The Quality of Ambulatory Care in Medicare Health Maintenance Organizations SHELDON M. RETCHIN, MD, MSPH,
AND
BARBARA BROWN, PHD
Abstract: The quality of ambulatory care received by Medicare recipients who enrolled in health maintenance organizations (HMOs) was compared to the care received by fee-for-service (FFS) Medicare recipients, in a quasi-experimental, non-randomized design. Both samples were drawn from the four major geographic areas in the country, and included two types of HMO practices: staff/group models, and independent practice associations (IPAs). A panel of expert physicians developed criteria for evaluating ambulatory care, and medical record abstractions using these criteria were performed on 1,590 outpatient records: 777 FFS and 813 HMO (441 staff/group,
372 IPA). While individual items of medical histories and physical examinations were performed most often for staff/group HMO patients and least often in FFS patients, odds ratios (OR) for performance in staff/group HMO patients were particularly large for health maintenance items: tonometry (OR = 8.4), mammography (OR = 2.7), pelvic examination (OR = 5.3), rectal examination (OR = 2.9), fecal occult blood test (OR = 3.3). The results suggest that recommended elements of routine and preventive care are more likely to be performed for Medicare enrollees in staff/group HMOs than in FFS settings. (Am J Public Health 1990; 80:411-415.)
Introduction Due to the rising costs of delivering health care to Medicare recipients, federal cost containment measures have been initiated. Among these initiatives, the use of prepaid care strategies has received increased attention. In 1982, the Health Care Financing Administration began a demonstration program of prepaid health care for Medicare recipients. The 27 participating health maintenance organizations (HMOs) provided comprehensive care, received prospective monthly payments for the enrollees, and assumed the financial risk of their complete health care. The purpose of the program was to show whether contracts with HMOs for Medicare recipients' health care could both reduce costs effectively and also maintain current standards of care. Since the demonstration program began, optional Medicare enrollment in HMOs has been extended, and there are now about one million Medicare enrollees in more than 100 separate HMOs. Since HMOs reduce the cost of care mainly by replacing hospitalizations with less expensive ambulatory care, utilization rates of their enrollees have been observed to fall to as low as half the rates of Medicare recipients in traditional care arrangements. 12 Although the number of ambulatory visits in prepaid systems of care does rise to compensate for the reduction in hospitalizations, it is possible that such increases may strain the resources on which elderly HMO enrollees depend to manage their disabilities. Multiple chronic illnesses are the rule and many have significant functional limitations; outpatient management of elderly persons thus requires considerable time and effort. Hence, misgivings exist as to whether financial constraints, under prepaid systems like HMOs, may lead physicians to compromises that reduce the quality of outpatient care elderly persons need.3.4
To study how prepaid reimbursement affects the care Medicare patients receive in HMOs, the federal government funded the National Medicare Competition Evaluation. This comprehensive study examined not only the effectiveness of prepaid care in cutting Medicare costs, but also its effects on patient satisfaction with the care,5 and whether HMO Medicare patient care matched the quality of that received by fee-for-service (FFS) Medicare patients. Several components of the evaluation are now either in press or in preparation. The evaluation of the process of routine and health maintenance care for ambulatory patients is presented here.
Address reprint requests to Sheldon M. Retchin, MD, MSPH, Associate Professor of Internal Medicine, Department of Internal Medicine and the Williamson Institute for Health Studies, Medical College of Virginia, Virginia Commonwealth University, Box 287 MCV Station, Richmond, VA 23298. Dr. Brown is Assistant Professor, Department of Health Administration, Williamson Institute for Health Studies, MCV/VCU, Richmond. This paper, submitted to the Journal February 9, 1989 was revised and accepted for publication October 18, 1989. Editor's Note: See related editorial p 403 this issue. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH April 1990, Vol. 80, No. 4
Methods HMO Selection
There were several considerations in selecting the study's sample of HMOs. First, adequate representation of the four principal HMO models was a concern: staff HMOs, group HMOs, individual independent practice associations (IPAs), and network IPAs. Staff HMOs employ physicians and other providers directly; group HMOs contract one or more group practices. Individual IPAs contract with many individual physicians who care for HMO enrollees in their own offices; network IPAs contract not only with individuals but also with groups of physicians, with whom they usually share some of the risk for covered services. Because evidence suggests that IPAs function similarly to FFS practices, adequate representation of all four HMO models in the sample was important. Second, those plans with fewer than 2,000 Medicare enrollees were eliminated because they were unlikely to have enough cases for statistical power. Third, medical care often follows the conventional practices of the area, so adequate representation by geographic location was important. Finally, to secure the participation of HMOs and ensure confidence in the integrity of the study objectives, individual HMO plans were not identified in the analysis. From the pool of 27 HMOs in the demonstration, eight, distributed among the four major geographic areas, were selected for study. Four were staff or group model HMOs (staff/group) and four were IPA or network model HMOs (IPA). Patient and Physician Selection
An important factor for selecting the sample of patients was that HMOs would have a high proportion of new evaluations. Routine care for new patients requires more 411
RETCHIN AND BROWN
detailed medical record-keeping than is required for care of established patients. Therefore, the samples of both HMO and FFS Medicare patients were limited to those who had new patient evaluations during the study time frame, the period from each plan's enrollment date (range: January 1983-May 1984) to March 31, 1986. From the HMOs selected for study, an appropriate sample of patients was identified by age, Medicare status, and the name of the primary care physician. Those enrolled in the HMO before becoming eligible for Medicare were excluded, as were rollovers, patients who had seen the same physician under FFS. For the FFS sample, primary care physicians with eligible patients were identified and recruited using master files from the American Medical Association and the American Osteopathic Association. Within the geographic areas used in selecting HMOS, 590 primary care physicians were identified. They were recruited in random number order by telephone, and their primary provider status confirmed. Screening eliminated 342 physicians, of whom 42 percent were ineligible because they could not be reached by phone, and the others for a variety of reasons: currently practicing in a staff/group model HMO, not in an office-based practice, no new patients during the study time frame, not in primary care, dead or retired. Of the 248 eligible physicians, 135 refused to participate and 113 participated in the study (recruitment rate, 46 percent). About 58 percent of the participating primary care physicians in the FFS sample reported also seeing HMO patients not enrolled in a staff! group model HMO. Each participating physician was promised confidentiality for the information collected in the abstracting process. Stipends were offered; they were accepted by 13 percent of participating physicians. Almost 60 percent of the participating physicians were board certified in family practice or internal medicine. About 50 percent had graduated from medical school by 1970. These data were not available for individual physicians in the HMO sample because agreement to participate in the study was reached with the HMOs. However, physician lists from HMO plans overall indicated professional profiles similar to those in the FFS sample. To avoid over- or under-representing a particular style of practice in the sample, records for about 10 patients were abstracted for each physician in the two groups. Abstraction Instrument Design
An advisory panel of physicians was assembled to develop detailed criteria lists for evaluating ambulatory care. The physicians were chosen on the basis of experience in quality of care research, background with prepaid medical plans, and recommendations from colleagues. Among them were both general internists and clinicians with expertise in
geriatrics. The panel developed three categories of ambulatory patient evaluation: medical history-taking, physical examination, and preventive screening. The first two represent time-honored bedside techniques, and as such were employed to measure the quality of care in new patient evaluations. Elements of preventive care, such as immunizations and screening procedures, were emphasized because substantial evidence supports their efficacy in health maintenance for the elderly.6 The abstraction instrument used is available by request. Medical Record Abstraction Data were collected by 10 registered nurse abstractors who had been specially trained. They first completed a set of 412
exercises mailed to them along with the training manual, and then attended five days of closely supervised sessions. For periodic health examinations abstractors were explicitly instructed to follow current guidelines.6 When a recommended examination was not performed, statements were accepted for deferral or noncompliance (e.g., history of a
hysterectomy). Interrater reliability was assessed by having all 10 abstractors and the principal investigator (SMR) review a medical record. Agreement among raters was assessed by a variation of the kappa statistic.7 Kappa values between raters ranged from .45 to .85, indicating good to excellent agreement among nurse abstractors for most items. The lower interrater values occurred with medical-history items, and the higher values with physical examinations, screening tests, and procedures. Analysis
While the study focused mainly on new patient evaluations, the follow-up time for the analysis of screening tests and procedures was extended from the initial patient evaluation to the time of the chart abstraction. Because there were differences between groups, the duration of time after the patient's initial evaluation was considered a potential confounder. Others were age and gender, since many screening items are both age- and gender-specific. To control for these confounders, a logistic regression model was used to test the relationship between the patient's membership in an IPA model HMO, a staff/group HMO or a FFS system of care, and the performance of individual health maintenance procedures. Performance of each health maintenance item was used as a single binary (0-1) dependent variable. Age was entered into the model as a continuous variable. Group status, gender, and duration of follow-up time were entered as categorical variables (duration of follow-up: 0 =
AND
BARBARA BROWN, PHD
Abstract: The quality of ambulatory care received by Medicare recipients who enrolled in health maintenance organizations (HMOs) was compared to the care received by fee-for-service (FFS) Medicare recipients, in a quasi-experimental, non-randomized design. Both samples were drawn from the four major geographic areas in the country, and included two types of HMO practices: staff/group models, and independent practice associations (IPAs). A panel of expert physicians developed criteria for evaluating ambulatory care, and medical record abstractions using these criteria were performed on 1,590 outpatient records: 777 FFS and 813 HMO (441 staff/group,
372 IPA). While individual items of medical histories and physical examinations were performed most often for staff/group HMO patients and least often in FFS patients, odds ratios (OR) for performance in staff/group HMO patients were particularly large for health maintenance items: tonometry (OR = 8.4), mammography (OR = 2.7), pelvic examination (OR = 5.3), rectal examination (OR = 2.9), fecal occult blood test (OR = 3.3). The results suggest that recommended elements of routine and preventive care are more likely to be performed for Medicare enrollees in staff/group HMOs than in FFS settings. (Am J Public Health 1990; 80:411-415.)
Introduction Due to the rising costs of delivering health care to Medicare recipients, federal cost containment measures have been initiated. Among these initiatives, the use of prepaid care strategies has received increased attention. In 1982, the Health Care Financing Administration began a demonstration program of prepaid health care for Medicare recipients. The 27 participating health maintenance organizations (HMOs) provided comprehensive care, received prospective monthly payments for the enrollees, and assumed the financial risk of their complete health care. The purpose of the program was to show whether contracts with HMOs for Medicare recipients' health care could both reduce costs effectively and also maintain current standards of care. Since the demonstration program began, optional Medicare enrollment in HMOs has been extended, and there are now about one million Medicare enrollees in more than 100 separate HMOs. Since HMOs reduce the cost of care mainly by replacing hospitalizations with less expensive ambulatory care, utilization rates of their enrollees have been observed to fall to as low as half the rates of Medicare recipients in traditional care arrangements. 12 Although the number of ambulatory visits in prepaid systems of care does rise to compensate for the reduction in hospitalizations, it is possible that such increases may strain the resources on which elderly HMO enrollees depend to manage their disabilities. Multiple chronic illnesses are the rule and many have significant functional limitations; outpatient management of elderly persons thus requires considerable time and effort. Hence, misgivings exist as to whether financial constraints, under prepaid systems like HMOs, may lead physicians to compromises that reduce the quality of outpatient care elderly persons need.3.4
To study how prepaid reimbursement affects the care Medicare patients receive in HMOs, the federal government funded the National Medicare Competition Evaluation. This comprehensive study examined not only the effectiveness of prepaid care in cutting Medicare costs, but also its effects on patient satisfaction with the care,5 and whether HMO Medicare patient care matched the quality of that received by fee-for-service (FFS) Medicare patients. Several components of the evaluation are now either in press or in preparation. The evaluation of the process of routine and health maintenance care for ambulatory patients is presented here.
Address reprint requests to Sheldon M. Retchin, MD, MSPH, Associate Professor of Internal Medicine, Department of Internal Medicine and the Williamson Institute for Health Studies, Medical College of Virginia, Virginia Commonwealth University, Box 287 MCV Station, Richmond, VA 23298. Dr. Brown is Assistant Professor, Department of Health Administration, Williamson Institute for Health Studies, MCV/VCU, Richmond. This paper, submitted to the Journal February 9, 1989 was revised and accepted for publication October 18, 1989. Editor's Note: See related editorial p 403 this issue. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH April 1990, Vol. 80, No. 4
Methods HMO Selection
There were several considerations in selecting the study's sample of HMOs. First, adequate representation of the four principal HMO models was a concern: staff HMOs, group HMOs, individual independent practice associations (IPAs), and network IPAs. Staff HMOs employ physicians and other providers directly; group HMOs contract one or more group practices. Individual IPAs contract with many individual physicians who care for HMO enrollees in their own offices; network IPAs contract not only with individuals but also with groups of physicians, with whom they usually share some of the risk for covered services. Because evidence suggests that IPAs function similarly to FFS practices, adequate representation of all four HMO models in the sample was important. Second, those plans with fewer than 2,000 Medicare enrollees were eliminated because they were unlikely to have enough cases for statistical power. Third, medical care often follows the conventional practices of the area, so adequate representation by geographic location was important. Finally, to secure the participation of HMOs and ensure confidence in the integrity of the study objectives, individual HMO plans were not identified in the analysis. From the pool of 27 HMOs in the demonstration, eight, distributed among the four major geographic areas, were selected for study. Four were staff or group model HMOs (staff/group) and four were IPA or network model HMOs (IPA). Patient and Physician Selection
An important factor for selecting the sample of patients was that HMOs would have a high proportion of new evaluations. Routine care for new patients requires more 411
RETCHIN AND BROWN
detailed medical record-keeping than is required for care of established patients. Therefore, the samples of both HMO and FFS Medicare patients were limited to those who had new patient evaluations during the study time frame, the period from each plan's enrollment date (range: January 1983-May 1984) to March 31, 1986. From the HMOs selected for study, an appropriate sample of patients was identified by age, Medicare status, and the name of the primary care physician. Those enrolled in the HMO before becoming eligible for Medicare were excluded, as were rollovers, patients who had seen the same physician under FFS. For the FFS sample, primary care physicians with eligible patients were identified and recruited using master files from the American Medical Association and the American Osteopathic Association. Within the geographic areas used in selecting HMOS, 590 primary care physicians were identified. They were recruited in random number order by telephone, and their primary provider status confirmed. Screening eliminated 342 physicians, of whom 42 percent were ineligible because they could not be reached by phone, and the others for a variety of reasons: currently practicing in a staff/group model HMO, not in an office-based practice, no new patients during the study time frame, not in primary care, dead or retired. Of the 248 eligible physicians, 135 refused to participate and 113 participated in the study (recruitment rate, 46 percent). About 58 percent of the participating primary care physicians in the FFS sample reported also seeing HMO patients not enrolled in a staff! group model HMO. Each participating physician was promised confidentiality for the information collected in the abstracting process. Stipends were offered; they were accepted by 13 percent of participating physicians. Almost 60 percent of the participating physicians were board certified in family practice or internal medicine. About 50 percent had graduated from medical school by 1970. These data were not available for individual physicians in the HMO sample because agreement to participate in the study was reached with the HMOs. However, physician lists from HMO plans overall indicated professional profiles similar to those in the FFS sample. To avoid over- or under-representing a particular style of practice in the sample, records for about 10 patients were abstracted for each physician in the two groups. Abstraction Instrument Design
An advisory panel of physicians was assembled to develop detailed criteria lists for evaluating ambulatory care. The physicians were chosen on the basis of experience in quality of care research, background with prepaid medical plans, and recommendations from colleagues. Among them were both general internists and clinicians with expertise in
geriatrics. The panel developed three categories of ambulatory patient evaluation: medical history-taking, physical examination, and preventive screening. The first two represent time-honored bedside techniques, and as such were employed to measure the quality of care in new patient evaluations. Elements of preventive care, such as immunizations and screening procedures, were emphasized because substantial evidence supports their efficacy in health maintenance for the elderly.6 The abstraction instrument used is available by request. Medical Record Abstraction Data were collected by 10 registered nurse abstractors who had been specially trained. They first completed a set of 412
exercises mailed to them along with the training manual, and then attended five days of closely supervised sessions. For periodic health examinations abstractors were explicitly instructed to follow current guidelines.6 When a recommended examination was not performed, statements were accepted for deferral or noncompliance (e.g., history of a
hysterectomy). Interrater reliability was assessed by having all 10 abstractors and the principal investigator (SMR) review a medical record. Agreement among raters was assessed by a variation of the kappa statistic.7 Kappa values between raters ranged from .45 to .85, indicating good to excellent agreement among nurse abstractors for most items. The lower interrater values occurred with medical-history items, and the higher values with physical examinations, screening tests, and procedures. Analysis
While the study focused mainly on new patient evaluations, the follow-up time for the analysis of screening tests and procedures was extended from the initial patient evaluation to the time of the chart abstraction. Because there were differences between groups, the duration of time after the patient's initial evaluation was considered a potential confounder. Others were age and gender, since many screening items are both age- and gender-specific. To control for these confounders, a logistic regression model was used to test the relationship between the patient's membership in an IPA model HMO, a staff/group HMO or a FFS system of care, and the performance of individual health maintenance procedures. Performance of each health maintenance item was used as a single binary (0-1) dependent variable. Age was entered into the model as a continuous variable. Group status, gender, and duration of follow-up time were entered as categorical variables (duration of follow-up: 0 =
