Vl. Phillips et al., Health care utilization by old-old long-term care facility residents: How do medicare fee-for-service and capitation rates compare?, J AM GER SO, 48(10), 2000, pp. 1330-1336
Citations number
18
Categorie Soggetti
Public Health & Health Care Science","General & Internal Medicine
OBJECTIVE: To describe the healthcare utilization of a long-term care popul
ation receiving primary and specialty care in a closed system and to compar
e Medicare fee-for-service (FFS) reimbursement with the amount that would h
ave been paid under capitation for these services.
SETTING: A life care community in California composed of two facilities, bo
th having residential care and nursing facility (NF) beds.
PARTICIPANTS: Residents (n = 700) living in the community between September
1995 and February 1996.
METHODS: Data on Medicare Part A and Part B reimbursements were gathered fr
om billing records for hospitalizations , based on diagnostic related group
payments, primary and specialty care visits, various procedures, diagnosti
c tests, and therapeutic services. These data were compared with what the f
acility, in collaboration with the providers and an affiliated hospital, wo
uld have received under Medicare capitated rates at that time.
RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 special
ist visits, and 3453 hospital days per thousand. Nursing facility residents
received significantly more primary care-than did those in residential car
e. Total Medicare Part A and B payments per resident per month averaged $55
8. The monthly capitation rate in effect at the time for this population wa
s substantially higher at $1085, generating an annual "risk pool" of $9.1 m
illion.
Care provided in the two facilities varied greatly. Hospitalization rates,
clinic-based primary Fare and Specialist visits, and therapy sessions were
greater in facility one. Overall expenditures were lower for residents at f
acility two, where the majority of care was provided by trained geriatricia
ns in collaboration with physician extenders and without sophisticated clin
ical pathways and utilization controls.
CONCLUSIONS: Our data support other studies that suggest that teams of geri
atricians and physician extenders can reduce hospitalization rates and over
all expenditures. Capitated rates for the frail, geriatric population warra
nt careful study. These rates must balance fiscal responsibility with the n
eed for adequate, risk-adjusted payments that create incentives for provide
rs to produce high quality as well as cost-effective care.