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Managed Care

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Managed care apparently does not constrain use of intensive care services

A full day in a hospital intensive care unit (ICU) costs about three to five times as much as a day in a regular inpatient unit. Thus, it makes sense that insurers would want to give physicians and hospitals incentives to limit the use of the ICU. However, managed care patients are no less likely to receive ICU services than other patients, finds a new study by researchers at the Agency for Health Care Policy and Research. Bernard Friedman, Ph.D., and Claudia Steiner, M.D., M.P.H., used 1992 hospital discharge summaries to analyze use of ICUs in Florida and Massachusetts by adult patients under age 65 and not covered by Medicaid.

When a hospital's ICU supply ratio (actual ICU use divided by expected demand based on patient case mix) was tight, that is, below the median for the State, all patients had a shorter length of stay (LOS) in the ICU, and there was no difference by payer class. It was only when hospitals were above the median in the supply ratio that HMO and self-pay patients received less ICU care relative to other insured patients. This occurred because other privately insured patients had a longer LOS than predicted by patient clinical factors, not because HMO and self-pay patients had much shorter stays.

In Florida, there was no significant difference in ICU charges (adjusted to estimate resource use) for HMO patients. In Massachusetts, for both HMO and self-pay patients, the length of ICU stay was about 4 days less than would be expected for their condition. However, this result reflected partly the distribution of patients across hospitals with different constraints on total ICU supply. In both States, at hospitals in the lowest quartile of supply ratio, patients received fewer ICU resources than predicted: a 28 percent shorter LOS in Massachusetts and 56 percent lower charges in Florida. The lack of a relationship between ICU admission rates and managed care should be reassuring to observers concerned about undue restriction of these services by managed care physicians, conclude the researchers.

More details are in "Does managed care affect the supply and use of ICU services?" by Drs. Friedman and Steiner, in the Spring 1999 Inquiry 36, pp. 68-77.

Reprints (AHCPR Publication No. 99-R071) are available from the AHCPR Clearinghouse.

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