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. 1991 Jun;26(2):137–163.

Enrollee health status under Medicare risk contracts: an analysis of mortality rates.

G Riley 1, J Lubitz 1, E Rabey 1
PMCID: PMC1069817  PMID: 2061054

Abstract

Previous studies comparing the health status of Medicare beneficiaries enrolled under HMO risk contracts to that of Medicare beneficiaries in fee-for-service (FFS) have generally focused on demonstration projects conducted before 1985. This study examines mortality rates in 1987 for approximately 1 million aged Medicare beneficiaries enrolled in 108 HMOs. We estimated adjusted mortality ratios (AMR) for each HMO and across all HMOs, by dividing the actual number of deaths among HMO enrollees by the "expected" number of deaths. The expected number of deaths was based on death rates among local FFS populations, adjusting for age, sex, Medicaid buy-in status, and institutional status. The AMR for all HMO enrollees pooled together was 0.80. For persons newly enrolled in 1987, the AMR was 0.69; in general, AMRs were higher for beneficiaries who had been enrolled for longer periods of time. Among individual HMOs, none exhibited an AMR substantially above 1.00. Regression analysis indicated lower AMRs for staff model HMOs than for either IPA or group models. Low mortality among Medicare HMO enrollees is consistent with favorable selection or with improvements in the health status of enrollees due to better access or quality of care in HMOs. In either case, health status differences between HMO enrollees and FFS beneficiaries have implications for the appropriateness of Medicare's Adjusted Average Per Capita Cost (AAPCC) payment formula for HMOs.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anderson G. F., Cantor J. C., Steinberg E. P., Holloway J. Capitation pricing: adjusting for prior utilization and physician discretion. Health Care Financ Rev. 1986 Winter;8(2):27–34. [PMC free article] [PubMed] [Google Scholar]
  2. Ash A., Porell F., Gruenberg L., Sawitz E., Beiser A. Adjusting Medicare capitation payments using prior hospitalization data. Health Care Financ Rev. 1989 Summer;10(4):17–29. [PMC free article] [PubMed] [Google Scholar]
  3. Beebe J. C. Medicare reimbursement and regression to the mean. Health Care Financ Rev. 1988 Spring;9(3):9–22. [PMC free article] [PubMed] [Google Scholar]
  4. Beebe J., Lubitz J., Eggers P. Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations. Health Care Financ Rev. 1985 Spring;6(3):27–38. [PMC free article] [PubMed] [Google Scholar]
  5. Dowd B. E. HMOs and Twin Cities admission rates. Health Serv Res. 1986 Jun;21(2 Pt 1):177–188. [PMC free article] [PubMed] [Google Scholar]
  6. Eggers P. W., Prihoda R. Pre-enrollment reimbursement patterns of Medicare beneficiaries enrolled in "at-risk" HMOs. Health Care Financ Rev. 1982 Sep;4(1):55–73. [PMC free article] [PubMed] [Google Scholar]
  7. Eggers P. Risk differential between Medicare beneficiaries enrolled and not enrolled in an HMO. Health Care Financ Rev. 1980 Winter;1(3):91–99. [PMC free article] [PubMed] [Google Scholar]
  8. Ellis R. P., McGuire T. G. Setting capitation payments in markets for health services. Health Care Financ Rev. 1987 Summer;8(4):55–64. [PMC free article] [PubMed] [Google Scholar]
  9. Epstein A. M., Cumella E. J. Capitation payment: using predictors for medical utilization to adjust rates. Health Care Financ Rev. 1988 Fall;10(1):51–69. [PMC free article] [PubMed] [Google Scholar]
  10. Francis A. M., Polissar L., Lorenz A. B. Care of patients with colorectal cancer. A comparison of a health maintenance organization and fee-for-service practices. Med Care. 1984 May;22(5):418–429. doi: 10.1097/00005650-198405000-00006. [DOI] [PubMed] [Google Scholar]
  11. Hellinger F. J. Selection bias in health maintenance organizations: analysis of recent evidence. Health Care Financ Rev. 1987 Winter;9(2):55–63. [PMC free article] [PubMed] [Google Scholar]
  12. Howland J., Stokes J., 3rd, Crane S. C., Belanger A. J. Adjusting capitation using chronic disease risk factors: a preliminary study. Health Care Financ Rev. 1987 Winter;9(2):15–23. [PMC free article] [PubMed] [Google Scholar]
  13. Kasper J. D., Riley G. F., McCombs J. S., Stevenson M. A. Beneficiary selection, use, and charges in two Medicare capitation demonstrations. Health Care Financ Rev. 1988 Fall;10(1):37–49. [PMC free article] [PubMed] [Google Scholar]
  14. Langwell K. M., Hadley J. P. Evaluation of the Medicare competition demonstrations. Health Care Financ Rev. 1989 Winter;11(2):65–80. [PMC free article] [PubMed] [Google Scholar]
  15. Lubitz J. Health status adjustments for Medicare capitation. Inquiry. 1987 Winter;24(4):362–375. [PubMed] [Google Scholar]
  16. Lubitz J., Prihoda R. The use and costs of Medicare services in the last 2 years of life. Health Care Financ Rev. 1984 Spring;5(3):117–131. [PMC free article] [PubMed] [Google Scholar]
  17. Luft H. S., Miller R. H. Patient selection in a competitive health care system. Health Aff (Millwood) 1988 Summer;7(3):97–119. doi: 10.1377/hlthaff.7.3.97. [DOI] [PubMed] [Google Scholar]
  18. Manton K. G. A longitudinal study of functional change and mortality in the United States. J Gerontol. 1988 Sep;43(5):S153–S161. doi: 10.1093/geronj/43.5.s153. [DOI] [PubMed] [Google Scholar]
  19. Manton K. G., Tolley H. D., Vertrees J. C. Controlling risk in capitation payment. Multivariate definitions of risk groups. Med Care. 1989 Mar;27(3):259–272. doi: 10.1097/00005650-198903000-00004. [DOI] [PubMed] [Google Scholar]
  20. McLaughlin C. G. The effect of HMOs on overall hospital expenses: is anything left after correcting for simultaneity and selectivity? Health Serv Res. 1988 Aug;23(3):421–441. [PMC free article] [PubMed] [Google Scholar]
  21. McMillan A., Lubitz J., Russell D. Medicare enrollment in health maintenance organizations. Health Care Financ Rev. 1987 Spring;8(3):87–93. [PMC free article] [PubMed] [Google Scholar]
  22. Newhouse J. P., Manning W. G., Keeler E. B., Sloss E. M. Adjusting capitation rates using objective health measures and prior utilization. Health Care Financ Rev. 1989 Spring;10(3):41–54. [PMC free article] [PubMed] [Google Scholar]
  23. Porell F. W., Turner W. M. Biased selection under the senior health plan prior use capitation formula. Inquiry. 1990 Spring;27(1):39–50. [PubMed] [Google Scholar]
  24. Riley G., Rabey E., Kasper J. Biased selection and regression toward the mean in three Medicare HMO demonstrations: a survival analysis of enrollees and disenrollees. Med Care. 1989 Apr;27(4):337–351. doi: 10.1097/00005650-198904000-00002. [DOI] [PubMed] [Google Scholar]
  25. Thomas J. W., Lichtenstein R. Functional health measure for adjusting health maintenance organization capitation rates. Health Care Financ Rev. 1986 Spring;7(3):85–95. [PMC free article] [PubMed] [Google Scholar]
  26. Thomas J. W., Lichtenstein R., Wyszewianski L., Berki S. E. Increasing Medicare enrollment in HMOs: the need for capitation rates adjusted for health status. Inquiry. 1983 Fall;20(3):227–239. [PubMed] [Google Scholar]
  27. Ware J. E., Jr, Brook R. H., Rogers W. H., Keeler E. B., Davies A. R., Sherbourne C. D., Goldberg G. A., Camp P., Newhouse J. P. Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care. Lancet. 1986 May 3;1(8488):1017–1022. doi: 10.1016/s0140-6736(86)91282-1. [DOI] [PubMed] [Google Scholar]
  28. Yelin E. H., Shearn M. A., Epstein W. V. Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis. Med Care. 1986 Mar;24(3):236–247. doi: 10.1097/00005650-198603000-00006. [DOI] [PubMed] [Google Scholar]

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