A study sparking controversy within the health care community suggests that older and poorer patients with chronic diseases have worse outcomes if they belong to health maintenance organizations than if they subscribe to traditional fee-for-service insurance plans.
The study, published today in the American Medical Association’s weekly journal, is one of few to address a growing consumer concern: Do HMOs provide good service to the patients who need the most attention, the closest monitoring and the best access to specialists?
Defenders of the managed care industry attacked the new study Tuesday for its methods and because its data were collected between six and 10 years ago. But some acknowledged they do not have evidence that the most challenging patients do as well in managed care plans.
Earlier studies generally have found no differences in quality of medical care or outcomes between HMOs and non-managed care plans when comparing overall patient populations.
However, many experts and consumer advocates worry that such general comparisons mask problems in the care of the most vulnerable and medically needy groups of patients - those with diabetes, heart disease, birth defects and genetic diseases, cancer, mental illness and physical disabilities.
“Clearly, the average result hides the subgroups that are having worse outcomes,” said John E. Ware of New England Medical Center, who led the study.
Robert Restuccia of Health Care for All, a consumer advocacy group, said his organization receives complaints from people with special medical needs who have difficulty with managed care plans. “But HMOs claim there’s no problem, that everything is anecdotal and we don’t have any concrete data,” Restuccia said.
Ware and his colleagues studied 2,235 patients in Boston, Chicago and Los Angeles over a period of four years. The patients all had one of five medical conditions: high blood pressure, non-insulin-dependent diabetes, recent heart attack, heart failure or depression.
The researchers found that chronically ill HMO patients who were elderly, poor or both were more likely to have declining health, compared to similar patients in traditional health plans that pay doctors on a piecemeal basis.
For instance, 54 percent of elders in HMOs had declines in health over four years compared with 28 percent in fee-for-service plans. Among those both elderly and poor, the difference in health status was even greater, with 68 percent of HMO patients experiencing health declines compared to 27 percent among fee-for-service patients.
Poor people who were in ill health at the beginning of the study were more likely to improve if they had fee-for-service coverage. Twenty-two percent of HMO patients in this group got better over four years, compared to 57 percent of fee-for-service subscribers.
The study does not address the reason for these differences, but many critics of managed care point out that fee-for-service insurance plans give consumers free choice among physicians, while managed care plans control patients’ access to more expensive specialists and other services.
“It’s clear from our study that certain vulnerable subgroups are at greater risk,” Ware said. “I would argue that plans should monitor the most vulnerable subgroups in their population, and not just look at the average.”
The American Association of Health Plans, which represents the managed care industry, called Ware “a very respected health researcher” and said the group plans to examine his findings carefully. But the association noted that the study “focuses only on one measure - whether or not patients believed their health improved, stayed the same or worsened. … It is typical to use more than one measure when analyzing health outcomes.”
The HMO group said Ware’s data “will require further analysis before we are able to determine whether such a small sample of old data based on only one measure can be extrapolated further.”
Dr. Karen Bell, associate medical director of Harvard Pilgrim Health Care, a Massachusetts facility that participated in the study, agreed with Ware that HMOs should study and monitor the elderly and other groups that have more intensive medical needs.
“On the other side of the coin, if you ask if this study leads to the conclusion that the poor and elderly receive lesser care, I would have to take umbrage with that,” Bell said.
One critic of the study is Dr. Sheldon Greenfield of New England Medical Center in Boston, a colleague of Ware’s who actually participated in the research project, called the Medical Outcomes Study.
Greenfield echoed the HMO industry’s criticism that the Ware study only looked at patients’ functional status - whether they said they were doing better, worse or the same on a range of measures such as “feeling tired most of the time.”
The study did not measure clinical outcomes, such as whether blood pressure, blood sugar or heart function had improved or worsened. “Most of the medical community has rejected the use of a single measure, such as functional status, to determine outcome,” Greenfield said.
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