Date of Award
Open Access Dissertation
Health Services and Policy Management
The Norman J. Arnold School of Public Health
Janice C. Probst
Purpose. As the aged population of this country grows, the U.S. healthcare system will face increased pressure to provide long-term care services and supports to increasing numbers of elderly Medicare beneficiaries. Studies have indicated that unmet long-term care need can lead to increased, unnecessary utilization of the healthcare system, thus further taxing the Medicare system. Little is known about how type of long-term care, as well as how long-term care policies—specifically payment policies—affect health care utilization. The objective of this original dissertation research was to examine the effects of place of residence (community versus residential long-term care facility) and long-term care payer type (private pay versus Medicaid) on Medicare-funded healthcare utilization in terms of both risk of potentially preventable hospitalization (PPH) and Medicare expenditures.
Methods. This study utilized data from the 5% sample of 2013 Medicare claims and enrollment data from the Centers for Medicare and Medicaid Services (CMS) merged with data from the Areas Health Resource File (AHRF). A retrospective cohort analysis examined the healthcare utilization and expenditure patterns of Medicare beneficiaries for whom, based on clinical and demographic factors, the provision of formal, comprehensive long-term care would be appropriate, among four cohorts: Medicare-only beneficiaries residing in the community; Medicare-only beneficiaries residing in long-term care facilities; Medicare/Medicaid dual eligible beneficiaries residing in the community; and Medicare/Medicaid dual eligible beneficiaries residing in long-term care facilities.
Results. This study found a significantly higher risk of both PPH and having Medicare expenditures in the top 90th percentile among both Medicare-only long-term care facility residents and dual eligible community residents as compared to dual eligible long-term care facility residents, yet Medicare-only long-term care facility residents had significantly lower per capita Medicare expenditures than did their dual eligible counterparts residing in long-term care facilities. The results of this study also indicate that state Medicaid bed hold policies had no statistically significant effect on either risk of PPH or on Medicare expenditures.
Conclusion. The finding that Medicare-only residents of long-term care facilities are less expensive to the Medicare system, on average, than their dual eligible long-term care facility resident peers, yet are more likely to be hospitalized for a preventable condition and are more likely to be among the most expensive Medicare beneficiaries, could indicate differential patterns of intensity of medical response to similar clinical conditions between the two groups. That state Medicaid bed hold policies were not associated with any of the measures of healthcare utilization in our study seems to suggest that this Medicaid policy does not provide the perverse incentive toward higher utilization that some studies suggest.
Robertson, A. S.(2016). Healthcare Utilization And Expenditure Patterns Among Older Adults With Functional And Medical Decline. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/3873