Carolee A. DeVito

The Medicare-HMO Revolving Door — The Healthy Go in and the Sick Go Out

BACKGROUND Enrollment in Medicare health maintenance organizations (HMOs) is encouraged because of the expectation that HMOs can help slow the growth of Medicare costs. However, Medicare HMOs, which are paid 95 percent of average yearly fee-for-service Medicare expenditures, are increasingly believed to benefit from the selective enrollment of healthier Medicare recipients. Furthermore, whether sicker patients are more likely to disenroll from Medicare HMOs, thus raising average fee-for-service costs, is not clear. METHODS We used Medicare enrollment and inpatient billing records for southern Florida from 1990 through 1993 to examine differences in the use of inpatient medical services by 375,406 beneficiaries in the Medicare fee-for-service system, 48,380 HMO enrollees before enrollment, and 23,870 HMO enrollees after disenrollment. We also determined whether these differences were related to demographic characteristics and whether the pattern of use after disenrollment persisted over time. RESULTS The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group. Beneficiaries who disenrolled from HMOs re-enrolled at about the time that their level of use dropped to that in the fee-for-service group. CONCLUSIONS These data show marked selection biases with respect to HMO enrollment and disenrollment. These biases undermine the effectiveness of the Medicare managed-care system and highlight the need for longitudinal and population-based studies.

Home Environmental Hazards and the Risk of Fall Injury Events Among Community‐Dwelling Older Persons

OBJECTIVE: To determine if home environmental hazards increase the risk of fall injury events among community‐dwelling older persons.

Chronic Medical Conditions and Risk of Fall Injury Events at Home in Older Adults

OBJECTIVE: To evaluate the association between selected chronic medical conditions (CMCs) and fall injury events at home among community‐dwelling older persons.

Fall injuries among the elderly. community-based surveillance

Falls are a leading cause of fatal and nonfatal injuries among the elderly in the United States. Despite the importance of fall injuries, epidemiological studies of falls among the elderly have identified neither their causes nor the methods to prevent them. Therefore, we established a community‐based surveillance system in Miami Beach, Florida, as part of a study to assess falls among the elderly. A total of 1,827 fall injury events occurred in this community between July 1985 and June 1986. More than 85% (1,567) of the persons who fell and received care were seen in an emergency room. The remaining cases were identified from one of the three other sources used: fire rescue reports, inpatient medical records, or medical examiner reports. Most falls (97%) were coded as accidental (E880–E888). More than 100 people sought medical assistance for a fall each month. The time of the injury was known for 68% (1,244) of the people who fell. Seventy‐four percent of these falls (921) occurred during daylight hours. Fifty‐four percent of the falls (986) occurred in and around the home, and 38% of these had a particular area of the home recorded: 42% occurred in the bedroom, 34% in the bathroom, 9% in the kitchen, 5% on the stairs, 4% in the living room, and the remaining 6% in other areas. This surveillance system will help us use the study to clarify the causes of falls in the elderly and identify and evaluate appropriate prevention efforts. It will also help others in designing and implementing other injury surveillance systems.

Alcohol as a Risk Factor for Fall Injury Events among Elderly Persons Living in the Community

To determine if alcohol use is a risk factor for fall injury events among community‐dwelling older persons.

Physical performance effects of low-intensity exercise among clinically defined high-risk elders

Background: Falls are among the leading causes of injuries and deaths. Results from a number of studies have suggested that a community-based exercise program may be effective in improving lower body strength, although some have shown only limited improvements. However, the impact of these programs on gait and balance are equivocal. Further, studies that have specifically targeted deconditioned elderly individuals, rather than individuals drawn from the general community, either showed limited or no improvements in gait and balance. Objective: This study examined the effectiveness of a community-based, short-term, low-intensity exercise intervention strategy on measures of mobility skills, gait and balance, and muscle strength for a clinically targeted group of elderly individuals at high risk of falls. Methods: 245 men and women aged 60 years or older were randomized into either an intervention or control group and received a baseline (T1) assessment. Subjects in the intervention group received up to 24 sessions (45 min long) of low-intensity standard exercise modalities tailored to the individual patient over an 8- to 10-week period. At the conclusion of the program, the participants in the intervention group were instructed to continue performing the exercises at home until 1 year after T1. Measures of physical function and performance were collected for all subjects at three different points of study enrollment. Results: Of the subjects assessed at baseline, 138 (56%) also had a postintervention assessment (T2), 128 (52%) had a 6-month follow-up assessment (T3), and 105 subjects had assessments at all time points. Primary analyses were based on the 105 subjects who had assessments at all time points. Intervention and control subjects did not differ in any of the physical function or performance measures at baseline. Between T1 and T2, the intervention subjects showed significantly greater improvement than the control subjects on all outcomes, with improvements plateauing for most measures between T2 and T3. Gait and balance scores continued to improve throughout the study period for both groups of subjects. Conclusions: This easily implemented, low-intensity exercise program may lead to improvements in physical functioning that are retained over the long term and effectively targets a clinically defined population of deconditioned elders at high risk of falling and sustaining serious injury.

Do Medicare HMOs and Medicare FFS differ in their use of the Medicare hospice benefit

This study compares use of the hospice benefit in Medicare fee-for-service (FFS) and Medicare risk-health maintenance organization (HMO) options in South Florida in 1992. A higher percentage of deaths occurred in hospice in the HMO option than in the FFS option. Compared to individuals in the FFS option, HMO-enrolled hospice users had longer lengths of hospice stay, lower 7-day mortality and higher 180-day (6 month) survival. These differences are consistent with the physicians financial incentives associated with the two programs.

Dependence in Activities of Daily Living as a Risk Factor for Fall Injury Events Among Older People Living in the Community

Dependence in Activities of Daily Living as a Risk Factor for Fall Injury Events Among Older People Living in the Community

Use of Veterans Affairs Medical Care by Enrollees in Medicare HMOs

To the Editor: Older people in the United States who use the medical services of the Veterans Health Administration are frequently also entitled to health care through Medicare. Although most do no...