Breast cancer survival and treatment in health maintenance organization and fee-for-service settings

BACKGROUND: Enrollment in health maintenance organizations (HMOs) has increased rapidly during the past 10 years, reflecting a growing emphasis on health care cost containment. To determine whether there is a difference in the treatment and outcome for female patients with breast cancer enrolled in HMOs versus a fee-for-service setting, we compared the 10-year survival and initial treatment of patients with breast cancer enrolled in both types of plans. METHODS: With the use of tumor registries covering the greater San Francisco-Oakland and Seattle-Puget Sound areas, respectively, we obtained information on the treatment and outcome for 13,358 female patients with breast cancer, aged 65 years and older, diagnosed between 1985 and 1992. We linked registry information with Medicare data and data from the two large HMOs included in the study. We compared the survival and treatment differences between HMO and fee-for-service care after adjusting for tumor stage, comorbidity, and sociodemographic characteristics. RESULTS: In San Francisco-Oakland, the 10-year adjusted risk ratio for breast cancer deaths among HMO patients compared with fee-for-service patients was 0.71 (95% confidence interval [CI] = 0.59-0.87) and was comparable for all deaths. In Seattle-Puget Sound, the risk ratio for breast cancer deaths was 1.01 (95% CI = 0.77-1.33) but somewhat lower for all deaths. Women enrolled in HMOs were more likely to receive breast-conserving surgery than women in fee-for-service (odds ratio = 1.55 in San Francisco-Oakland; 3.39 in Seattle). HMO enrollees undergoing breast-conserving surgery were also more likely to receive adjuvant radiotherapy (San Francisco-Oakland odds ratio = 2.49; Seattle odds ratio = 4.62). CONCLUSIONS: Long-term survival outcomes in the two prepaid group practice HMOs in this study were at least equal to, and possibly better than, outcomes in the fee-for-service system. In addition, the use of recommended therapy for early stage breast cancer was more frequent in the two HMOs.     

A neural network model of the McCollough effect

Recent federal legislation has contained the stipulation that participating health maintenance organizations (HMOs) include a quality assurance program which stresses health outcomes. This provision was ostensibly directed at correcting alleged abuses in HMOs serving the urban poor. One version of the outcome method was employed for an 18-month period at an urban HMO caring for 2,000 Medicaid subscribers. The program involved comparing diagnostic accuracy and therapeutic outcomes for clinical conditions relevant to the study population with ideal standards established by the HMO. Three conditions were selected: contraception, depression, and hypertension. The results revealed widespread underdiagnosis (44-74%) in each condition and unacceptable therapeutic outcomes in two. Data collection was hampered by shifts in geography and financial eligibility among the denominator population and low response rates (38-63%) to telephone and mail surveys. Applying the general project guidelines to specific conditions proved considerably more difficult than anticipated. Further refinement of this approach to quality assessment must occur before its widespread use is feasible. Its effectiveness in improving quality remains to be seen. This experience raises doubts regarding the wisdom of legislating a specific outcome approach to quality assessment before feasibility and effectiveness have been demonstrated in organized health settings.     

Medicare managed care. How physicians can make it better

The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.     

Health maintenance organizations and children with special health needs. A suitable match?

OBJECTIVE: To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans. DESIGN: A cross-sectional survey. MEASUREMENTS/MAIN RESULTS: Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. PARTICIPANTS: Individual HMO plans. SELECTION PROCEDURE: A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. INTERVENTIONS: None. CONCLUSIONS: Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.     

Results of a radiology performance report for a health maintenance organization

PURPOSE: To present results with a radiology performance report to help evaluate utilization of radiologic examinations by primary-care practices (family practice, internal medicine, or pediatrics) in an independent practice association health maintenance organization (HMO). MATERIALS AND METHODS: Utilization reports for primary-care-physician practices (n = 5,000) over a 12-month period (July 1, 1993 through June 30, 1994) were derived from administrative data collected from claim and encounter forms submitted by radiologic practices. Data were divided into 22 measures to help define practice utilization. five overall measures helped evaluate procedures performed by HMO member or nonmember practices per 1,000 members. Twelve specific measures helped evaluate patterns of use of frequently ordered imaging procedures (eg, computed tomography, magnetic resonance imaging, bone scanning, cardiovascular nuclear imaging, nonobstetric ultrasound, and plain radiography). Five quality measures helped evaluate utilization of screening mammography in women aged 50-64 years (as a percentage of all women in the HMO aged 50-64 years) and of low-yield examinations (ie, sinus, rib, and skull radiography per 1,000 adult members). RESULTS: Individual practice utilisation mean results were compared with overall HMO mean results adjusted for practice type and age and sex of members. CONCLUSION: Utilization data are an integral part of evaluation of HMOs and their providers, and these results helped establish a baseline level of performance.     

HMO market structure and performance: 1985-1995

This paper estimates the effect of market structure on hospital days and ambulatory visits in independent practice associations (IPAs) and group-model health maintenance organizations (HMOs) where market structure is measured by HMO penetration and the number of HMOs operating in a market. There was a steady decline in inpatient use in HMOs during the study period and a steady increase in use of ambulatory care. In multivariate analyses, inpatient use is significantly higher in IPAs, but there is no difference in ambulatory use. As HMO penetration increases and the number of HMOs increases, group-model HMOs have lower hospital use and greater ambulatory use. In contrast, use of both inpatient and ambulatory care decreases in IPAs but only at high levels of penetration and numbers of competitors.     

Do Medicare HMOs cost shift?

We tested the hypothesis that health maintenance organizations (HMOs) increase their commercial premiums when Medicare pays less. Such a linkage would be taken as evidence of "cost shifting." Other studies have tested the cost-shifting hypothesis among health care providers, but this is the first to examine the HMO industry. Our data consisted of annual observations on all HMOs that operated in the United States between 1990 and 1995 and had a Medicare risk contract. A comparison group of HMOs that had no Medicare contract during that period also was analyzed. The main finding from this study is that HMOs have not shifted costs from Medicare to commercial premiums. This results supports the skeptical consensus that is developing toward the cost-shifting hypothesis. Additional findings include the negative effects of competition and for-profit status on HMOs' commercial premiums.     

Aging increases CD8 T cell apoptosis induced by hyperstimulation but decreases apoptosis induced by agonist withdrawal in mice

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.     

Dual agency, dual relationships, boundary crossings, and associated boundary violations: a survey of military and civilian psychiatrists

We hypothesized that psychiatrists with high dual-agency potential (military and health maintenance organization [HMO] psychiatrists) were more likely than non-HMO civilian psychiatrists to engage in dual relationships, report pressures to do so, participate in other general boundary-crossing activities, and report associated counter-therapeutic outcomes (boundary violations). Ninety military and 191 demographically matched civilian psychiatrists reported the number of boundary-crossing activities (including dual relationships) and associated counter-therapeutic outcomes in the preceding year with adult patients. Military and HMO psychiatrists reported greater external pressures than non-HMO civilian psychiatrists to engage in dual relationships; however, all three groups were similar in their reported numbers of dual relationships. The reported boundary-crossing activities and dual relationships studied here are not necessarily associated with reported boundary violations. The relative risk of a particular boundary crossing associating with harm to a patient likely depends on the therapeutic context and should be determined on a case-by-case basis.     

An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data

This study distinguishes between organizational characteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indicators of structural care (SC), and investigates the degree to which measures of SC vary by ownership mode (defined by four combinations of chain affiliation and profit status) for 142 certified and licensed nursing facilities (NFs) in a southern state. Structural care measures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expenditures. In addition, seven (four process and three outcome) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level quality indicators. A causal mode of NF quality arranged according to the structure, process and outcome paradigm is specified and estimated using path analysis. Organizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were developed from the Minimum Data Set Plus Resident Assessment Instrument. Using the percentage of Medicaid and private pay residents as covariates, there was a significant overall multivariate effect due to ownership mode on the SC measures. Although there were several significant direct effects, the overall path model was unconfirmed. The multivariate results suggest that some organizational characteristics of structure quality may be more appropriately considered exogenous to causal quality models and therefore have indirect (versus direct) effects on process or outcome quality indicators. The path analysis implies that the structure-process-outcome paradigm may not accurately capture the way NF health care is delivered. Research which considers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

When medical group and HMO part company: disenrollment decisions in Medicare HMOs

Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.     

The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence

OBJECTIVES: To help resolve the current controversy over the validity of early readmission as an indicator of the quality of care, the authors critically reviewed the literature using meta-analysis to derive summary estimates of effect and evaluate inter-study heterogeneity. METHODS: The authors selected reports meeting five criteria: (1) presentation of new data on medical-surgical hospitalization of adults; (2) measurement of outcome as a person-specific readmission; (3) readmission within < or = 31 days; (4) examination of some aspect of the process of inpatient care; (5) inclusion of a comparison group. One meta-analysis examined 13 comparisons of readmission rates after substandard versus normative care, another examined 9 comparisons of readmission rates after normative versus exceptional care, and the third examined all 22 comparisons together. Two authors applied inclusion criteria and extracted data on methods and findings. Two others classified studies on 11 methodological variables for the heterogeneity evaluation. RESULTS: The summary odds ratio for readmission after substandard care was 1.24 (0.99-1.57) relative to normative care; for readmission after normative care the summary odds ratio was 1.45 (0.90-2.33) relative to exceptional care. The individual odds ratios varied significantly (chi2, 21 df = 50.34, P = 0.0003). Most of the variance in study odds ratios could be explained by whether the study focused on the quality of patient care or the qualifications of patient care providers. The summary odds ratio for the 16 homogeneous comparisons focusing on the quality of patient care was 1.55 (1.25-1.92). CONCLUSIONS: Early readmission is significantly associated with the process of inpatient care. The risk of early readmission is increased by 55% when care is of relatively low quality, that is, substandard or normative instead of normative or exceptional.     

Educational and behavioral interventions for back pain in primary care

STUDY DESIGN AND OBJECTIVES: A review of the literature was undertaken to identify and summarize randomized trials of educational, cognitive, and behavioral interventions for people with chronic low back pain. SUMMARY OF BACKGROUND DATA: Studies of back schools have varied widely in patient characteristics, back school length and content, and comparison treatment. The available evidence suggests that back schools do not affect long-term outcomes of people with back pain. METHODS: MEDLINE and PsycLIT databases were searched to identify randomized trials of cognitive and behavioral treatments for chronic low back pain. Outcome data were extracted from articles that met the meta-analysis inclusion criteria. RESULTS: The meta-analysis found that cognitive and behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain behavior, and disability. Follow-up comparisons of cognitive and behavioral treatments versus control conditions were not available. This meta-analysis did not find cognitive and behavioral therapies to differ from other active treatments on specific outcome measures, although only a few studies were available for each measure. CONCLUSION: It may be useful to incorporate cognitive-behavioral interventions in primary care settings, but additional research is needed to evaluate their efficacy in improving specific outcomes.     

Endometrial cytology in postmenopausal hormone replacement therapy

INTRODUCTION: The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS: A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS: California's HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION: For the majority of California's PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.     

The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: Quality versus quantity.

Cognitive-behavioral therapy (CBT) is skill based and assumes active patient participation in regard to treatment-related assignments. The effects of patient compliance in CBT outcome studies are equivocal, however, and 1 gap in the literature concerns the need to account for the quality versus the quantity of assigned work. In this study, both quality and quantity of home-based practice were assessed to better evaluate the effects of treatment compliance in patients with panic disorder (N?=?48) who participated in a 12-session CBT protocol. Patient estimates of compliance were not significantly associated with most outcome measures. On the other hand, therapist ratings of compliance significantly predicted positive changes on most outcome measures. Moreover, therapist and independent rater estimates of the quality of the participant's work, relative to the quantity of the work, were relatively better predictors of outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reversal of fortune: commercial HMOs in the Medicaid market

Between 1992 and 1996 the number of health maintenance organizations (HMOs) entering the Medicaid market grew at an average annual rate of approximately 22 percent. Participation among all ownership segments grew, resulting in a broad distribution of beneficiaries across the HMO industry. However, recent declines in financial performance within the industry appear to be more dramatic for plans with many Medicaid members. In addition, growing concerns about rate adequacy and volatility as well as expanding administrative demands raise questions about the long-term commitment of commercial HMOs to Medicaid participation. This paper analyzes operating characteristics and financial performance of licensed commercial HMOs from 1992 through 1996, drawing on indepth interviews with health plan executives and managed care stock analysts.     

Correlates of outcomes in patients with congestive heart failure

This study relates components of care, including patient characteristics, degree of initial morbidity, and process of care, to patient outcomes. One hundred twenty-two adults who were being treated for congestive heart failure by a sample of physicians in Fort Wayne, Indiana were studied. Data were obtained on the patients' personal characteristics; degree of illness at the beginning of the six-month study period; process measures (physician awareness, communication, medication use, therapeutic management, patient satisfaction, and utilization of services); and level of activity and symptoms at the end of the study period. These components were quantified and subjected to correlation and regression analysis. The largest and most significant predictors of outcome status were measures of initial disease status. Process variables were strongly and significantly associated with outcome only in a group of patients who were minimally symptomatic initially. The lack of an overall association between process of medical care and patient outcome cannot be generalized beyond these patients with congestive heart failure. A similar approach of dissection, quantification, and analysis of components of care, however, can be used to explore a possible relationship in other conditions and care delivery settings.