Review of studies that compare the quality of cardiovascular care in HMO versus non-HMO settings

OBJECTIVES: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature. METHODS: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research. RESULTS: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results. CONCLUSIONS: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.     

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.     

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.     

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.     

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.     

Nonspecific resistance in patients with chronic gastritis undergoing treatment by drinking a calcium-sodium chloride low-mineralized mineral water

A Diabetes Care Management program was developed by PrimeCare, a network model HMO, to improve quality of life health outcomes and reduce the costs of medical care for its members with diabetes. The HMO used a systems-based approach to communicate information about appropriate self-management and standards of care to members and physicians. The focus of the program was to educate and encourage patients to self-manage their illness, and to partner with physicians, other health care providers and community organizations to achieve improved quality of life, clinical and financial results. Clinical process indicators were used to measure results of interventions. Significant increases in the percentage of participants receiving glycosylated hemoglobin (HbA1c) tests, retinal eye exams and lipid panel tests were achieved.     

Mental health staffing in managed care organizations: a case study

This paper examines temporal changes in staffing ratios and configuration of mental health providers per 100,000 members within two full-service staff-model health maintenance organizations (HMOs). Overall workforce reductions in all classes of mental health professionals occurred in the two HMOs from 1992 to 1995. Staffing ratios decreased in both HMOs for psychiatrists and psychologists. In one HMO, the ratio of clinical social workers also decreased over this period. Provider ratios from 1995 are benchmarked against state ratios per 100,000 population. Workforce mix for the two HMOs is contrasted with a single-year average for a large managed behavioral health (carve-out) organization. The authors discuss potential implications of the findings for training of several categories of mental health professionals.     

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.     

Patterns of mental health services provided by HMOs.

Surveyed 145 US health maintenance organizations (HMOs) to determine outpatient mental health services offered, psychologists and other providers used, and practices followed in offering such services. Results show that basic assessment and intervention modalities were available to almost all HMO members. Health education programs (weight control, smoking control, and stress adaptation) were not as broadly available as were the more traditional mental health efforts. Almost all HMOs utilized psychologists as providers, either as employees or consultants; subdoctoral qualifications for employment were accepted by one-fifth of the plans. In most plans, physicians referred patients for psychological services. HMOs based on individual practice association models offered fewer services than either group or staff models. The level of mental health service required for federal qualification is exceeded by plans enrolling 82% of all members. Data did not support the argument that requiring mental health services results in forcing both services and costs upward. It is concluded that the current rate of HMO growth will not provide large numbers of additional jobs for psychologists. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expression of carboxymethylcellulase on the surface of Escherichia coli using Pseudomonas syringae ice nucleation protein

Geriatric assessment is a means to collect health and functional data of an individual older person in a standard way. It has been developed on the secondary care level in the specialties of geriatric and rehabilitative medicine. Transferring geriatric assessment into primary care may improve health outcomes of older people, especially as it facilitates preventive diagnostic and therapeutic intervention. Yet, it is not possible to use geriatric assessment, as it is carried out in secondary care, under primary care conditions. Several adaptations will be necessary. An assessment instrument will have to be developed which takes epidemiological features of the older population into account. It will have to be tailored to the specific conditions of health delivery in primary care. Moreover, to achieve effectiveness and acceptance by health care providers and users, we see the necessity of creating an algorithmic assessment instrument which allows the use in different health situations with different levels of diagnostic detail. A primary care assessment for older people then would need to be evaluated according to its effectiveness of improving health outcomes. Potential negative effects on health beliefs may be worth considering. The final task lies in the implementation of a primary care assessment instrument into our existing health delivery format.     

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.     

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.     

Psychotherapeutic services in the HMO: Zen and the art of mental health maintenance.

Examines current research data concerning the provision of mental health services within health maintenance organizations (HMOs) and describes in detail one HMO mental health department. Findings of current research indicate that nearly 11 million people are already members of the almost 300 HMOs nationwide. Survey data indicate that the provision of mental health services is universal within such plans. Conclusions are drawn about the ways in which developing prepaid programs might best meet the psychotherapeutic needs of members of HMOs. (48 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What is necessary and sufficient information for outcome assessment?

Third-party payers are increasingly requiring that professional psychologists gather data to demonstrate therapeutic effectiveness. Missing data rates were examined in an urban mental health agency that serves children and adolescents. Complete outcome assessments were available for about 1 of 4 children whose parents completed intake scales and for 1 of 2 possible clinician-rated Global Assessments of Functioning, with complete data sets more likely for healthier children. The authors suggest that psychologists whose measurements are based on substantial data collection rates and include evidence of data quality have a sound empirical basis to reject demands for additional outcome assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

The changing role of psychologists in health maintenance organizations.

Discusses the functioning of health maintenance organizations (HMOs) with reference to characteristics that make them receptive to interdisciplinary programs involving psychologists. Interdisciplinary cooperation is considered in relation to status issues and the importance of consultation skills. Two HMO programs on smoking cessation and coping with chronic pain are described to illustrate the role of psychologists in the treatment of medical conditions in which behavior change is important. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tax policy and Health Maintenance Organizations: the case for a section 501(c)(3) tax exemption

The Internal Revenue Service typically grants health maintenance organizations (HMOs) and I.R.C. section 501(c)(4) exemption from federal income taxation. If these prepayment group medical providers were classified as section 501(c)(3) tax exempt organizations, however, they would receive many additional advantages including increases in private funding and decreases in material and operating costs. This Note contends that most nonprofit HMOs--whether or not they have qualified under the federal HMO Act--should be granted 501(c)(3) status because they conform with all the specific requisites and general theoretical justifications of a "charitable purpose" tax exempt organization. Specifically, HMOs serve a tax exempt purpose by providing health care, by benefiting the community as a whole, and relieving the government of some of its public health burdens. HMOs comply with further requirements of section 501(c)(3) and its accompanying I.R.C. regulations by serving a broad membership while avoiding insider control or commercial dealings. Therefore, if an organization is a nonprofit prepayment group practice health provider that serves a broad community and provides health benefits without insider control, it should receive a 501(c)(3) tax exemption.     

Providers' views of HMO mental health services.

112 health maintenance organization (HMO) mental health providers from 19 HMOs were asked to describe the services provided by their mental health department, give demographic data about providers themselves, and rate the services provided as well as their satisfaction with providers' benefits and compensation. More than half of the Ss reported having a private practice in addition to their position at an HMO. The average full-time person doing direct clinical practice reported seeing about 23 clients per week. Other results suggest differences in satisfaction level varying with salary and patient load. (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.