A study of differences between social/HMO and other Medicare beneficiaries enrolled in Kaiser Permanente under capitation contracts regarding intermediate care facility use rates and expenditures

This is a hypothesis generating study which provides descriptive information about the effects of adding an Expanded Care Benefit (ECB) to the capitated (Risk) HMO Kaiser Permanente (KP) Medicare Supplemental Insurance plan, regarding use of ICF services, related payments received by nursing homes, and need for Medicaid assistance.; User data was collected on all Medicare beneficiary KP members residing in all (48) Multnomah County nursing homes between 7/86-7/88. Nursing home (SNF + ICF) use rates and rates for related revenues are compared for 1,331 residents grouped by Cost, Risk and S/HMO Medicare beneficiary status while enrolled in KP during the time of each nursing home stay. SNF and ICF days were censored by transfers between Medicare beneficiary, KP enrollment status and study period dates. Such rates are standardized by age-cohort and gender distribution of research population (HPM) members (19,261).; The probability of admission to SNFs and ICFs was greater for S/HMO than for Risk members but, overall, S/HMO residents used fewer cumulative SNF and ICF days per year of eligibility than Risk residents. SHMO ICF residents had a statistically significant (less) mean LOS compared to Risk.; Overall rates of: spend-down per 1000 HPM, Medicaid payments as a proportion of total payments (statistically significant difference), and total payments received by nursing homes per 1000 S/HMO members were lower for S/HMO ICF residents than those for Risk residents. Cumulative nursing home days for short-stay and long-stay subsets are less for S/HMO than Risk residents. A substantially higher proportion of S/HMO ICF residents had less than 100 cumulative days of stay, which was the maximum ICF days allowed by KP for S/HMO members by ECB policy, during the study period. A higher proportion of S/HMO members were discharged from ICFs to home than among Risk members, consistent with S/HMO ECB objectives.; No prior information has been published comparing differences in nursing home use rates between Risk and S/HMO capitated HMO member groups. Hypotheses are formulated from findings for use in future research to confirm and further explain observations in this dissertation study.