PubMed · 9324639
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S Snyder. 1997-10-09. Putting patients first?. https://pubmed.ncbi.nlm.nih.gov/9324639/
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CONTEXT: Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans. OBJECTIVE: To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care. DESIGN AND SETTING: Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas. PATIENTS: All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease. MAIN OUTCOME MEASURE: Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area. RESULTS: In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures. CONCLUSIONS: Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.
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BACKGROUND: The number of nursing home (NH) residents enrolled in managed care plans (HMO) will increase, and there is concern that the quality of their medical care may be compromised by cost-containment pressures. In this study, we evaluated the medical care of residents enrolled in 3 health maintenance organizations (HMO) that developed specific long-term care programs. OBJECTIVES: To compare the medical care received by NH residents enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of care and consumer perception (subjective) measures. To describe the relationship between the objective and subjective measures. MEASURES: Number of primary care visits per month; process of medical care for 2 geriatric tracer conditions (falls, fevers); family and residents' perceptions of the adequacy of sickness episode management; and the frequency of primary provider visits. DESIGN: Quasi-experimental. RESULTS: HMO residents received more timely and appropriate responses to falls and fevers than did FFS residents. HMO residents also received more frequent routine visits by a primary care provider team consisting of a physician and nurse practitioner. Consumer perceptions of quality did not differ between the HMO and FFS groups. Families within both groups were significantly more positive than were residents about the frequency of visits by both physicians and nurse practitioners. Within the HMO group, both families and residents were more positive about the frequency of nurse practitioner visits than were physician visits even when the frequency of visits by the 2 providers were similar. CONCLUSIONS: Although the medical care received by HMO residents was better on most objective process measures than that received by FFS residents, consumer perceptions of care did not detect those differences. NH residents and families have different perceptions about the adequacy of visits by physicians and nurse practitioners, and both families and residents appear to have different expectations concerning how often they want physicians to visit as compared with nurse practitioners.