The case-mix of chronic illness hospitalization rates in a managed care population: implications for health management programmes.

OBJECTIVE This paper reports on the case-mix of hospitalized patients based on their health plan enrollment and utilization experience, absent a health management (HM) programme. The implications for achieving targeted reductions in admissions within the context of implementing a population hm programme are discussed. STUDY DESIGN descriptive. METHODS Members were identified with asthma, coronary artery disease, congestive heart failure and diabetes. These cohorts were then mapped to disease-specific hospitalizations across a 2-year period (2004-2005). Four distinct case-mix categories were developed. Group 1 comprised members hospitalized for the specific condition in both years. Group 2 comprised all identified members of a disease cohort in 2004 that were not hospitalized in that year but were admitted for the condition in 2005. Members were assigned to Group 3 if they were hospitalized in 2005, did not appear in the 2004 identified cohort but were, in fact, enrolled in the health plan. Group 4 comprised new health plan enrollees in 2005 and were subsequently hospitalized during that year. RESULTS Of the total admissions in 2005, on average 6.4% came from Group 1, 62.4% came from group 2, 10% from group 3 and 21.2% from Group 4. CONCLUSIONS If an HM programme was to be implemented in this population, the typical identification methods currently used by the industry would have resulted in most hospitalized patients either being initially classified as low risk or going undetected. Improving identification and stratification methods will allow HM programmes to better tailor interventions to impact hospitalization rates for the chronically ill.