Social/health maintenance organization and fee-for-service health outcomes over time - Hospital Payment: Beyond the Prospective Payment System

Health Care Financing Review, Winter, 1993 by Kenneth G. Manton, Robert Newcomer, Gene R. Lowrimore, James C. Vertrees, Charlene Harrington

RESULTS

To assess FFS or S/HMO outcomes, health variation over persons and time must be described. This requires defining multiple "Profiles" to characterize a person's health. The six profiles in Table 1 are described by comparing [[lambda].sub.kjl]s to the overall frequency of an attribute--e.g., 27.1 percent need help with meals. Someone who "f its" Profile 3, 4, or 6 (i.e., has a high [g.sub.ik[multiplied by]t]) requires assistance. Individuals matching Profiles 1, 2, or 5 do not. The [[lambda].sub.kjl] can be discussed both as a profile of J attributes and as groups of cases characterized by a profile.

[TABULAR DATA 1 OMITTED]

The profiles in Table 1 are defined by their association ([[lambda].sub.kjt]) with health variables:

* "Healthy"--Individual is unimpaired

but has diabetes, hypertension, and

joint disease. This profile is "healthy"

relative to other case-mix groups.

* "Acutely III"--Individual has cancer

(100 percent), cardiopulmonary problems,

and hypertension, but no impairment.

* "Impaired"--Individual has IADL impairments

suggesting early dementia

but few other neurological problems.

Medical conditions (e.g., diabetes) may

be present.

* "Pulmonary"--Individual has ADL impairments

(42.2 percent bedfast), pulmonary

problems (80.8 percent), and

cancer (49.8 percent).

* "Cardiac"--Individual is not impaired,

but has multiple medical problems--including

cardiopulmonary conditions

(no stroke) and arteriosclerosis.

* "Frail"--Individual is bedfast (100 percent)

and limited on all ADLs and

IADLs. Medical problems include

stroke, cancer, neurological, stomach,

and bowel problems. A person with a

high score on this dimension, unless

having excellent social and economic

resources, would be at risk of institutionalization

because he or she is 88.9

percent impaired on the 17 functional

items. Thus, as the population ages,

movement into the frail category serves

as a measure of persons potentially

needing institutionalization--because

institutional residents were excluded at

the study's start and are not represented

in baseline health measures.

The predictive validity of the [g.sub.ik[multiplied by]t] was examined on sociodemographics and service use (Reuben, Siu, and Kimpau, 1992). The [[lambda].sub.kNI]s describing these relations (calculated conditionally on case-mix scores) are presented in Table 2.

[TABULAR DATA 2 OMITTED]

Approximately 93.6 percent of the "healthy" group report good or excellent health; 100 percent of the "acutely ill" group report fair or poor health. Persons in the "impaired" group (48.9 percent reporting fair or poor health) are similar to those in the "pulmonary" group (38.3 percent), while the "cardiac" (65.2 percent fair or poor) and "frail" (60.1 percent fair or poor) groups are similar. Case mix is not strongly associated with age because health changes ([g.sub.ik[multiplied by]t]) estimated from the combined HSF and CAF data, represent most age effects. Healthy individuals are young--a mean age of 71.7. The frail group members are the oldest, with a mean age of 83.2. Acutely ill persons are older (77.5) than the healthy, but are little different than the two chronically ill groups.