Clinical care with a retail flavor: Twin Cities employer group tries a bold new experiment

In this revolutionary new healthcare purchasing model, individual consumers--employees, not employers--make healthcare buying decisions. Providers, in turn, are directly accountable to consumers and design their networks to compete for consumer market share.

Women and managed care: satisfaction with provider choice, access to care, plan costs and coverage

This article reports on differences in satisfaction with provider choice, access to care, and plan costs and coverage between women enrolled in fee-for-service and those in managed car plans. It also examines differences in satisfaction, access, and costs and coverage between higher and lower income women and between those in reported fair or poor health and those in excellent or good health, among women in managed care plans. The data for this study are from The Commonwealth Fund's 1994 Managed Care Survey, which included 1,544 women with employer- or union-sponsored insurance in Boston, Los Angeles, and Miami. The study found that women in managed care were less satisfied with provider choice and access to services, but more satisfied with out-of-pocket costs for services and the range of services covered. Both low-income women and those in fair to poor health reported more problems with access barriers than did either higher income women or those in excellent or good health.

Use of ineffective or unsafe medications among members of a Medicare HMO compared to individuals in a Medicare fee-for-service program

Adverse drug reactions and inappropriate prescribing practices are an important cause of hospitalization, morbidity, and mortality in the elderly. This study compares prescribing practices within a Medicare risk contract health maintenance organization (HMO) in 1993 and 1994 with prescribing practices for two nationally representative samples of elderly individuals predominantly receiving medical care within the Medicare fee-for-service sector. Information on prescriptions in the fee-for-service sector came from the 1987 National Medical Expenditures Survey (NMES) and the 1992 Medicare Current Beneficiary Survey (MCBS). A total of 20 drugs were studied; these drugs were deemed inappropriate for the elderly because their risk of causing adverse events exceeded their health benefits, according to a consensus panel of experts in geriatrics and pharmacology. One or more of the 20 potentially inappropriate drugs was prescribed to 11.53% of the Medicare HMO members in 1994. These medications were prescribed significantly less often to HMO members in 1994 than to individuals in the fee-for-service sector, based on information from both the 1987 NMES and the 1992 MCBS. Utilization of unsafe or ineffective medications actually decreased with increasing age in the HMO sample, with lowest rates in individuals over the age of 85. However, no relationship between age and medication use was seen in the NMES study, except for individuals over the age of 90 years. The study data support the conclusion that ineffective or unsafe medications were prescribed less often in the Medicare HMO than in national comparison groups. In fact, for the very old, who are most at risk, the use of these medications was much lower in the Medicare HMO than in the Medicare fee-for-service sector. Nevertheless, in 1994, approximately one of every nine members of this Medicare HMO received at least one such medication. Continued efforts and innovative strategies to further reduce the use of unsafe and ineffective drugs among elderly Medicare HMO members are needed.

By the numbers. Care for arthritis and other chronic conditions

This issue's "By the Numbers" highlights recent findings on care for patients with rheumatoid arthritis in HMO and fee-for-service (FFS) settings. It also looks at the prevalence of arthritis and other chronic conditions in these plans.

Federal employees health benefits program: limitation on physician charges and FEHB Program payments--Office of Personnel Management. Final rule

The Office of Personnel Management (OPM) is making final its interim regulation that amends current Federal Employees Health Benefits (FEHB) Program regulations. The final regulation requires that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services.

Is referral source a risk factor for coronary surgery? Health maintenance organization versus fee-for-service system

We began performing coronary artery bypass grafting for a large health maintenance organization (HMO) in 1974, as the sole provider of their cardiac surgery. The outcomes of our HMO group of patients were compared with those of our patients treated on a fee-for-service (FFS) basis. The HMO system entails preintervention and multidisciplinary screening conferences and is devoid of self-referral and personal financial incentives. Since 1985, the operative mortality for HMO patients has been consistently lower than for FFS patients. There were 8483 operations during this study period: 3168 (37%) were in the HMO group, with an overall operative mortality of 2.7%, and 5315 (63%) were in the FFS group, with an operative mortality of 4.6% (p=0.00002). This difference was investigated with univariate and multivariable analyses. Sixteen factors were found to univariately affect the risk of operative mortality; for five of these risk correlates there was a significant maldistribution between the HMO and FFS patients. Logistic regression was used to explore the influence of this imbalance in risk factors. The model found seven independent risk factors (left ventricular failure, emergency coronary bypass, redo bypass, nonuse of the internal thoracic artery, unstable angina, age, and diabetes) that significantly affected operative mortality. The FFS group variable closely approached independent risk significance at p=0.059. This multivariable model explained only one third of the observed differences in actual mortality between the HMO and FFS groups. The system-wide angioplasty/coronary bypass ratio, which could not be used in a patient-specific model, was 0.6 in the HMO system and 1.5 in the FFS group. Other factors related to the operating structure of a mature, large HMO may account for the remainder of the difference. The HMO referral system, through a powerful selection process, resulted in fewer emergencies, redo bypass operations, and catheterization complications that, in turn, yielded lower operative mortality than a noncoordinated FFS system of cardiovascular management.

Reassessing the number and mix of system physicians needed

As the fee-for-service reimbursement environment gives way to managed care in many parts of the country, healthcare executives are facing the need to reassess the number and specialty mix of their systems' physician populations. By using two sets of guidelines--one developed for fee-for-service environments (the Graduate Medical Education National Advisory Committee guidelines) and the other developed for managed care environments (the Kaiser Permanente guidelines)--healthcare executives can calculate the appropriate number and specialty mix of physicians their systems need to serve their communities.

Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study

OBJECTIVE

To compare the outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus (NIDDM) who were cared for in three different systems of care and by generalist and subspecialist physicians.

DESIGN

An observational study with follow-up at three periods: (1) a 2-year study of 532 patients with hypertension and 170 patients with NIDDM who had entrance and exit histories, physical examinations, and laboratory tests; (2) a 4-year follow-up of 1044 patients with hypertension and 317 patients with NIDDM based on patient-reported functional status; and (3) 7-year mortality for 1296 patients with hypertension and 424 patients with NIDDM.

SETTING AND PARTICIPANTS

Patients sampled from health maintenance organizations, large multispecialty groups, and solo or single-specialty group practices in Boston, Mass, Los Angeles, Calif, and Chicago, Ill. Patients were designated as belonging to one of three systems of care: fee for service; prepaid patients in solo or small single-specialty groups or in large multispecialty group practices, referred to as independent practice associations; and staff-model health maintenance organizations. The principal providers were family practitioners, general internists, cardiologists, or endocrinologists.

MAIN OUTCOME MEASURES

Physiological, functional, and mortality. For hypertension, we measured blood pressure and stroke incidence. For NIDDM, we measured blood pressure, glycosylated hemoglobin level, visual function, vibration sense, ulcers and infections in the feet, and albumin excretion rate. Functional outcomes were assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Mortality was assessed for the 7 years following the entrance examination.

RESULTS

We found no evidence that any one system of care or physician specialty achieved consistently better 2-year or 4-year outcomes than others for patients with NIDDM or hypertension. Endocrinologists appeared to achieve better foot-ulcer and infection outcomes for patients with NIDDM, particularly when compared with family practitioners. However, no other specialist differences were found in any individual measures for either condition. Moreover, no adjusted mortality differences among systems or among physicians specialties were observed in the 7-year follow-up period.

CONCLUSION

No meaningful differences were found in the mean health outcomes for patients with hypertension or NIDDM, whether they were treated by different care systems or by different physician specialists. Although prepaid medicine relies more heavily on generalist physicians than does fee for service, there is no evidence from these analyses that the quality of care of moderately ill patients with these two common disease was adversely affected. These findings must be viewed in light of the historically higher costs of fee-for-service medicine and of subspecialty physician practice.

Are you ready for the computer-based patient record?

Moving to a computer-based patient record (CPR) involves much more than simply putting computers in clinical offices. To achieve success, a health care organization must rethink and revise traditional workflows and organizational structures. Diverse constituencies within an organization must be targeted to gain buy-in to the process. Other considerations include cost justification and implementation strategies. Current market dynamics suggest that organizations should be contemplating the move to a CPR in order to gain competitive advantage or even to maintain the status quo.

The measure of Medicare services

Trying to make managed care more responsive to the demands of employers and consumers is a challenge. More and more HMOs are providing financial incentives for doctors to deliver better quality and service. But critics contend that bonuses can weaken quality.

What members want

One large multi-market study recently confirmed that people are more satisfied in HMOs than they are in other types of health plans--and the results have nothing to do with health status. Here's a look at what drives HMO member satisfaction.

Medicare beneficiaries rate their medical care: new data from the MCBS (Medicare Current Beneficiary Survey)

The Medicare Current Beneficiary Survey (MCBS) contains a wealth of information about the people whose care is financed by the program. This article examines their satisfaction with medical care received and explores the relationship of these attitudes with the characteristics of subgroups of the enrolled population. Satisfaction with medical care among Medicare beneficiaries is found to be generally high (80-90 percent). Disabled Medicare beneficiaries are less satisfied than the aged, and health maintenance organization (HMO) enrollees less satisfied than fee-for-service (FFS) patients. Others with lower-than-average satisfaction are people with poorer health status, those covered by Medicaid, and those without supplementary insurance.

Choice matters: enrollees' views of their health plans

Enrollees' views of their health plans and physicians are important measures of the performance of the health care system. The Commonwealth Fund's 1994 survey of 3,000 adults in fee-for-service and managed care organizations documents enrollees' experiences with choosing a plan and satisfaction with that plan. Fee-for-service enrollees were more satisfied with their plan's access to and quality of care; managed care enrollees were more satisfied with their plan's cost, paperwork, and coverage of preventive care. The survey also found a high rate of involuntary plan changing, limited choice of physicians, and low levels of satisfaction among low-income managed care enrollees.

Home health care outcomes under capitated and fee-for-service payment

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.