How does managed care manage the frail elderly? The case of hospital readmissions in fee-for-service versus HMO systems

Objectives: This study examined whether hospital readmissions varied among the frail elderly ill managed care versus fee-for-service (FFS) systems, Setting and Participants: Random sample of 450 patients, aged 65 and over, from a lar-ge vertically integrated health care system in San Diego, Califo rnia. Participants were receiving physician-authorized home health and surv ived and 18-month follow-up period. Main Outcome Measures: Multiple logistic regression analyses were used to c onduct comparisons of readmissions and preventable readmissions by plan typ e. Two methods to identify preventable readmissions were developed, one bas ed on a computerized algorithm of service use patterns, and another based o n blind clinical review. Results: The odds of having a preventable hospital readmission within 90 da ys of an index admission were 3.51 (P = 0.06) to 5.82 (P = 0.02) times as h igh for Medicare HMO enrollees compared to Medicare FFS participants, depen ding on the method used to assess preventability, Readmission patterns were similar for Medicare HMO enrollees and FFS study participants dually enrol led in Medicare and Medicaid. Conclusions: In this group of frail elderly Medicare beneficiaries, those e nrolled in an HMO were more likely to have a preventable hospital readmissi on than those receiving care under FFS, These results suggest that policies promoting stringent approaches to utilization control (e.g., early hospita l discharge, reduced levels of post-acute care, and restricted use of home health services) may be problematic for the frail elderly. (C) 1999 America n Journal of Preventive Medicine.