Academic journal article Health Care Financing Review

Rates of Hospitalization for Ambulatory Care Sensitive Conditions in the Medicare+Choice Population

Academic journal article Health Care Financing Review

Rates of Hospitalization for Ambulatory Care Sensitive Conditions in the Medicare+Choice Population

Article excerpt

BACKGROUND

In recent years, HCFA has begun the process of transforming itself from being a passive payer for health services to being an active purchaser of health care. HCFA is also encouraging its beneficiaries to be equally as active. As part of this transformation, HCFA has broadened its consumer information mission by collecting a variety of data from Medicare managed care enrollees: health status information from the Health Outcomes Survey, satisfaction information from the Consumer Assessment of Health Plans, and health plan performance from the Health Employer Data and Information Set among other initiatives. Also as part of this transformation effort, HCFA has started making some of this information available to Medicare beneficiaries, thereby encouraging its M+C enrollees to select their M+C organizations based on comparative performance.

This article evaluates the feasibility of including annual hospitalization rates for ACSCs as part of HCFA's comparative performance information database. Over the past decade, ACSCs have become an established tool for analyzing access to care. If treated in a timely fashion with adequate primary care and managed properly on an outpatient basis, medical practitioners broadly concur that, in most instances, commonly defined ACSCs (e.g., bacterial pneumonia, diabetes mellitus, etc.) should not advance to the point where hospitalization is required. Because lack of primary care for ACSCs does, in fact, often result in hospitalization, the rate of preventable inpatient admissions provides a practical way of evaluating primary care delivery and, thereby, identifying appropriate areas for improving access and quality in the health care delivery system.

The use of ACSCs is appealing for several reasons. First, ACSC admission rates have been used extensively in analysis of access to care for patients in the fee-for-service (FFS) sector. Although revisions may be needed, the methodology for deriving the rates in managed care can build on an existing literature. Second, ACSC rates are constructed using enrollment and inpatient stay data. Thus, they can be constructed using data that HCFA currently collects from M+C organizations. No additional financial burden would be placed on M+C organizations, nor would special data collection efforts be necessary. Further, because hospitalization data are available relatively soon after a hospitalization, ACSC rates can be constructed on a timely basis providing early outcome feedback to M+C organizations. This information could be used by the M+C organizations to evaluate their providers' processes of care, and to develop case management strategies to reduce rates of ACSC hospitalizations.

SELECTION OF ACSCS FOR STUDY

Fifteen ACSCs were selected for evaluation following an extensive review of the literature (Pappas et al., 1997; Billings et al. 1993; Billings et al. 1996; Weissman, Gatsonis, and Epstein, 1992; Institute of Medicine 1993; Bindman et al., 1995; Krakauer et al., 1996; Culler, Parchman, and Przybylski, 1998; Blustein, Hanson, and Shea, 1998; Schreiber and Zielinski, 1997; Braverman et al., 1994; and Mitchell, 1993). Because ACSCs were developed primarily as a measure of access to care for the non-elderly population, each measure was reviewed by two clinical consultants to ensure that selected ACSCs were appropriate for the elderly population. Critical examination of the previously used specifications for identifying both the population at risk and the clinical conditions of interest was undertaken as well as an evaluation of the likely accuracy of coding of the clinical condition on hospital bills.

ACSCs tend to be relatively rare events raising questions about the statistical reliability of the ACSC rates calculated at the M+C organization level. In addition to the problem of small numerator values for individual events, reporting each rate individually may lead to an overload of information. …

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