Case mix controlled service use and expenditures in the social/health maintenance organization demonstration.

Published

Journal Article

BACKGROUND:The social health maintenance organization (S/HMO) demonstration was implemented, in part, to determine if the presumed integration of acute and chronic care in these plans could produce sufficient savings to allow plans to offer expanded and chronic care benefits without increased cost to the Medicare program. METHODS:S/HMO members and a sample of fee-for-service (FFS) recipients were tracked over three years to assess their utilization experience. Analyses controlled for case mix, using Grade of Membership procedures. RESULTS:In 1987, the last year of risk sharing, S/HMOs reported higher total expenditures than FFS in each health status class. For the "healthy," differences were largest for physician care. In other classes, differences in nonskilled nursing or home care use were noted. In 1988, the first year of full risk, Seniors Plus had equivalent or lower expenditures relative to FFS for all classes. Elderplan had lower expenditures in four of six classes and provided more service to the "frail" and the "acutely ill." SHP had higher expenditures in all classes because of higher hospital and nursing home expenditures. Medicare Plus II had higher expenditures in all classes, for physician, nonskilled nursing home, and home care expenditures. CONCLUSIONS:Overall plan losses and higher expenditures among a number of case mix groups suggest a need for refinement of S/HMO operations--especially in case management relationships to medical care and in the selection of "high risk" cases.

Full Text

Duke Authors

Cited Authors

  • Newcomer, R; Manton, K; Harrington, C; Yordi, C; Vertrees, J

Published Date

  • January 1995

Published In

Volume / Issue

  • 50A / 1

Start / End Page

  • M35 - M44

PubMed ID

  • 7814787

Pubmed Central ID

  • 7814787

Electronic International Standard Serial Number (EISSN)

  • 1758-535X

International Standard Serial Number (ISSN)

  • 1758-535X

Digital Object Identifier (DOI)

  • 10.1093/gerona/50a.1.m35

Language

  • eng