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.
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 χ2 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.
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.
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.