Healthcare utilization in community-acquired pneumonia episodes of care: a comparison across the continuum of managed care.
OBJECTIVE
Compare healthcare utilization and total payments for community-acquired pneumonia (CAP) episodes-of-care among 5 health plan designs spanning the continuum of managed care.


METHODS
Medical and prescription claims analysis of CAP episodes among enrollees of employer-sponsored health plans. Episode characteristics, healthcare utilization, and payments were compared across fee-for-service, Preferred Provider Organizations (PPO), point of service, partial capitation, and Health Maintenance Organizations as defined by the employers. Medstat Episode of Care Grouper Version 2.1.5 was employed to create episodes of CAP care. Categorical and continuous measures of patient and care characteristics across plan designs were compared by chi tests and one-way analysis-of-variance as appropriate. Total per-episode payments for provided services across plan designs were compared using a general linear model with a log-link function and gamma distribution.


RESULTS
Greater average patient age, episode severity, number of office visits, rate of hospitalization, length of stay, and inpatient mortality overall were found within PPO episodes compared with all other plan designs. Total episode payments controlling for age, sex, disease severity, and geography were greatest among PPO episodes and attributed largely to more office visits and longer lengths of hospital stays compared with other plan types.


CONCLUSIONS
As previously shown among other patient populations and conditions, PPO episodes of CAP are associated with greater total payments due in large part to increased resource utilization among the episodes of lowest severity.
Landsman
Pamela B
PB
Health and Human Performance, Merck and Co., Inc, West Point, Pennsylvania 19486, USA. pamela_blumberg@merck.com
Smith
Dean G
DG
Fendrick
A Mark
AM
D000367:Age Factors; D000704:Analysis of Variance; D002204:Capitation Fee; D016009:Chi-Square Distribution; D017714:Community-Acquired Infections / Q000191:economics*; D003430:Cross-Sectional Studies; D017050:Episode of Care; D018588:Fee-for-Service Plans / Q000191:economics; D006264:Health Benefit Plans, Employee / Q000191:economics; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D008137:Longitudinal Studies; D008329:Managed Care Programs / Q000191:economics* / Q000706:statistics & numerical data*; D009819:Office Visits / Q000706:statistics & numerical data; D011014:Pneumonia / Q000191:economics*; D011243:Preferred Provider Organizations / Q000191:economics; D012307:Risk Factors; D012720:Severity of Illness Index; D014481:United States