Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare

BACKGROUND: Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. OBJECTIVES: To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. METHODS: Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. RESULTS: For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. CONCLUSIONS: The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.     

A comparison of length of stay and costs for health maintenance organization and fee-for-service patients

Enrollees of health maintenance organizations (HMOs) are less frequently hospitalized than are patients cared for by fee-for-service physicians. To determine if care provided to HMO and fee-for-service patient is different once they are hospitalized, we compared length of stay, total costs, and severity of illness for 617 HMO and fee-for-service patients hospitalized during the period 1983 through 1985 at a major teaching hospital. Severity was gauged in the following two ways: the Severity of Illness Index developed by Horn, and ratings by two physicians who were given all records from the first day of each patient's hospitalization. Length of stay was shorter and total costs were less for HMO patients in 7 of 11 diagnosis related groups. Using regression analysis to adjust for age, sex, emergency ward admission, diagnosis related group, and severity, we found that overall length of stay was 14% shorter for HMO patients than for fee-for-service patients (6.2 vs 5.3 days, P less than .01), whereas total costs were only 4% less ($4251 vs $4090, P greater than .2). These findings indicate that while patterns of utilization may vary by diagnosis related groups, HMO patients had shorter lengths of stay but comparable overall costs. Whether shorter lengths of stay represent greater efficiency, substitution of outpatient for inpatient care, or diminution in the quality of care is not clear.     

Effects of cost containment on the care of elderly diabetics

OBJECTIVE--Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. DESIGN--Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. SETTING--The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. PATIENTS--Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. RESULTS--Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. CONCLUSION--We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.     

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals

Objectives. This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals.Background. The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization.Methods. Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992.Results. The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% Cl 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was ∼1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05).Conclusions. Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.     

The management of geriatric hypertension in health maintenance organizations

OBJECTIVE: To evaluate the quality of medical care received by Medicare enrollees with hypertension in health maintenance organizations (HMOs) compared to that received by a similar group of elderly hypertensives in a fee-for-service (FFS) setting. DESIGN: A quasi-experimental design was used to study an historical cohort of newly evaluated hypertensive patients over a 2-year period. SETTING: Medicare HMO and FFS practice settings. PARTICIPANTS: Eight Medicare HMOs and 87 FFS primary care physicians in the same communities were selected. A sample of 685 elderly hypertensive patients was studied, 336 in FFS settings and 349 in HMOs. MEASUREMENTS AND MAIN RESULTS: An expert panel of physicians selected standards of care for the management of geriatric hypertension, and medical records were reviewed. The results showed significant differences (P less than 0.01) in recording medications (94.5% HMO versus 88% FFS) and smoking histories (75.8% HMO versus 64.7% FFS), checking orthostatic blood pressures (9.5% HMO versus 3.3% FFS), performing funduscopy (44.4% HMO versus 27% FFS), completing cardiac examinations (90.8% HMO versus 79.8% FFS), and obtaining chest x-rays (72.8% HMO versus 64.3% FFS, P less than 0.05). Treatment and follow-up were similar between the two groups, except that FFS hypertensives were more likely to have medications adjusted and electrolytes ordered. CONCLUSIONS: The results suggest that elderly hypertensives in HMOs received equal or better quality of care for most criteria compared to elderly hypertensives in FFS settings.     

Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region.

PURPOSE: To evaluate use of effective cardiac medications and rehabilitation after myocardial infarction in the ambulatory setting in health maintenance organizations (HMOs) and fee-for-service care, and by region. SUBJECTS AND METHODS: We surveyed elderly Medicare patients during 1996 and 1997 in California (n = 516), Florida (n = 304), and the Northeast (n = 220; Massachusetts, New York, and Pennsylvania) approximately 18 months after myocardial infarction. We assessed use of cardiac medications and rehabilitation for HMO (n = 520) and fee-for-service (n = 520) patients matched by age, sex, month of infarct, and region. RESULTS: Across all regions, similar proportions of HMO and fee-for-service patients were using aspirin (72%, n = 374 vs. 74%, n = 387), beta-blockers (38%, n = 195 vs. 32%, n = 168), angiotensin-converting enzyme inhibitors (31%, n = 159 vs. 29%, n = 148), cholesterol-lowering agents (28%, n = 146 vs. 30%, n = 157), and calcium channel blockers (31%, n = 162 vs. 31%, n = 159; all P >0.07), except in California where more HMO patients received beta-blockers (36%, n = 93 vs. 26%, n = 66, P = 0.01). In adjusted analyses, use of these drugs did not differ significantly between HMO and fee-for-service patients. Substantial regional differences were evident in the use of beta-blockers (Northeast 46%, n = 102; Florida 34%, n = 102; California 31%, n = 159) and cholesterol-lowering agents (California 35%, n = 182; Florida 24%, n = 73; Northeast 22%, n = 48; each P <0.001). Fee-for-service patients were more likely than HMO patients to receive cardiac rehabilitation in unadjusted (32%, n = 167, vs. 22%, n = 141, P = 0.001) and adjusted analyses. CONCLUSIONS: Both HMO and fee-for-service patients would likely benefit from greater use of beta-blockers and cholesterol-lowering agents. Professional fees for cardiac rehabilitation may promote increased use among fee-for-service patients. Future studies should assess the quality of ambulatory cardiac care in different types of HMOs and the reasons for geographic variations in cardiac drug use.     

Comparison of the quality of ambulatory care for fee-for-service and prepaid patients

OBJECTIVE: To determine whether the quality of care for common ambulatory conditions is adversely affected when physicians are provided with incentives to limit the use of health services. DESIGN: Retrospective cohort study over a 2-year period. SETTING: Four group practices that cared for both fee-for-service patients and prepaid patients within a network model health maintenance organization (HMO). PATIENTS: Equal numbers of prepaid (HMO) and fee-for-service patients were selected by randomly choosing medical records from each group practice: 246 patients with chronic uncomplicated hypertension and 250 women without chronic diseases who received preventive care. MAIN OUTCOME MEASURES: Adequate hypertension control was defined as a mean blood pressure of less than 150/90. Adequate preventive care was defined as the provision of blood pressure screening, colon cancer screening, breast cancer screening, and cervical cancer screening within guidelines recommended by the 1989 U.S. Preventive Services Task Force. Resource use was measured by the annual number of visits and tests. MAIN RESULTS: The adjusted relative odds of HMO patients having controlled hypertension, compared with fee-for-service patients, were 1.82 (95% CI, 1.02 to 3.27). The relative risks of HMO patients receiving preventive care within established guidelines were 1.19 (CI, 0.93 to 1.51) for colon cancer screening, 1.78 (CI, 1.11 to 2.84) for annual breast examinations, 1.75 (CI, 1.08 to 2.84) for biannual mammography, and 1.35 (CI, 1.13 to 1.60) for Papanicolaou smears every 3 years. Prepaid patients had visit rates that were 18% to 22% higher than those of fee-for-service patients. CONCLUSIONS: In the type of network model HMO we studied, the quality and quantity of ambulatory care for HMO patients was equal to or better than that for fee-for-service patients. In this setting, the incentives for physicians to limit resource use may be offset by lack of disincentives for HMO patients to seek care.     

Physicians as gatekeepers. The impact of financial incentives

Incentives encouraging physicians to reduce their use of diagnostic tests are controversial. We studied physicians enrolled in an independent practitioner association who see both fee-for-service and prepaid (health maintenance organization [HMO]) patients concurrently. We asked the following questions: (1) Do physicians order fewer tests for their patients enrolled in an HMO relative to their patients seen on a fee-for-service basis? (2) Are any reductions in testing selective or indiscriminate? We reviewed the charts of 273 new patients, 167 enrolled in a fee-for-service system and 106 enrolled in an HMO, who were seen by 17 physicians "for a check-up," and graded test use as "indicated" or "discretionary." We used multiple logistic regression to control for the effects of patient age and sex. Patients in the HMO underwent fewer tests than did patients in the fee-for-service system, as well as fewer discretionary tests, but received the same proportion of preventive services. We conclude that physicians ordered fewer tests for patients in the HMO, apparently because of selective omission of discretionary tests. Physicians also did not reduce preventive services for patients in the HMO relative to all other physicians.     

Health effects of managed care among the near-elderly

OBJECTIVE: The authors evaluate whether enrolling in a health maintenance organization (HMO) or preferred provider organization (PPO) affects the health of adults ages 55 to 64, relative to fee-for-service plans. METHODS: A nationwide random sample of 4,044 adults with employer-sponsored health insurance is drawn from the 1994 to 2000 waves of the Health and Retirement Study. Multinomial logit regressions are estimated for self-reported general health status, first using a sample of all near-elders, then using subsamples of near-elders with and without longstanding chronic health conditions. The possibility of selection bias into managed care plans is considered and explicitly addressed in model estimation. RESULTS: We find no ill effects of HMOs on health status, and older adults with a history of chronic health conditions actually fare better upon enrolling in these plans. DISCUSSION: More research is needed to understand the reasons for the observed beneficial effects of managed care.     

Elderly patients with congestive heart failure under prepaid care

PURPOSE: Because of concern about the quality of care received by Medicare patients in health maintenance organizations (HMOs), the care of patients with congestive heart failure (CHF) in eight HMOs was compared with the care of fee-for-service (FFS) Medicare cases. PATIENTS AND METHODS: We compared the care of 170 patients with CHF enrolled in one of eight Medicare HMOs with the care of 191 similar FFS patients. Panels of expert physicians developed criteria for evaluating quality of care, and specially trained nurse clinicians abstracted medical records. RESULTS: Outpatient evaluation and management were similar in both settings, although HMO patients were significantly more likely to be advised to restrict salt intake. However, FFS patients with uncontrolled hypertension were more likely to have their medication regimens changed (62% versus 36%, p less than 0.01). Ejection fractions were obtained equally as often, and inpatient management was similar for both groups. Nonetheless, HMO providers scheduled follow-up visits within 1 week of hospital discharge more often (42% versus 27%, p less than 0.01). CONCLUSIONS: This study suggests that financial incentives of prepaid care are not detrimental to most aspects of care for CHF patients. More rapid follow-up after hospital discharge for patients with CHF suggests that HMOs may be more effective in delivering continuity of care for patients with chronic illness.     

Preferences for patient cost sharing among medicare beneficiaries after HMO plan withdrawals

OBJECTIVE: To assess Medicare beneficiaries' willingness to cost share in order to minimize disruptions in coverage from HMO plan withdrawals. DESIGN: Cross-sectional survey of Medicare beneficiaries from February 1999 to March 1999. SETTING: Ten U.S. counties with the highest HMO plan withdrawal rates. PATIENTS/PARTICIPANTS: Seven hundred one Medicare beneficiaries for response rate of 69%. MEASUREMENTS AND MAIN RESULTS: Percentage of respondents willing to accept more out-of-pocket costs in order to continue their Medicare HMO coverage. Most respondents (67%) were willing to pay more out-of-pocket costs so that their HMO could have continued Medicare coverage. Those who were white (P =.03), had higher incomes (P =.01), and returned to traditional fee-for-service Medicare (P =.004) were more likely than other respondents to accept increased patient cost sharing. Most beneficiaries preferred Medicare policies requiring HMOs to sign longer-term Health Care Financing Administration (HCFA) contracts (72%) and to offer coverage to beneficiaries regardless of where they lived in a given state (87%). However, respondents' preferences for such policy options were not associated with the amount of cost sharing that respondents were willing to accept. CONCLUSIONS: Most Medicare beneficiaries are willing to accept increased patient cost sharing in order to reduce disruptions in their HMO coverage. Policies intended to reduce HMO plan withdrawals, such as requiring health plans to sign longer-term HCFA contracts, are supported by many Medicare beneficiaries, but these policy preferences were not related to willingness to cost share. In light of an apparent willingness to pay more out-of-pocket medical costs, Medicare beneficiaries in general may accept increased cost sharing in order to retain their HMO coverage.     

Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance.

BACKGROUND: A commonly voiced concern is that health maintenance organizations (HMOs) may withhold or delay the provision of urgent, essential care, especially for vulnerable patients like the elderly. OBJECTIVE: To compare the quality of emergency care provided in Minnesota to elderly patients with acute myocardial infarction (AMI) who are covered by HMO vs fee-for-service (FFS) insurance. METHODS: We reviewed the medical records of 2304 elderly Medicare patients who were admitted with AMI to 20 urban community hospitals in Minnesota (representing 91% of beds in areas served by HMOs) from October 1992 through July 1993 and from July 1995 through April 1996. MAIN OUTCOME MEASURES: Use of emergency transportation and treatment delay (>6 hours from symptom onset); time to electrocardiogram; use of aspirin, thrombolytics, and beta-blockers among eligible patients; and time from hospital arrival to thrombolytic administration (door-to-needle time). RESULTS: Demographic characteristics, severity of symptoms, and comorbidity characteristics were almost identical among HMO (n = 612) and FFS (n = 1692) patients. A cardiologist was involved as a consultant or the attending physician in the care of 80% of HMO patients and 82% of FFS patients (P = .12). The treatment delay, time to electrocardiogram, use of thrombolytic agents, and door-to-needle times were almost identical. However, 56% of HMO patients and 51% of FFS patients used emergency transportation (P = .02); most of this difference was observed for patients with AMIs that occurred at night (60% vs 52%; P = .02). Health maintenance organization patients were somewhat more likely than FFS patients to receive aspirin therapy (88% vs 83%; P = .03) and beta-blocker therapy (73% vs 62%; P = .04); these differences were partly explained by a significantly larger proportion of younger physicians in HMOs who were more likely to order these drug therapies. All differences were consistent across the 3 largest HMOs (1 staff-group model and 2 network model HMOs). Logistic regression analyses controlling for demographic and clinical variables produced similar results, except that the differences in the use of beta-blockers became insignificant. CONCLUSIONS: No indicators of timeliness and quality of care for elderly patients with AMIs were lower under HMO vs FFS insurance coverage in Minnesota. However, two indicators of quality care were slightly but significantly higher in the HMO setting (use of emergency transportation and aspirin therapy). Further research is needed in other states, in different populations, and for different medical conditions.     

Management of colorectal cancer in medicare health maintenance organizations

Because of the financial incentives of prepaid care, the quality of care for Medicare enrollees in Health Maintenance Organizations (HMOs) is a concern. Therefore, the care in 150 newly diagnosed cases of colorectal cancer in eight HMOs was compared with that in 180 similar fee-for-service (FFS) cases. As part of the diagnostic workup, HMO patients were more likely to have bad fecal occult blood tests (74% vs 52%, p<0.01) and endoscopy or barium enemas (97% vs 90%, p<0.05). FFS patients were more likely to have had preoperative imaging studies (54% vs 38%, p<0.01). Although there were longer diagnostic delays for HMO enrollees with gastrointestinal bleeding, there were no significant differences in disease stage or clinical status, and postoperative follow-up was similar. The authors conclude that enrollees in Medicare HMOs with colorectal cancer receive medical and surgical care at least equal to that received in FFS settings. Received from the Departments of Medicine and Health Administration, and the Williamson Institute for Health Studies, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia. Supported by a contract from the Health Care Financing Administration, No. 500-83-0047. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 27, 1989.     

Disability outcomes of older Medicare HMO enrollees and fee-for-service Medicare beneficiaries

OBJECTIVES: To investigate whether older Medicare beneficiaries enrolled in Medicare risk health maintenance organizations (HMOs) have different rates of disablement than fee-for-service (FFS) beneficiaries. DESIGN: Secondary analysis of annual functional status transitions using the Medicare Current Beneficiary Survey, 1991 to 1996. SETTING: Telephone interviews. PARTICIPANTS: Forty-four thousand seven hundred and sixty-five person-years of annual functional status transitions for noninstitutionalized older Medicare beneficiaries who were either risk HMO enrollees or FFS beneficiaries with or without private supplementary insurance. MEASUREMENTS: Five multinomial logit models were estimated as single-state transition models, with five functional states, death, and censored as outcomes. The probability of being in a certain functional state the following year was specified as a function of individual risk factors and HMO versus FFS supplementary insurance status. RESULTS: Among functionally independent beneficiaries, the odds of becoming disabled in activities of daily living (ADLs) within a year were lower among FFS individuals with supplementary insurance (odds ratios (OR) = 0.67, P <.01) and HMO enrollees (OR = 0.58, P <.01). Among older people who were functionally impaired, neither HMO enrollment nor private supplementary insurance affected the risk of further functional decline or functional improvement. Supplementary insurance, but not HMO enrollment, was associated with lower mortality risk among beneficiaries with functional limitations (OR = 0.65, P <.05) or moderate ADL disability (OR = 0.72, P <.05). CONCLUSION: Medicare risk HMO enrollment and FFS private supplementary insurance convey similar benefits of slowing functional decline and extending life span for nonseverely disabled older people. That no association was found between adverse functional status outcomes and risk HMO enrollment has favorable implications regarding the quality of care of managed care plans.     

An evaluation of substance misuse treatment providers used by an employee assistance program.

Structural measures of access, continuity, and quality of substance misuse treatment services were compared in 30 fee-for-service (FFS) facilities and nine health maintenance organizations (HMOs). Probit models related effects of the provider system (FFS or HMO) and the system's structural characteristics to 243 employees' access to and outcomes from treatment. Access was decreased in Independent Practice Association (IPA)/network HMOs and in all facilities which did not employ an addictionologist or provide coordinated treatment services. When bivariate correlations were examined, both use of copayments and imposing limits to the levels of treatment covered were negatively related to access, while a facility's provision of ongoing professional development was positively associated with access. These correlations did not remain significant in the multivariate probits. Receiving treatment in a staff model HMO and facing limits to the levels of treatment covered were negatively associated with attaining sufficient progress, while receiving treatment in a facility which provided ongoing professional development was positively related to progress: these effects did not remain significant in multivariate analyses. Implications for employee assistance program (EAP) staff in their role as case managers and for EAP staff and employers in their shared role as purchasers of treatment are discussed.     

Age and patterns of HMO satisfaction

Consumerism and increasing complexity in health care options highlight the importance of health care satisfaction. Patterns and sources of satisfaction are assessed for health maintenance organizations (HMOs), a relatively novel option, using national survey data. Particular attention is paid to age differences, because HMO Medicare coverage is a recent development and older people generally express little HMO familiarity or receptivity. Higher satisfaction is expressed by HMO members than by nonmembers for both younger and older persons. HMO satisfaction is higher for older than for younger members, a pattern at odds with nonmember attitudes about HMOs. Member satisfaction is a function of the nature of patient/provider ties and related attitudes, as it is among nonmembers. Importance of a "regular" provider is particularly evident among older HMO members. Patterns of HMO satisfaction among older members likely reflects both cohort differences and age-associated patterns of health and related attitudes.     

Age differences in HMO receptivity.

The changing health care market has highlighted the role of the individual in choosing health care providers. HMOs are a relatively novel option, particularly for Medicare beneficiaries. National survey data are used to assess patterns of HMO receptivity. Older persons are less familiar with the HMO model. They also express less favorable attitudes toward HMOs and less enrollment interest. HMO receptivity is a function of health care attitudes and experiences and the nature of available information about HMOs. Age differences in HMO receptivity reflect the effects of cohort membership and aging on these factors.     

HMOs and utilization of emergency medical services: a metropolitan survey

A survey was conducted of a diverse group of health maintenance organizations (HMOs) serving a large metropolitan area regarding enrollee instructions for use of emergency medical services. Written and verbal requests for written information concerning emergency medical system instructions for enrollees were made to the 25 largest HMOs serving Chicago and surrounding suburbs. Sixteen responses, representing more than 95% of total HMO enrollees, were obtained. Options for access for prehospital care were reviewed and categorized: call 911, call toll-free telephone number, call HMO office or primary physician, go to the nearest HMO-affiliated hospital, and go to the nearest hospital. Of the 16 respondents, 15 HMOs responsible for 99% of the total HMO enrollees advised their subscribers to contact their HMO office or primary physician or to call a toll-free number in the case of an emergency. No HMO advised use of the 911 access as a first response for an emergency. Only two HMO brochures, responsible for 7% of the total HMO enrollees, recommended that 911 access be used. These data suggest that HMO enrollees may not be adequately informed regarding proper use of 911 and the emergency medical services system.     

Impact of managed care on the use of biologic agents for rheumatoid arthritis

OBJECTIVE: To compare the use of biologic agents among persons with rheumatoid arthritis (RA) in managed care and fee-for-service settings. METHODS: The present study uses data from the University of California, San Francisco RA Panel Study in which 529 patients with RA from a random sample of northern California rheumatologists were interviewed annually between 1999 and 2002 using a structured survey instrument. Linear and logistic regression were used to compare current utilization, initiation, and cessation of biologic agents and other treatments among patients with RA in managed care and fee-for-service settings, with and without adjustment for differences in demographic and health characteristics. RESULTS: After adjustment, patients with RA in health maintenance organizations (HMOs) were significantly less likely to use biologic agents than those in other managed care settings (difference of -6.6%; 95% confidence interval [95% CI] -11.4%, -1.7%) or than those in fee-for-service settings (difference of -12.5%; 95% CI -19.0%, -5.9%); patients in other managed care settings and fee-for-service did not differ significantly in their use of biologic agents. Patients with RA in HMOs were significantly less likely than those in other managed care settings to initiate the use of biologic agents (difference of -7.3%; 95% CI -11.5%, -3.1%); there were no other differences between patients in HMOs and those in other managed care and fee-for-service settings in rates of initiation or cessation of these agents. Patients with RA in HMOs were less likely to use methotrexate, cyclooxygenase 2 (COX-2) inhibitors, and corticosteroids than those in other managed care settings; they were also less likely to use COX-2 inhibitors than those in fee-for-service settings. CONCLUSION: Patients with RA in HMOs were significantly less likely to use biologic agents than those in other managed care and fee-for-service settings, primarily due to lower rates of initiation.     

Outcome and utilization differences for older persons with stroke in HMO and fee-for-service systems

OBJECTIVES: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems. DESIGN: Inception cohort stratified by payer and followed for 1 year. SETTING: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States. PARTICIPANTS: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995. MEASUREMENTS: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits. RESULTS: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5). CONCLUSION: Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.