TRANSITIONS IN HEALTH-CARE USE AND EXPENDITURES AMONG FRAIL OLDER ADULTS BY PAYOR PROVIDER TYPE

OBJECTIVES: To assess whether transitions in health care expenditures differed over time by payor/provider type: Medicare fee-for-service (F FS), Medicaid-Medicare, and Medicare HMO. DESIGN: Longitudinal study. SETTING: A large, nonprofit healthcare system in San Diego, California . PARTICIPANTS: A total of 450 frail older people who responded to the baseline and follow-up surveys and who survived the 18-month study pe riod. MEASUREMENTS: Measures included three total expenditure categori es for each 6-month period: low users (<$4000); medium users ($4000-$1 9,999); or high users ($20,000+). Seven conceptually meaningful expend iture trajectories over time were identified: (1) consistently low exp enditures, (2) consistently medium expenditures, (3) consistently high expenditures, (4) decreasing expenditures, (5) increasing expenditure s, (6) U-shaped expenditures, and (7) inverted U-shaped expenditures. MAIN RESULTS: Logistic regression analyses showed that HMO enrollees w ere about twice as likely as Medicaid-Medicare beneficiaries to have c onsistently low expenditures, but no differences were found between th e FFS and HMO groups on this trajectory. Other expenditure patterns sh owed no significant differences by payor/provider group. Significant i nteractions among payor/provider type, low/medium/high expenditure sta tus, and time were observed for inpatient hospital care, skilled nursi ng/rehabilitation care, and home health care. CONCLUSION: This study i llustrates the complexity of frail older people with respect to their health care expenditures and service use. Expanded efforts to control health care expenditures for frail older people should focus first on those who are dually-enrolled. In addition, because mean medical expen ditures for high users enrolled in different payor/ provider groups we re surprisingly similar, the data suggest that containing expenditures for individuals in the highest usage group ($20,000+) presents challe nges for physicians practicing in an era of healthcare reform, regardl ess of payor/ provider setting.