HSR: Patients under managed care see physicians with worse outcomes

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Floridians undergoing PCI and insured by Medicare managed care (MMC) tended to see physicians who had worse reported outcomes compared with patients insured by Medicare fee-for-service (MFFS), according to a study published in the April issue of Health Services Research.

“How managed care impacts the trade-off between healthcare efficiency and quality remains unresolved,” wrote the author.

Marco D. Huesch, PhD, of the Fuque School of Business at Duke University in Durham, N.C., looked at Florida Department of Health’s Agency for Health Care Administration data of PCI discharges at state-regulated hospitals between 2003 and 2006 to investigate the differences between patients who are insured by MMC and MFFS.

“Informed MMC plans may be able to selectively contract with more efficient, higher quality providers, guide enrollees to these, and positively influence care quality and resource consumption during the admission,” hypothesized Huesch.

Huesch identified 67,476 patients seen by 486 physicians at 97 hospitals across the state.

The most significant differences found between MFFS and MMC patients were demographic. Compared to MFFS, MMC patients came from more ethnically diverse backgrounds—16 percent were Hispanic and 9 percent black. These same ratios for MFFS were each 6 percent.

Additionally, MMC patients presented emergently more often and were more likely to come through the ER with a physician referral.

“Whether this is correlated with slower presentations or poorer preadmission care is unknown in these data,” wrote Huesch.

Seventy-six of the  486 physicians evaluated in the study saw no MMC insured patients, while 85 physicians had more than 20 percent of their patients insured by MMC. Huesch said that these numbers likely mean that physicians who saw more MMC patients were more likely to have stent experience and practice more frequently.

These data also showed that MMC insured patients were less likely to see physicians with mortality profiles that were below the median or the absolute lowest mortality. However, MMC patients also had the highest probability for seeing physicians with the absolute highest mortality profiles.

“This study’s results were unexpected and did not confirm the hypotheses that managed care insurers are able to procure more efficient and (weakly) higher quality stent physicians for their members,” wrote Huesch. “No evidence was found that Medicare payor type significantly influenced the likelihood of using physicians with different admission length profiles. Instead, MMC subscribers had significantly worse odds of seeing those physicians with favorable outcome profiles.”

The author said that limitations stem from possible coding errors in these data sets and the short term and limited look at in-hospital mortality rates.

“These findings raise questions surrounding the screening, self-selection, and care management of MMC plan members,” said Huesch.

In addition, he pondered whether or not MMC policies “actually benefit their members” from a cost-based perspective compared to MFFS and whether benefits are fairly distributed across ethnic and racial groups and varied health status sectors.

“Further research into minority and managed care member health status and impact of such factors on risk models and expected outcomes will help to address important individual health services questions such as these,” Huesch concluded.

“Public policy on the appropriate level of cross-subsidies and the appropriate role of commercial managed care in health entitlement programs would also be informed by such research,” he wrote.