Dn. Pearlman et al., TRANSITIONS IN HEALTH-CARE USE AND EXPENDITURES AMONG FRAIL OLDER ADULTS BY PAYOR PROVIDER TYPE, Journal of the American Geriatrics Society, 45(5), 1997, pp. 550-557
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.