the elderly are noted.

The contribution of case-mix severity to the hospital cost-output relation.

Analyses of the cost-output relation of hospital care often omit diagnostic case mix from the analytic model. In this study, we examine the bias that arises from the use of either single-dimensional output volume or structural hospital capacity, but not case-mix severity, to analyze hospital costs and outputs. We found that hospitals with higher admission rates tend to admit less severe case mixes, other things equal, which implies that specialized facilities are relatively underutilized. Our finding provides a rationale for regionalization and sharing of costly specialized services and for reimbursement controls on the cost of capital. We conclude that public policy should focus on optimizing the mix of treatment services rather than on hospital size per se.

Assessing relative health plan risk with the RAND-36 health survey.

Unbiased risk assessment models base health plan payments on enrollee health care needs. We explored the risk structure of employed adult health maintenance organization (HMO) members using the RAND-36 health survey. We used multivariate techniques to estimate risk weights on demographic and health status factors. The dependent variable was annual real total health plan expense for covered services for the year following the survey. Repeated random-split-sample validation techniques minimized outlier influences. Five scales improved prediction over simple demographic factors, but demographic factors still were required to achieve unbiased forecasts. Self-reported health status is a useful and powerful risk measure for adults.

Allocative medicine: efficiency, disease severity, and the payment mechanism.

Health care expenditures now account for nearly 10 percent of our gross national product, the highest share ever recorded. Concerned that this represents too many resources being devoted to health care, policymakers are searching for ways to control health care expenses. These include higher coinsurance and deductibles, measures to increase market shares of health maintenance organizations, and conversion from cost reimbursement to prospective reimbursement. These measures contain many incentives for patients and providers to alter use of health care services. However, aggregate resource use may or may not be lower and more efficient under these new programs. To determine whether limited resources would be devoted to maximizing the nation's health, incentives inherent in each policy option must be examined. This article describes a classification of types of disease and medical care outputs. The framework is then used to examine incentives offered to patients and providers by three alternative payment mechanisms--capitation, fee-for-service, and payment by diagnosis--regarding types of disease treated and mix of outputs produced. This type of analysis is required to select an appropriate payment mechanism for obtaining a socially acceptable allocation of resources.

Treatment refusal procedures and service utilization: a comparison of involuntarily hospitalized populations.

This article examines treatment refusal in a large group of hospitalized civilly committed patients. Comparison is made between those subjects whose refusal was reviewed by Oregon's administrative procedures for treatment refusal (override group) and those committed patients who more readily accepted treatment and were not evaluated by this procedure. The objective was to examine the override process and to explore potential differences between these groups in their utilization of hospital and community mental health services before and after the index hospitalization. We reviewed hospital charts on all subjects who went through the administrative override procedure and collected state hospital and community mental health services information from the statewide computerized information system on all subjects in the study. Several key differences were found between the groups. The override sample had significantly more women, and these patients spent significantly more time in the index hospitalization and had had more past hospitalizations. There were no differences between the groups in their utilization of community services before or after the index hospitalization and no difference in hospitalization rates after the index hospitalization. The conclusion is that the Oregon override procedure is functioning consistently, without undue delay in decision making. More investigation is necessary to determine whether override subjects represent a distinct subpopulation within the larger group of chronically mentally ill patients.