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Implications for Medicare

Derek C. Angus, MB, ChB, MPH; Walter T. Linde-Zwirble; Carl A. Sirio, MD; Armando J. Rotondi, PhD; Lakshmipathi Chelluri, MD, MPH; Richard C. Newbold III, MD; Judith R. Lave, PhD; Michael R. Pinsky, MD

JAMA. 1996;276(13):1075-1082.

Abstract
Objective.
—To determine whether insurance status (managed care vs traditional commercial and Medicare) influences resource consumption (as measured by length of stay [LOS]) in the intensive care unit (ICU).

Design.
—Retrospective analysis of the 1992 Massachusetts state hospital discharge database, using prospectively developed and validated risk-stratification models.

Setting.
—All nonfederal hospitals in Massachusetts.

Subjects.
—Of all adult hospitalizations where an ICU stay was incurred (n=104270), we selected those covered by 1 of 4 payer groups (n=88 050): (1) commercial fee-for-service (patients aged <65 years); (2) commercial managed care (patients aged <65 years); (3) traditional Medicare (patients aged 65 years); and (4) Medicare-sponsored managed care (patients aged 65 years).

Main Outcome Measure.
—Mean ICU LOS.

Analysis.
—The ICU LOS regression models were constructed using split-halves validation to adjust for differences in age, sex, severity of illness, diagnosis, discharge status, and payer. Separate models were constructed for those younger than 65 years and those aged 65 years or older. Robustness of the models was explored using goodness of fit and correlation. The effect of payer on hospital mortality was also explored using logistic regression. Observed minus predicted mean ICU LOS and mortality rates were correlated with managed care penetration at the hospital level.

Results.
—The ICU LOS models performed well (R²=0.84 and R²_L [likelihood ratio statistic]=0.92 for the development set, and R²=0.83 and R²_L=0.89 for the validation set). Significant covariables affecting LOS included age, severity of principal illness, comorbidity, reason for admission, and discharge status (P<.001 for each). Among the cohort younger than 65 years (n=27 805), although unadjusted mean ICU LOS was shorter (2.9 vs 3.43 days; P<.05) for those covered by managed care organizations, payer status had no independent effect on ICU LOS (P=.48). Among those older than 65 years, there was neither a difference in unadjusted ICU LOS (3.94 vs 3.88 days; P.05) nor an independent effect of payer on ICU LOS (P=.35). Unadjusted mortality was lower among managed care patients (3.9% vs 5.1% in patients aged < 65 years [P<.05] and 8.7% vs 12.1% in patients aged 65 years [P<.05]). Age, severity of principal diagnosis, comorbidity, and reason for admission significantly influenced mortality (P<.001). After controlling for these factors with the mortality model (R²_L=0.92 and 0.89, C statistic [12 df]=8.45 and 17.58, and P=.75 and.13 [where a large P reflects good agreement] for the development and validation sets, respectively), payer continued to have a small but significant effect on mortality (odds ratios ranging from 1.67 at 0.1% probability of death to 1.11 at 30% probability of death). Managed care penetration among the commercially insured varied across hospitals (n=82) from 0% to 68%. There was no correlation between managed care penetration and either ICU LOS (R²=0.04; P=.09) or mortality (R²=0.0; P=.88).

Conclusions.
—Though patients covered under managed care consume fewer ICU resources, this appears to be primarily attributable to a difference in patientrelated factors. Thus, as managed care case mix changes in the future to include sicker and older patients, the initial advantages of reduced resource consumption may diminish.

Author Affiliations
From the Health Delivery and Systems Evaluation Team, Department of Anesthesiology and Critical Care Medicine (Drs Angus, Sirio, Rotondi, Chelluri, and Pinsky), Graduate School of Public Health (Dr Lave), University of Pittsburgh (Pa); and Health Process Management Inc, Doylestown, Pa (Mr Linde-Zwirble and Dr Newbold).

Footnotes
Presented in part at the American Thoracic Society Annual Scientific Assembly, Seattle, Wash, May 23, 1995.

Reprints: Derek C. Angus, MB, ChB, MPH, Division of Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213-2582.

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.

Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, III; Joseph E. Parrillo, MD, Chicago, III; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.

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