Gozalo Pedro L, Miller Susan C, Intrator Orna, Barber Janet P, Mor Vincent
Center for Gerontology & Health Care Research, Department of Community Health, Brown University School of Medicine, 2 Stimson Street, Providence, RI 02912, USA.
Health Serv Res. 2008 Feb;43(1 Pt 1):134-53. doi: 10.1111/j.1475-6773.2007.00746.x.
To examine the effect of the Medicare hospice benefit on Medicare and Medicaid expenditures by dual-eligible Medicare-Medicaid nursing home (NH) residents.
DATA SOURCES/STUDY SETTING: Secondary data for NH residents for 1998-1999.
Retrospective cohort study of NH residents in the state of Florida who died between July and December 1999 (N=5,774). Medicare claims identified hospice enrollment, and Medicare and Medicaid claims identified expenditures by categories of care. Nursing home resident assessments were used to control for case-mix differences. Geocoding of nursing homes, hospice providers and hospitals was used to identify and characterize local health care markets.
DATA COLLECTION/EXTRACTION METHODS: A file was constructed linking Medicare and Medicaid claims to Minimum Data Set assessments of NH residents, and NH provider (Online Survey and Certification Automated Record) and hospice provider files.
Hospice enrollment results in substantial savings in government expenditures (22 percent) among all short-stay (< or =90 days) dying NH residents. For long-stay (>90 days) dying NH residents, hospice provides some savings (8 percent) among cancer residents while it is cost-neutral among dementia residents and adds some cost (10 percent) for residents with a diagnosis other than cancer or dementia. There is evidence of selection bias, particularly among residents with cancer (19 percent savings unadjusted versus 8 percent adjusted). Among short-stay NH residents, hospice greatly reduces Medicare expenditures but increases Medicaid expenditures.
Hospice enrollment results in lower combined Medicare/Medicaid expenditures in the last month of life, particularly among short-stay NH residents. This effect, however, varies by diagnosis and NH length of stay. In addition, for short-stay NH residents, current payment policy creates a Medicare incentive and Medicaid disincentive for promoting residents' referral to hospice.
研究医保临终关怀福利对符合医保和医疗补助条件的医保-医疗补助疗养院（NH）居民的医保和医疗补助支出的影响。
数据来源/研究背景：1998 - 1999年NH居民的二手数据。
对1999年7月至12月间在佛罗里达州死亡的NH居民进行回顾性队列研究（N = 5774）。医保理赔记录确定临终关怀登记情况，医保和医疗补助理赔记录确定各类护理的支出情况。疗养院居民评估用于控制病例组合差异。通过对疗养院、临终关怀服务提供者和医院进行地理编码来识别和描述当地医疗保健市场。
数据收集/提取方法：构建一个文件，将医保和医疗补助理赔记录与NH居民的最低数据集评估、NH服务提供者（在线调查和认证自动记录）及临终关怀服务提供者文件相链接。
对于所有短期住院（≤90天）且濒死的NH居民，加入临终关怀可大幅节省政府支出（22%）。对于长期住院（>90天）且濒死的NH居民，临终关怀在癌症患者中可节省部分费用（8%），而在痴呆症患者中成本持平，对于非癌症或痴呆症诊断的患者则会增加一些费用（10%）。有证据表明存在选择偏差，尤其是在癌症患者中（未调整时节省19%，调整后为8%）。在短期住院的NH居民中，临终关怀大幅降低了医保支出，但增加了医疗补助支出。
加入临终关怀可降低生命最后一个月医保/医疗补助的合并支出，尤其是在短期住院的NH居民中。然而，这种效果因诊断和NH住院时长而异。此外，对于短期住院的NH居民，当前的支付政策在促进居民转诊至临终关怀方面，对医保形成了激励，对医疗补助则形成了抑制。
