Health care factors related to stage at diagnosis and survival among Medicare patients with colorectal cancer

BACKGROUND: With the growth in enrollment of Medicare patients in HMOs the effectiveness of care received by Medicare/HMO patients continues to be of concern. By considering the relationship of insurance to stage at diagnosis, this study inquires whether HMOs emphasize early diagnosis of colorectal cancer to a greater extent than FFS plans, if particular HMO types (group/nongroup models) are more successful in doing so, and how this pertains to survival. METHODS: Data for 1329 Medicare patients with colorectal cancer, diagnosed 1987 to 1993, and residing in northern California, were acquired from a population-based cancer registry. Insurance included two types of Medicare HMOs (group and nongroup model) and three fee-for-service (FFS) categories: Medicare with private supplement, Medicare/Medicaid, and Medicare only. The relationships of insurance to AJCC stage at diagnosis and of insurance to survival following diagnosis were examined, respectively, with logistic regression models and survival analysis (controlling for age, ethnicity, tumor location, educational level, sex, and hospital type). RESULTS: Likelihood of early stage colorectal cancer was greater for Medicare patients in nongroup model HMOs or having private FFS supplements than for those in group model HMOs, Medicare/Medicaid, or Medicare alone. All-cause and colorectal cancer mortality did not differ significantly among Medicare patients with group model HMO, nongroup model HMO and private FFS supplements. Medicare/Medicaid patients experienced significantly greater all-cause mortality than private FFS patients. CONCLUSIONS: Differences within this study population in early stage diagnosis of colorectal cancer and breast cancer, respectively, by type of Medicare supplemental insurance may be attributable to which preventive screening measures are included in health plan report cards.     

Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans

BACKGROUND: Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. OBJECTIVES: We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. DESIGN: We reviewed administrative data in 11 regions from Medicare and a large national health plan. SUBJECTS: We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998-2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. MEASURES: We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. RESULTS: Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14-1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85-4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34-0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60-0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. CONCLUSIONS: Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of post-acute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.     

Stage at diagnosis of breast cancer. Comparison in a fee-for-service and health maintenance organization practice

This study assessed the effectiveness of two types of health plans in the diagnosis of female breast cancer by comparing the clinical stage at final diagnosis. Data on 202 cases diagnosed over a 4-year period from May 1983 to May 1987 were abstracted from medical records. Of these, 133 (65.8%) used fee-for-service (FFS) and 69 (34.2%) used health maintenance organization (HMO) plans. The two groups differed significantly on age and employment status; the HMO cases were younger than the FFS cases and were more likely to be employed. HMO cases also were more likely to have had some tests and procedures, but the test results were similar. Other demographic, risk factor, behavioral, clinical, and laboratory findings did not differ significantly by health plan, suggesting a uniformity of characteristics and of service availability. Overall, there was no difference between the groups in clinical stage of breast cancer at final diagnosis. On age-specific tests, however, the 45 to 55 year age group showed a significant difference in the stage of breast cancer at diagnosis with a higher proportion of HMO cases diagnosed at stage 1 than FFS cases. In contrast, in the 20 to 44 year age group, there was a nonsignificant trend for more FFS than HMO cases to be diagnosed at stage 1. Results from this study suggest that when offered by one medical practice, both FFS and HMO plans may be equally effective in the detection of breast cancer.     

The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes

BACKGROUND: The current climate of anger and frustration with managed care has heightened interest in the quality of health care provided by managed-care plans, particularly health maintenance organizations (HMOs). This breast cancer outcomes study, investigating relationships of health insurance and delivery systems to stage at diagnosis, treatment selected, and survival, is based in a heavily penetrated, highly competitive HMO market. METHODS: Data for 1,788 residents of northern California younger than 65 years of age at diagnosis (1987-1993) were provided by a population-based cancer registry. Patient insurance included fee-for-service (FFS), group-model HMO, nongroup HMO, publicly insured, and uninsured. Diagnosis and treatment occurred in 73 hospitals (large, medium/moderately small, or very small community, rural, teaching, or HMO-owned hospitals). Regression models examined relationships of insurance and hospital type to 3 outcomes (stage, treatment, and survival), controlling for age, ethnicity, education, neighborhood occupational class, and time period. RESULTS: Early diagnosis was as likely for group-model and nongroup-model HMO-insured patients as for the private FFS-insured patients. In 1987-1990, HMO-owned hospitals were leaders in treating 46% of early-stage breast cancers with breast-conserving surgery plus radiation (BCS+); by 1991-1993, the most significant increases in BCS+ use occurred at teaching and large community hospitals. Survival of group-model HMO, nongroup-model HMO, and FFS patients was not significantly different. Publicly insured/uninsured patients had more stage III/IV disease (OR=2.01, P = 0.006) and greater all-cause mortality (risk ratio 1.46, P = 0.015). CONCLUSIONS: Group-model and nongroup-model HMO patients are similar to FFS-insured patients in stage at diagnosis and survival outcomes. Treatment selection is related to hospital type rather than insurance coverage.     

The impact of a change in Medicare reimbursement policy and HEDIS measures on stage at diagnosis among Medicare HMO and fee-for-service female breast cancer patients

OBJECTIVE: To examine the effects of health plan enrollment [health maintenance organizations (HMO) or fee-for-service (FFS)], a change in Medicare reimbursement policy which allowed for annual rather than biennial mammograms, and Health Plan Employer Data Information Set (HEDIS) measures on stage at diagnosis among older women with breast cancer. METHODS: We used the population-based Surveillance Epidemiology and End Results (SEER)-Medicare database to identify all elderly women age 65-74 who were diagnosed with breast cancer from 1994 to 2002. We compared stage at diagnosis, demographic characteristics, and tumor characteristics for FFS or HMO enrollment in the periods before and after the 1998 policy change. We compared the effect of women age 65-69 whose mammography use in the HMO system is measured by HEDIS and those who are older (age 70-74). RESULTS: We identified 20,106 women enrolled in FFS Medicare, and 10,751 women enrolled in an HMO. Women ages 65-74 who were enrolled in a Medicare HMO were more likely to be diagnosed at an early stage both before and after the policy change, but the disparity decreased from 4.7% to 2.3%, a relative change of 51.1%. The disparity was not specific to the ages included in the HEDIS measure. CONCLUSIONS: A decrease of 51.1% in the HMO-FFS disparity in breast cancer stage at diagnosis coincided with the 1998 change in Medicare mammography reimbursement policy. The existence of HEDIS measures for HMOs does not create a disparity in stage at diagnosis between those whose mammograms are measured by HEDIS (younger women) and those whose are not (older women).     

Objective and subjective measures of the quality of managed care in nursing homes

BACKGROUND: The number of nursing home (NH) residents enrolled in managed care plans (HMO) will increase, and there is concern that the quality of their medical care may be compromised by cost-containment pressures. In this study, we evaluated the medical care of residents enrolled in 3 health maintenance organizations (HMO) that developed specific long-term care programs. OBJECTIVES: To compare the medical care received by NH residents enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of care and consumer perception (subjective) measures. To describe the relationship between the objective and subjective measures. MEASURES: Number of primary care visits per month; process of medical care for 2 geriatric tracer conditions (falls, fevers); family and residents' perceptions of the adequacy of sickness episode management; and the frequency of primary provider visits. DESIGN: Quasi-experimental. RESULTS: HMO residents received more timely and appropriate responses to falls and fevers than did FFS residents. HMO residents also received more frequent routine visits by a primary care provider team consisting of a physician and nurse practitioner. Consumer perceptions of quality did not differ between the HMO and FFS groups. Families within both groups were significantly more positive than were residents about the frequency of visits by both physicians and nurse practitioners. Within the HMO group, both families and residents were more positive about the frequency of nurse practitioner visits than were physician visits even when the frequency of visits by the 2 providers were similar. CONCLUSIONS: Although the medical care received by HMO residents was better on most objective process measures than that received by FFS residents, consumer perceptions of care did not detect those differences. NH residents and families have different perceptions about the adequacy of visits by physicians and nurse practitioners, and both families and residents appear to have different expectations concerning how often they want physicians to visit as compared with nurse practitioners.     

Process of care for Medicaid-enrolled children with asthma: served by community health centers and other providers

OBJECTIVE: To compare the process of care received by Medicaid-enrolled children with asthma served by community health centers (CHCs) and other Medicaid providers. DESIGN: Retrospective cohort study. SETTING: Five provider types serving Massachusetts Medicaid enrollees: three provider groups--CHCs, hospital outpatient departments (OPDs), and solo/group physicians--participating in the statewide Primary Care Clinician Plan; a staff model health maintenance organization (HMO); and fee-for-service (FFS) providers. STUDY POPULATION: Six thousand three hundred twenty-one Medicaid-enrolled children (age 2-18) with asthma assigned to one of the above provider types in 1994. DATA: Person-level files were constructed by linking Medicaid claims, demographic and enrollment files with HMO encounter data. METHODS: Five claims-based process of care measures reflecting aspects of care recommended in national guidelines were developed and used to analyze patterns of care across provider types, controlling for case-mix and other covariates. RESULTS: Children served by CHCs and the HMO had significantly higher asthma visit rates compared with those served by OPDs, solo/group physicians and FFS providers. CHCs emergency department (ED) visit rates for asthma were lower than those of OPDs (P <0.001) and similar to other providers. However, CHC patients averaged more asthma hospitalizations relative to solo/group physicians or the HMO (P <0.0001). In multivariate analyses, children served by CHCs were 2.2 times as likely (95% CI, 1.02-4.91) as those served by solo/group physicians to receive a follow-up visit within 5 days of an asthma ED visit and 4.3 times as likely (95% CI, 1.45-12.68) to receive a follow-up visit within 5 days of hospital discharge. CHC patients with utilization suggestive of persistent asthma were less likely (OR, 0.28; 95% CI, 0.13-0.59) than those served by solo/group physicians to be seen by an asthma specialist. There were no significant differences in measures of asthma pharmacotherapy across providers types. CONCLUSION: These data suggest that CHCs provide more timely follow-up care after an asthma ED visit or hospitalization relative to solo/group physicians, but diminished access to asthma specialists. There were no differences in asthma pharmacology across providers. Relatively low access to asthma specialists among children served by CHCs warrants further investigation.     

Completeness of information on adjuvant therapies for colorectal cancer in population-based cancer registries

BACKGROUND: Population-based cancer registries represent a potentially valuable tool to evaluate treatment; however, information on the completeness of registry treatment data is sparse. OBJECTIVE: To evaluate the completeness of registry treatment data for patients with colorectal cancer and to identify predictors of complete reporting. RESEARCH DESIGN: We surveyed physicians or reviewed office records of 1956 northern California patients diagnosed with colorectal cancer during 1996 to 1997 to assess the completeness of registry data regarding use of adjuvant chemotherapy and radiation therapy. RESULTS: For patients with a record of receipt of chemotherapy in either the registry or physician survey, information was in the original registry records for 82.0%. In the multivariate analysis, completeness of chemotherapy reporting was lower for patients aged 65 to 74, those with colon cancer, [corrected] and higher for patients treated in hospitals that are part of a large health maintenance organization (HMO). For patients with a record of receipt of radiation therapy, information was in the original registry records for 90.2%. In the multivariate analysis, completeness of radiation therapy reporting was higher for patients aged 18 to 54 and those treated in HMO hospitals. CONCLUSIONS: Because the completeness of the registry treatment data varied by patient and hospital characteristics, use of registry data without supplementation could bias estimates of the proportion of patients treated, and of the patient and provider characteristics associated with treatment. Enhanced cancer registry data could be a valuable component of population-based cancer data systems for assessing quality of cancer care.     

Biased selection and regression toward the mean in three Medicare HMO demonstrations: a survival analysis of enrollees and disenrollees

Mortality of aged Medicare enrollees in three demonstration health maintenance organizations (HMOs) was compared with that of three cohorts of local fee-for-service (FFS) beneficiaries as a measure of group differences in health status. Mortality of the HMO and FFS cohorts was tracked via life-table analysis for 6 years after enrollment to measure the persistence of health status differences existing at enrollment. After adjustment for age, sex, Medicaid-eligibility, and institutional status, HMO enrollee mortality was lower than FFS at all three plans in the first year after enrollment. Enrollee mortality at two plans increased to near FFS levels in year 2 and remained relatively stable thereafter. Enrollee mortality at the third plan increased toward FFS levels more gradually and was significantly below FFS levels for the first 5 years of follow-up. Mortality of disenrollees in the 2 years after disenrollment was significantly higher than that of the continuously enrolled in one plan and marginally significantly higher in a second. These findings suggest a pattern of favorable selection at enrollment, followed by different rates of decay in the favorable health status of enrollees. Other health status measures may exhibit different patterns, however. Selection effects may cause payments based on Medicare's AAPCC to be too high or low, in some cases for several years after enrollment.     

Discharge disposition from acute care after traumatic brain injury: the effect of insurance type

OBJECTIVE: To determine if persons with traumatic brain injury (TBI) who are insured by Medicaid or health maintenance organizations (HMOs) are more likely to receive postacute care in skilled nursing facilities (SNFs) than in rehabilitation facilities, compared with persons insured by commercial fee-for-service (FFS) plans. DESIGN: Retrospective cohort study. SETTING: County hospital admitting 30% of all Washington State TBI patients. PATIENTS: Patients with moderate to severe TBI discharged to rehabilitation facilities or SNFs between 1992 and 1997 (n = 1271); 56.3% were insured by Medicaid, 26.1% by FFS plans, and 17.6% by HMOs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disposition on discharge from acute care (rehabilitation facilities vs SNF); adjusted relative risk (RR) and confidence interval (CI) for different insurance types. RESULTS: After accounting for confounding factors, Medicaid patients were 68% more likely (RR = 1.68, 95% CI = 1.34-2.11) and HMO patients were 23% more likely (RR = 1.23, 95% CI =.90-1.68) to go to a SNF than FFS patients. However, the latter difference was not statistically significant. CONCLUSIONS: An association exists between insurance type and postacute care site. Efforts should be made to determine the effect this relationship has on the cost and outcomes for TBI patients.     

Impact of a managed-Medicare physical activity benefit on health care utilization and costs in older adults with diabetes

OBJECTIVE: The purpose of this article was to determine the effects of a managed-Medicare physical activity benefit on health care utilization and costs among older adults with diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative and claims data for 527 patients from a diabetes registry of a staff model HMO. Participants (n = 163) were enrolled in the HMO for at least 1 year before joining the Enhanced Fitness Program (EFP), a community-based physical activity program for which the HMO pays for each EFP class attended. Control subjects were matched to participants according to the index date of EFP enrollment (n = 364). Multivariate regression models were used to determine 12-month postindex differences in health care use and costs between participants and control subjects while adjusting for age, sex, chronic disease burden, EFP attendance, prevention score, heart registry, and respective baseline use and costs. RESULTS: Participants and control subjects were similar at baseline with respect to age (75 +/- 5.5 years), A1C levels (7.4 +/- 1.4%), chronic disease burden, prevention score, and health care use and costs. After exposure to the program, there was a trend toward lower hospital admissions in EFP participants compared with control subjects (13.5 vs. 20.9%, P = 0.08), whereas total health care costs were not different (P = 0.39). EFP participants who attended > or = 1 exercise session/week on average had approximately 41% less total health care costs compared with those attending <1 session/week (P = 0.03) and with control subjects (P = 0.02). CONCLUSIONS: Although elective participation in a community-based physical activity benefit at any level was not associated with lower inpatient or total health care costs, greater participation in the program may lower health care costs. These findings warrant additional investigations to determine whether policies to offer and promote a community-based physical activity benefit in older adults with diabetes can reduce health care costs.     

Cancer presentation in the emergency department: a failure of primary care.

Emergency departments are intended to be the location of entry into the health care system for patients with acute problems, such as injuries and myocardial infarctions. In contrast, cancer should optimally be detected during periodic health examinations, either through screening procedures or by early detection from signs and symptoms which prompt a routine visit to a primary care physician. This study was undertaken to describe patients who present to an emergency department with urgent symptoms and signs, are hospitalized, and subsequently diagnosed with cancer (ED group). One hundred twenty-nine patients were retrospectively studied. When compared with patients diagnosed in a primary care setting (tumor registry patients), the ED group was significantly older, more often male, had a significantly lower survival rate, and more frequent metastatic disease at diagnosis (P less than .001). The ED group accounted for 5.3% of the new tumor registry patients for the study years. Only 3.1% of the ED group had no insurance, and 21% reported no personal physician. Strategies are needed for patients and physicians to reduce the number of late-diagnosed cancer cases presenting in emergency departments.     

Effects of medicaid managed care on adults

BACKGROUND: Despite the rapid growth in Medicaid managed care (MMC) during the 1990s, only limited research exists on how such care affects beneficiaries. OBJECTIVE: The objective of this study was to assess how switching from a fee-for-service (FFS) delivery system to managed care affects Medicaid beneficiaries' access to, use of, quality of, and satisfaction with health care services. METHODS: Using a quasi-experimental design framework, we compared the experiences of 540 Minnesota Medicaid recipients living in counties that had switched to managed care with those of 528 recipients living in counties operating under FFS. The data for the analysis came from a 1998 survey of Minnesota Medicaid clients. Data were analyzed by logit regression. RESULTS: We find limited effects of MMC on access to, use of, quality of, and satisfaction with health care. Among others, we found no significant differences between the share of managed care and FFS enrollees (78.5% versus 76%) who had a health care visit during the last year. We also found no evidence of a significant reduction in the proportion of managed care and FFS enrollees (17.6% versus 17%) who had had a hospital stay during the past year. The results did show some negative effects of MMC on satisfaction with care, the most consistent being that managed care enrollees are somewhat less satisfied with their health care than their FFS counterparts. CONCLUSIONS: Our results suggest that a shift from FFS to MMC did not fundamentally change the patterns of health care service use, the location at which care was delivered, or quality.     

HMO membership and patient age and the use of specialty care for hospitalized patients with acute stroke: The Minnesota Stroke Survey

BACKGROUND: The number of older patients enrolling in health maintenance organizations (HMOs) is increasing. Concerns have been raised that older patients may be targeted by HMOs for more stringent cost-containment mechanisms, including reduced access to expensive specialty care. OBJECTIVES: We investigated the relationship between membership in an HMO and the decision to consult with a neurologist or admit to a neurology ward for patients hospitalized with acute stroke. We then compared 1-year mortality of patients who received neurology care to the 1-year mortality of those who did not receive neurology care. DESIGN: Retrospective medical record review. SUBJECTS: A sample of hospitalized acute stroke patients (age range, 30-79 years) who were discharged from Minneapolis-St. Paul metropolitan hospitals with a diagnosis code of acute cerebrovascular disease from 1991 to 1993. MEASURES: Trained nurses abstracted the medical records. Stroke events (n = 2,320) were validated using clinical criteria and neuroimaging reports. Mortality data were obtained from the Minnesota Death Index. RESULTS: Among patients enrolled in HMOs, 30% of validated stroke patients did not receive neurology care in comparison with 19% of patients not enrolled in HMOs. After adjusting for patient mix and hospital characteristics, the odds of receiving neurology care were half as great for patients enrolled in HMOs as compared with patients not enrolled in HMOs (odds ratio [OR] = 0.52, 95% confidence interval [CI] 0.36-0.74). The association of membership in HMOs with lower use of neurology care was concentrated in older patients. Within each age group, the odds ratios and 95% CI of receiving neurology care for patients enrolled in HMOs versus patients not enrolled in HMOs were: < 55 years (1.06, 0.42-2.67), 55 to 64 years (0.54, 0.34-0.87), 65 to 74 years (0.51, 0.36-0.71), and >75 years (0.40, 0.24-0.68). Using Cox regression, 30-day mortality did not differ between patients who received neurology care and those who did not. Among 30-day survivors, the mortality hazards ratio (HR) during the next 11 months for patients who received neurology care was 71% of the hazard for patients who did not receive neurology care (HR = 0.71, 95% CI = 0.55-0.91). CONCLUSIONS: These data suggest that membership in an HMO was associated with reduced access to neurology care for older patients with acute stroke and that patients who received neurology care had a lower risk of death during the year after their stroke. It remains to be determined if these differences in outcome are caused by true differences in stroke management or by unmeasured characteristics.     

Chronic care clinics for diabetes in primary care: a system-wide randomized trial

OBJECTIVE: To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients. RESEARCH DESIGN AND METHODS: We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients > or = 30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems. RESULTS: In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA1c levels. CONCLUSIONS: Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes.     

Utilization patterns and mortality of HMO enrollees

Data from a 6-year follow-up period were used to analyze the mortality of adults who had been continuously enrolled in a prepaid group practice health maintenance organization (HMO) for the previous 7 years. Thirteen percent of the HMO members were classified as consistently high users of outpatient care. Even after adjustment for age, sex, and cigarette smoking, this high user group's mortality rates during the follow-up period were significantly greater than those of the other HMO enrollees. The HMO members as a whole had mortality rates marginally lower than the mortality of the general Oregon population. It can be concluded that HMO enrollees who consistently use high quantities of health care resources generally have significant medical problems in addition to psychosocial difficulties. Assuming that mortality reflects health, long-term HMO members as a group are not much healthier than ordinary Oregonians.     

Risk selection of families electing HMO membership

This study analyzes the health plan selection history of approximately 30,000 employees of a large aerospace corporation. The data show that families selecting HMOs were younger, had lower income, and had less time on the job. HMOs attracted families with lower annual claimed expenditures, and these families' claimed expenses were lower still in the year immediately prior to switching into the HMO. Lower costs among families switching into the HMOs are partly explained by the composition of these families compared with families who stayed in the FFS plan. However, the selection pattern persisted even after adjusting for the size of the family, the age and sex of family members, and other family characteristics, such as race and income. Families switching out of HMOs had higher total annual claims during their first year back in the FFS sector compared with families about to switch into HMOs. However, recent HMO exiters did not always differ from families who never left the FFS plan.     

Evaluation of the Washington State Workers' Compensation Managed Care Pilot Project I: medical outcomes and patient satisfaction.

OBJECTIVES: This study examined the effect of managed care on medical outcomes and patient satisfaction as part of an evaluation of the Washington State Workers' Compensation Managed Care Pilot. METHODS: One hundred twenty firms (7,041 employees) agreed to have their injured workers treated in managed-care plans. Managed care introduced two changes from the fee-for-service (FFS) delivery system currently used by injured workers in Washington State: (1) experience-rated capitation, and (2) a primary occupational-medicine delivery model. The FFS control group included injured workers employed at 392 firms (12,000 employees). A total of 1,313 workers who experienced occupationally related injuries or illnesses between April 1995 and June 1996 were interviewed by telephone at 6 weeks after injury regarding their medical outcomes and satisfaction with care. Workers whose injuries resulted in four or more lost workdays (n = 372) were also interviewed at 6 months after injury on the same topics. The areas surveyed included functional outcomes and satisfaction with care, providers, and access to providers. RESULTS: The measures of functional outcome reflected no consistent differences between the managed care and the FFS conditions. The workers who attended the managed-care system reported lower levels of satisfaction with care, particularly with access to providers. For example, 58% of managed-care patients reported satisfaction with their attending physician as compared with 69% of FFS patients (P<0.01). CONCLUSIONS: Workers treated through managed-care arrangements were less satisfied with their care, but their medical outcomes were similar to those of workers who received traditional FFS care. The current workers' compensation system in Washington State affords injured workers great latitude in choosing providers. If provider choice is substantially restricted by managed care, worker satisfaction is likely to diminish.     

Use of preventive services by Medicare fee-for-service beneficiaries: does spillover from managed care matter?

BACKGROUND: Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear. OBJECTIVE: We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA. RESEARCH DESIGN: This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources. SUBJECTS: We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study. MEASURES: We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL). RESULTS: Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13). CONCLUSIONS: From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.     

Elderly patients' satisfaction with care under HMO versus private systems

In one community, 100 elderly persons (25 HMO and 75 private patients) completed a 20-item scale that measured satisfaction with medical care. Data on demographics, health care utilization, and self-assessed health status also were collected to determine whether these variables would relate to HMO membership. Satisfaction scores were compared between HMO and private care groups by multivariate analysis of variance. Satisfaction with the doctor-patient relationship and convenience of care was higher in the private care group, whereas satisfaction with cost was higher in the HMO group. Interestingly, the HMO group evaluated private care and HMO care similarly. The private group rated HMO care less favorably. Additional comments reveal specific areas of satisfaction/dissatisfaction.