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PubMed1997

How HMOs assess medical groups and IPAs.

California health maintenance organizations (HMOs) frequently capitate physician organizations--independent practice associations (IPAs) and multispecialty medical groups--to export their risk for professional and outpatient ancillary services. Physician organizations benefit when successful in managing the risk, and from having greater control over medical management decisions. HMOs carefully assess the physician organization's ability to manage capitated risk and provide high-quality care. HMOs gather information on the physician organization's finances, business relationships, physician compensation arrangements, credentialing, hospital relationships, ancillary contracts, procedures for 24-hour care, claims administration, member services, information systems for reporting and tracking utilization, and procedures for utilization/quality management. These data are analyzed to determine whether capitation contract negotiation should proceed.

California↗

PubMed2001

Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial.

OBJECTIVE: To assess the impact and costs of coverage for tobacco dependence treatment benefits with no patient cost sharing for smokers with employer sponsored coverage in two large independent practice association (IPA) model health maintenance organisations (HMOs) in California, USA. METHODS: A randomised experimental design was used. 1204 eligible smokers were randomly assigned either to the control group, which received a self-help kit (video and pamphlet), or to the treatment group, which received the self-help kit and fully covered benefits for over the counter (OTC) nicotine replacement therapy (NRT) gum and patch, and participation in a group behavioural cessation programme with no patient cost sharing. RESULTS: The quit rates after one year of follow up were 18% in the treatment group and 13% in the control group (adjusted odd ratio (OR) 1.6, 95% confidence interval (CI) 1.1 to 2.4), controlling for health plan, sociodemographics, baseline smoking characteristics, and use of bupropion. Rates of quit attempts (adjusted OR 1.4, 95% CI 1.1 to 1.8) and use of nicotine gum or patch (adjusted OR 2.3, 95% CI 1.6 to 3.2) were also higher in the treatment group. The annual cost of the benefit per user who quit ranged from $1495 to $965 or from $0.73 to $0.47 per HMO member per month. CONCLUSIONS: Full coverage of a tobacco dependence treatment benefit implemented in two IPA model HMOs in California has been shown to be an effective and relatively low cost strategy for significantly increasing quit rates, quit attempts, and use of nicotine gum and patch in adult smokers.

Adult↗

PubMedDate not supplied

Insights into managed care--operational, legal and actuarial.

Understanding the operational, legal and actuarial dimensions of managed care is essential to developing managed care contracts between managed care organizations and individual health care providers or groups such as provider-sponsored organizations or independent practice associations. Operationally, it is important to understand managed care and its trends, emphasizing business issues, knowing your practice and defining acceptable levels of reimbursement and risk. Legally, there are a number of common themes or issues relevant to all managed care contracts, including primary care vs. specialist contracts, services offered, program policies and procedures, utilization review, physician reimbursement and compensation, payment schedule, terms and conditions, term and termination, continuation of care requirements, indemnification, amendment of contract and program policies, and stop-loss insurance. Actuarial issues include membership, geography, age-gender distribution, degree of health care management, local managed care utilization levels, historical utilization levels, health plan benefit design, among others.

Actuarial Analysis↗

PubMed1994

Risk management in an IPA setting--Part I.

Over the past several years, HMO enrollment has grown the most in independent practice association (IPA) and network models. HMOs in general have expanded as a means to control the cost of health care. Key customers, including large employers and government agencies such as the Health Care Financing Administration (HCFA), require such control. IPA and network models retain a greater sense of choice on the part of participating physicians and patients than do closed-panel group- or staff-model programs. As physician and patient choice increases, however, the HMO's control over health care diminishes. Thus, customers require HMOs to manage health care. The HMO must market, develop delivery systems, meet regulatory requirements, and make profits. It must control both the quality and the cost of health care. Doing so without the level of control found in staff-model HMOs has created unique challenges for IPA HMO managers. IPA-model HMOs adapt quality improvement programs to this lesser level of control. Staff-model HMOs and hospitals closely link quality assurance to risk management. Programs designed to improve quality will naturally also reduce the risk of providing care below standards. This relationship is less clear in IPA- and network-model HMOs, in which the HMO does not provide the care. Thus, IPA-model quality improvement programs often do not address their risk management implications. This two-part article examines the differences between staff-model and IPA-model HMOs in liability and in ability to manage risk. In the first part, the nature of the risks is described. In the next issue of the journal, the management of those risks will be discussed.

Health Maintenance Organizations↗

PubMed2003

Support for smoking cessation interventions in physician organizations: results from a national study.

OBJECTIVES: To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization. CONCLUSION: Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

Group Practice↗

PubMed1995

A national survey of the arrangements managed-care plans make with physicians.

BACKGROUND: Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians. METHODS: In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs). RESULTS: Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs. CONCLUSIONS: Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Capitation Fee↗

PubMed1995

Profiling physician practice patterns using diagnostic episode clusters.

Health plans and providers need to profile current practice patterns to understand better the resources used in managing medical conditions. A profiling system is presented that groups International Classification of Diseases (ICD-9-CM) codes into 125 diagnostic clusters based on clinical homogeneity with respect to physician treatment response. For each diagnostic cluster, diagnostic episode clusters (DECs) are formulated. A DEC links all services incurred in treating a patient's medical condition within a specific period of time. Each DEC is marked with a severity-of-illness, comorbidity, and age indicator. To test the validity of the diagnostic cluster methodology, claims were analyzed from a preferred provider organization (PPO) and an independent practice association (IPA). PPO and IPA DEC charges and utilization were compared with t-tests. Physician practice patterns differed based on patient severity of illness, comorbidities, and age. Both PPO and IPA physicians delivered significantly more resources to patients in higher severity-of-illness categories. PPO physicians generally treated older patients with more resources than younger patients. Patient age did not have the same impact on IPA physicians' practice patterns. IPA physicians' average treatment pattern was about 22% less expensive than that of PPO physicians. IPA physicians decreased average expenses by reducing hospital days by about 73% (P < 0.01) and hospital outpatient visits by about 89% (P < 0.01) compared to the rates of PPO physicians. Ambulatory services among IPA physicians were not significantly higher than rates for PPO physicians. The DEC methodology is a valid approach for profiling patterns of treatment. The style of medicine in the IPA was less hospital intensive and, consequently, less expensive than that practiced by PPO physicians. PPO physicians also had greater practice pattern variations than IPA physicians.

Cluster Analysis↗

PubMed1999

Blended payment methods in physician organizations under managed care.

CONTEXT: Independent practice associations (IPAs) are developing new methods of physician reimbursement to balance the objectives of encouraging individual productivity and clinical cooperation. The economic literature on payment incentives, derived from nonhealth industries, predicts that methods blending elements of fee-for-service and capitation will outperform exclusive reliance on either form of payment. OBJECTIVE: To identify emerging payment methods within IPA physician groups that contract with managed care organizations. DESIGN AND SETTING: Case studies of 7 large IPAs in the San Francisco, Calif, metropolitan region that served 826000 health maintenance organization (HMO) patients during the summer and fall of 1998. MAIN OUTCOME MEASURE: Payment methods of IPAs for primary care physicians, specialists, and physicians grouped by specialty department within the overall IPA structure. RESULTS: All the IPAs contracted with multiple HMOs for the full range of primary and specialty care physicians' services but paid member physicians using methods that blended elements of fee-for-service and subcapitation. For primary care, most IPAs used monthly capitation adjusted for patient age, sex, and selected diagnoses, supplemented with fee-for-service payment for a wide range of visits and procedures, including patient visits in subacute, skilled nursing facility, emergency department, or home settings; for preventive care services; for office procedures requiring expensive supplies; and, most importantly, for borderline primary care procedures that either could be performed directly or referred to specialty care. All the IPAs paid specialty departments on a capitated basis and delegated to the departments responsibility for allocating the budget among individuals. Allocation mechanisms for individual specialists included adjusted fee-for-service, referral-based capitation, and blends of both. CONCLUSION: Our results and case studies indicate that IPAs are developing payment methods that blend elements of fee-for-service and capitation in innovative ways for primary care and specialty physicians.

Budgets↗

PubMed1988

Implementation of an outpatient prescription drug formulary in a managed-care system.

The development and implementation of an outpatient prescription formulary in an independent-practice model health maintenance organization (HMO) and the role of the pharmacy and therapeutics (P&T) committee in the process are described. Approximately 600 physicians provide medical care and control the operation of this independent practice association (IPA); of approximately 45,000 members, 95% are eligible for outpatient prescription services provided by one of 188 local pharmacies. The formulary, which is restricted to noninjectable medications, was developed by a P&T committee composed of eight IPA physicians, a representative of the local pharmaceutical association, and three staff members of the IPA's pharmacy department. The printed version of the formulary indexed almost 1800 items and included only commonly used medications to limit its size. Requests for additions or deletions of drugs were evaluated monthly. After a four-month period during which physicians were asked to comply with the formulary, mandatory compliance was imposed, with a limit of 16 nonformulary prescriptions per physician per month being allowed. Based on the results of an informal survey, the physicians indicated that the formulary was relatively easy to adjust to (44.1%), somewhat difficult to work with (43.6%), and somewhat disruptive to their prescribing practices (55.3%). When asked about quality of patient care, 74.3% indicated there was no change. Physician compliance with the formulary system increased from 88.0% to 96.1% after the formulary was mandated by the IPA. Under the direction of the P&T committee, a formulary was implemented effectively in this HMO outpatient prescription drug program.

Delivery of Health Care↗

PubMed2001

Differences in the kinds of problems consumers report in staff/group health maintenance organizations, independent practice association/network health maintenance organizations, and preferred provider organizations in California.

BACKGROUND: Little is known about the extent to which consumers have specific problems with their managed care organizations (MCOs) or whether these problems differ by type of MCO. OBJECTIVE: To estimate the prevalence at which consumers in managed care report specific problems and to assess whether rates in preferred provider organizations (PPOs), independent practice association (IPA)/network health maintenance organizations (HMOs), and staff/group HMOs differ. DESIGN: Random probability sample of insured adults weighted to reflect the underlying population in California. A computer-assisted telephone interview survey was conducted in September 1997. Logistic regression models estimate the adjusted odds of reporting each problem in the last year in IPA/network HMOs versus PPOs, IPA/network HMOs versus staff/group HMOs, and staff/group HMOs versus PPOs. SUBJECTS: One thousand two hundred one insured adults who had resided in California for > or = 12 months. MEASURES: Prevalence of 11 consumer problems in MCOs. RESULTS: Forty-two percent of adult Californians in managed care in our sample reported > or = 1 problem with their MCO in the last year. Adjusted odds that adults in IPA/ network or staff/group HMOs reported delays in getting needed care, not receiving the most appropriate or needed care, and being forced to change doctors were higher than for adults in PPOs. Adjusted odds that adults in IPA/network HMOs reported difficulty getting a referral to a specialist and difficulty selecting a doctor or hospital were higher than for adults in PPOs and staff/group HMOs. Adjusted odds that adults in staff/ group HMOs reported misunderstandings over benefits and coverage; important benefits not covered; and problems with claims, billing, or payments were lower than for adults in PPOs and IPA/network HMOs. Adjusted odds that consumers in HMOs in our sample reported any problem with their health plan was higher for those in IPA/network HMOs compared with staff/group HMOs. No differences were seen by MCO type in the rates at which consumers reported being denied care or treatment, forced to change medications, or language and communication barriers. CONCLUSIONS: Rates at which consumers report problems with managed care and the kinds of problems they report differ significantly across different types of MCOs. These findings have important implications for federal and state policy for consumer protections in managed care.

Adult↗

PubMedDate not supplied

The effect of a comprehensive breast screening program on self-reported mammography use by primary care physicians and women in a health maintenance organization.

BACKGROUND: Mammography use is increasing in the United States, but most women older than 50 years still are not being screened regularly. A multicomponent program, with components for women and physicians, was conducted to increase screening among women aged 50 to 74 years in an independent practice association (IPA)-model health maintenance organization (HMO). METHODS: The participating women and physicians were surveyed in four waves to evaluate the program. We report on changes in mammography practices by both women and physicians between 1988 (preintervention year) and 1992 (postintervention year). Bivariate and multivariate analyses were calculated. RESULTS: The proportion of responding HMO physicians who recommended annual mammograms for women aged 50 to 74 years increased by 16 percent from 1988 to 1992 compared with an increase of 10 percent for control group physicians (nonsignificant). There was a 30 percent increase from 1988 to 1992 in the proportion of HMO women respondents who reported having had a mammogram in the past year compared with a 19 percent increase among control group women. The difference between these differences was highly significant. The intervention had the strongest effect on women with incomes of less than $30,000. CONCLUSIONS: A multicomponent program in an IPA-model HMO resulted in significant increases in the proportion of HMO women who had mammograms. Similar approaches should be tested in other settings.

Adult↗

PubMed2003

Chronic disease medication use in managed care and indemnity insurance plans.

OBJECTIVE: To evaluate the impact of managed care on the use of chronic disease medications. DATA SOURCE: Claims data from 1997 from two indemnity and three independent practice association (IPA) model managed care insurance plans. RESEARCH DESIGN: Cross-sectional analysis of claims data. DATA COLLECTION: Adult patients with diabetes mellitus (DM, n = 26,444), congestive heart failure (CHF, n = 7,978), and asthma (n = 9,850) were identified by ICD-9 codes. Chronic disease medication use was defined through pharmacy claims for patients receiving one or more prescriptions for drugs used in treating these conditions. Using multiple logistic regression we adjusted for patient case mix and the number of primary care visits. PRINCIPAL FINDINGS: With few exceptions, managed care patients were more likely to use chronic disease medications than indemnity patients. In DM, managed care patients were more likely to use sulfonylureas (43 percent versus 39 percent for indemnity), metformin (26 percent versus 18 percent), and troglitazone (8.8 percent versus 6.4 percent), but not insulin. For CHF patients, managed care patients were more likely to use loop diuretics (45 percent versus 41 percent), ACE inhibitors or angiotensin receptor blockers (50 percent versus 41 percent), and beta-blockers (23 percent versus 16 percent), but we found no differences in digoxin use. In asthma, managed care patients were more likely to use inhaled corticosteroids (34 percent versus 30 percent), systemic corticosteroids (18 percent versus 16 percent), short-acting beta-agonists (42 percent versus 33 percent), long-acting beta-agonists (9.9 percent versus 8.6 percent), and leukotriene modifiers (5.4 percent versus 4.1 percent), but not cromolyn or methylxanthines. Statistically significant differences remained after multivariate analysis that controlled for age, gender, and severity. CONCLUSIONS: Chronic disease patients in these managed care plans are more likely to receive both inexpensive and expensive medications. Exceptions included older medications partly supplanted by newer therapies. Differences may be explained by the fact that patients in indemnity plans face higher out-of-pocket costs and managed care plans promote more aggressive medication use. The relatively low likelihood of condition-specific medications in both plan types is a matter of concern, however.

Adult↗

PubMed1992

Increased ambulatory utilization in IPA plans among children receiving hyposensitization therapy.

There is concern that children with chronic conditions are less likely to be enrolled in managed care systems and that they may not receive optimal care. We studied the relationship between enrollment in an Independent Practice Association (IPA) plan and utilization of ambulatory services among children in a suburban pediatric practice with one mild chronic condition--those receiving hyposensitization therapy for allergic diseases. Ambulatory utilization by IPA patients (N = 102) was determined by medical chart review for one year before and one year after each patient switched from Blue Cross to IPA coverage. Blue Cross hyposensitization patients (N = 57) matched for age served as controls. Patients receiving hyposensitization were more likely to have enrolled in an IPA than those not receiving hyposensitization (70% vs 45%, p < .001). Before enrollment pre-IPA patients had 41% fewer well-child care (WCC) visits than Blue Cross patients (p < .01); both underutilized WCC visits according to established guidelines. Controlling for age and baseline utilization, we found a significant increase in WCC and acute care visits after IPA enrollment (p < .05), but no change in hyposensitization visits or referrals. In this setting, there was no evidence for reduced access to ambulatory services but rather evidence for improved utilization of primary care.

Adolescent↗

PubMed1998

Consolidation of medical groups into physician practice management organizations.

CONTEXT: Medical groups are growing and merging to improve efficiency and bargaining leverage in the competitive managed care environment. An increasing number are affiliating with physician practice management (PPM) firms that offer capital financing, expertise in utilization management, and global capitation contracts with health insurance entities. These physician organizations provide an alternative to affiliation with a hospital system and to individual physician contracting with health plans. OBJECTIVE: To describe the growth, structure, and strategy of PPM organizations that coordinate medical groups in multiple markets and contract with health maintenance organizations (HMOs). DESIGN: Case studies, including interviews with administrative and clinical leaders, review of company documents, and analysis of documents from investment bankers, the Securities and Exchange Commission, and industry observers. SETTING: Medical groups and independent practice associations (IPAs) in California and New Jersey affiliated with MedPartners, FPA Medical Management, and UniMed. OUTCOME MEASURES: Growth in number of primary care and specialty care physicians employed by and contracting with affiliated medical groups; growth in patient enrollment from commercial, Medicare, and Medicaid HMOs; growth in capitation and noncapitation revenues; structure and governance of affiliated management service organizations and professional corporations; and contracting strategies with HMOs. RESULTS: Between 1994 and 1996, medical groups and IPAs affiliated with 3 PPMs grew from 3787 to 25763 physicians; 65% of employed physicians provide primary care, while the majority of contracting physicians provide specialty care. Patient enrollment in HMOs grew from 285503 to 3028881. Annual capitation revenues grew from $190 million to $2.1 billion. Medical groups affiliated with PPMs are capitated for most professional, hospital, and ancillary clinical services and are increasingly delegated responsibility by HMOs for utilization management and quality assurance. COMMENT: Physician practice management organizations and their affiliated medical groups face the challenge of continuing rapid growth, sustaining stock values, and improving practice efficiencies while maintaining the loyalty of physicians and patients.

California↗

PubMed1997

Increasing immunization: a Medicaid managed care model.

OBJECTIVE: To evaluate the impact of an immunization outreach program on immunization rates. SETTING: A Pennsylvania independent practice association model managed care organization (100% Medicaid). DESIGN: Retrospective cohort study (N = 2511) of children 30 to 35 months of age from two age cohorts that compared immunization rates for Advisory Committee on Immunization Practices schedules for diphtheria-tetanus-pertussis, oral polio vaccine, measles-mumps-rubella, and Haemophilus influenza type b. An evaluation of the outreach component of the program compared treatment and nontreatment subgroups of one age cohort (N = 1002). INTERVENTION: The immunization program targeted approximately 19 000 members from birth to 6 years of age. The program components included computerized tracking and reminders, member and provider education, provider incentives, member incentives, and home visiting outreach. RESULTS: Data indicate that the treatment group has higher completed immunization rates at 35 months of age than does the control group. Furthermore, data show that members with home visits have significantly higher completed immunization rates than do other members. The corresponding comparisons for age-appropriate immunizations by 24 months indicate a nonsignificant trend of increased rates. CONCLUSION: The data provide evidence supporting a correlation between comprehensive strategies (computerized tracking, member and provider education and incentives, and home visiting) and increased immunization rates. Those individuals who received home visits were more likely to complete an immunization series by 35 months of age than those who did not. However, within the Mercy Health Plan program, age-appropriate immunizations are not significantly affected by home-visiting outreach.

Child, Preschool↗

PubMed1996

New assumptions concerning IPAs and cost of dental care.

OBJECTIVES: Previous studies suggest that fee-for-service (FFS) patients receive more treatment and at a greater cost than capitation patients. In this study treatment plans of dentists who are members of an independent practice association (IPA), a preferred provider organization (PPO), or who are paid their usual fee for service are compared. METHODS: A carefully selected and trained professional actor, with actual dental disease and recent radiographs, was sent to the offices of general practice dentists for an examination and treatment plan. To one group of dentists (n = 21) the patient said he was a member of a PPO plan served by that dentist, to a second group (n = 15) he said he was a member of an IPA plan served by that dentist, and to the third group (n = 19) he said he would pay by the traditional FFS method. RESULTS: IPA dentists recommended more restorations (mean = 9.60) than those in the PPO program (mean = 5.95) or those paid by the traditional FFS method (mean = 5.58). The anticipated mean cost to the patient was higher for the IPA dentists ($1,815.20) compared to the other two types (PPO = $1,186.24, FFS = $1,470.42). CONCLUSIONS: The IPA models studied in this investigation permitted dentists to charge copayments for most treatments beyond basic services. This type of IPA might be similar to a fee-for-service model that provides practitioners with an incentive to do more rather than less treatment.

Adult↗

PubMed1996

Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the Medical Outcomes Study.

OBJECTIVE: To compare physical and mental health outcomes of chronically ill adults, including elderly and poor subgroups, treated in health maintenance organization (HMO) and fee-for-service (FFS) systems. STUDY DESIGN: A 4-year observational study of 2235 patients (18 to 97 years of age) with hypertension, non-insulin-dependent diabetes mellitus (NIDDM), recent acute myocardial infarction, congestive heart failure, and depressive disorder sampled from HMO and FFS systems in 1986 and followed up through 1990. Those aged 65 years and older covered under Medicare and low-income patients (200% of poverty) were analyzed separately. SETTING AND PARTICIPANTS: Offices of physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry, in HMO and FFS systems of care. Types of practices included both prepaid group (72% of patients) and independent practice association (28%) types of HMOs, large multispecialty groups, and solo or small, single-specialty practices in Boston, Mass, Chicago, Ill, and Los Angeles, Calif. OUTCOME MEASURES: Differences between initial and 4-year follow-up scores of summary physical and mental health scales from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) for all patients and practice settings. RESULTS: On average, physical health declined and mental health remained stable during the 4-year follow-up period, with physical declines larger for the elderly than for the nonelderly (P<.001). In comparisons between HMO and FFS systems, physical and mental health outcomes did not differ for the average patient; however, they did differ for subgroups of the population differing in age and poverty status. For elderly patients (those aged 65 years and older) treated under Medicare, declines in physical health were more common in HMOs than in FFS plans (54% vs 28%; P<.001). In 1 site, mental health outcomes were better (P<.05) for elderly patients in HMOs relative to FFS but not in 2 other sites. For patients differing in poverty status, opposite patterns of physical health (P<.05) and for mental health (P<.001) outcomes were observed across systems; outcomes favored FFS over HMOs for the poverty group and favored HMOs over FFS for the nonpoverty group. CONCLUSIONS: During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems; mental health outcomes varied by study site and patient characteristics. Current health care plans should carefully monitor the health outcomes of these vulnerable subgroups.

Adult↗

PubMed1999

Using a quality scorecard to measure and improve medical groups' performance.

BACKGROUND: Blue Cross of California (BCC) uses an annual Quality Scorecard to measure performance of participating medical groups (PMGs) and independent practice associations (IPAs). The scorecard provides information to the PMGs/IPAs on their performance in several domains relative to the average network score. BCC pays annual bonuses to PMGs/IPAs with superior quality performance. A structured intervention was designed to improve the performance of PMGs/IPAs that performed poorly on the scorecard. METHODS: A cohort study was conducted in a large health maintenance organization in California in 1997. All PMGs/IPAs received a detailed summary of the components of the annual quality scorecard. Scorecard components include an annual audit of quality, utilization management, credentialing, and members' rights and responsibilities, grievance rates, member transfer for quality reasons, a satisfaction survey, and a preventive health review. Twenty-two of 124 PMGs/IPAs with more than 1,000 BCC members during 1996 that had scored lower than 1 standard deviation below the mean were targeted. These 22 outlier PMGs/IPAs received additional information indicating that their performance was below average. A BCC quality team subsequently visited the outlier PMGs/IPAs to provide supplementary information on the deficient areas and provide assistance in making improvements. RESULTS: The outlier groups showed significant improvements in the annual audit of quality score, member satisfaction with access, member satisfaction with last visit, overall member satisfaction with PMGs/IPAs, mammography screening, and the total score. CONCLUSIONS: A structured quality improvement intervention in poorly performing PMGs/IPAs was followed by improvements in specific performance measures.

Benchmarking↗