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Differences in 4-Year Health Outcomes for Elderly and Poor, Chronically III Patients Treated in HMO and Fee-for-Service Systems: Results From the Medical Outcomes Study
Abstract
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, III, 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-ltem 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.
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“A change of 4 and above is regarded as a clinically relevant change [60–62].”
From Feasibility of group-based acceptance and commitment therapy for adolescents (AHEAD) with multiple functional somatic syndromes: A pilot study (2020) · cites this paper as [62]
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Recognizing the family caregiver: integral and formal members of the rehabilitation process
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“As such, the quality of this care may be directly related to the ultimate health of the client and eventual health care expenditures (Ware et al., 1996).”
Kazis, L., Selim, A. J., Rogers, W., et al. (2012) · The journal of ambulatory care management · doi:10.1097/jac.0b013e318267468f · Cited by 32
“The 8 scales are summarized into 2 summary scores, PCS and MCS (Kazis et al., 2006a; Ware et al., 1996).”
BackgroundMethodResultInfluentialSelim, A. J., Berlowitz, D., Kazis, L., et al. (2010) · Health Services Research · doi:10.1111/j.1475-6773.2009.01068.x · Cited by 32
“More recent studies of the elderly have found no differences between Medicare managed care and FFS with respect to functional declines and to mortality (Retchin et al. 1992; Riley 2000; Porell and Miltiades 2001).”
BackgroundMethodInfluentialChanging physician behavior: half‐empty or half‐full?
Alvanzo, A. A. H., Cohen, G. M., & Nettleman, M. D. (2003) · Clinical Governance An International Journal · doi:10.1108/14777270310459995 · Cited by 27
Zaslavsky, A., & Cleary, P. (2002) · Medical Care · doi:10.1097/00005650-200210000-00012 · Cited by 32
Porell, F. (2001) · Medical Care Research and Review · doi:10.1177/107755870105800402 · Cited by 32
“Ware et al. (1996) found that Medicaid HMO enrollees exhibited significantly worse health outcomes than Medicaid FFS recipients over a period of 4 years.”
BackgroundAlegría, M., Mcguire, T., Vera, M., et al. (2001) · American Journal of Public Health · doi:10.2105/ajph.91.9.1431 · Cited by 31
“For each wave, the US Bureau of the Census definition of poverty for a family of 4 (2 Concerns have been raised about the differential impact of managed mental health care on poor Medicaid populations.(1,2) The poor tend to have more need of care but appear less successful in obtaining services from managed care organ…”
BackgroundCuijpers, P., van Lammeren, P., & Duzijn, B. (1999) · International Psychogeriatrics · doi:10.1017/s1041610299006067 · Cited by 32
The future of capitation The physician role in managing change in practice
Goodson, J., Bierman, A., Fein, O., et al. (2001) · Journal of general internal medicine · doi:10.1046/j.1525-1497.2001.016004250.x · Cited by 30
Beyond Managing Medicaid Costs: Restructuring Care
Stuart, M. E., & Weinrich, M. (1998) · Milbank Quarterly · doi:10.1111/1468-0009.00088 · Cited by 32
Luft, H. (1998) · Annual Review of Public Health · doi:10.1146/annurev.publhealth.19.1.459 · Cited by 30
Metadata
- Authors
- Ware, J. E.
- Corresponding author
- Ware, John E.
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 1996-10-02
- Volume
- 276
- Issue
- 13
- Pages
- 1039
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W7214213080
- Cited by
- 0
- References
- 0
- FWCI
- 0.00
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Family Practice › Primary Care and Health Outcomes
- Keywords
- health maintenance organizations, chronic disease, elderly patients, low-income patients, physical health outcomes, mental health outcomes, Medicare, prepaid group practice, independent practice associations, hypertension, type 2 diabetes, acute myocardial infarction, congestive heart failure, depressive disorders, SF-36, health care delivery systems, health disparities, general practice
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