Phillips V L, Paul W, Becker E R, Osterweil D, Ouslander J G
Department of Health Policy and Management, Rollins School of Public Health of Emory University, Atlanta, Georgia 30322, USA.
J Am Geriatr Soc. 2000 Oct;48(10):1330-6.
To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services.
A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds.
Residents (n = 700) living in the community between September 1995 and February 1996.
Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time.
Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls.
Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.
描述在一个封闭系统中接受初级和专科护理的长期护理人群的医疗服务利用情况，并比较医疗保险按服务收费（FFS）报销金额与这些服务按人头付费时本应支付的金额。
加利福尼亚州的一个生命护理社区，由两个设施组成，均设有住宅护理和护理机构（NF）床位。
1995年9月至1996年2月期间居住在该社区的居民（n = 700）。
从住院费用账单记录中收集医疗保险A部分和B部分的报销数据，这些记录基于诊断相关组支付、初级和专科护理就诊、各种程序、诊断测试和治疗服务。将这些数据与该机构当时与提供者及一家附属医院合作按照医疗保险人头费率本应收到的金额进行比较。
居民每年平均进行16.3次初级护理就诊、7.7次专科护理就诊，每千人每年有3453个住院日。护理机构居民比住宅护理居民接受的初级护理显著更多。每位居民每月的医疗保险A部分和B部分总支付平均为558美元。当时该人群的每月人头费率则高得多，为1085美元，产生了910万美元的年度“风险池”。两个设施提供的护理差异很大。设施一中的住院率、基于诊所的初级护理和专科护理就诊以及治疗疗程更多。设施二中居民的总体支出较低，在该设施中，大部分护理由经过培训的老年病医生与医生助理合作提供，没有复杂的临床路径和利用控制措施。
我们的数据支持其他研究，这些研究表明老年病医生和医生助理团队可以降低住院率和总体支出。对于体弱的老年人群体，人头费率值得仔细研究。这些费率必须在财政责任与提供足够的、经过风险调整的支付需求之间取得平衡，这种支付要能激励提供者提供高质量且具有成本效益的护理。
