AHCPR Research About Managed Care Organizations

Contents

· Introduction

· Factors Affecting Costs, Premiums, and Employee Choice of Health Plan

· Interventions to Increase Value

· The HMO as Laboratory for Clinical and Effectiveness Research

· HMOs and Managed Care in Rural Areas

 

Introduction

The last few years have witnessed a remarkable transformation in all facets of America's health care system, from its financing to the way health care services are organized and delivered.

The driving force in this transformation is the shift from traditional fee-for-service systems to managed care networks, which run the gamut from tightly structured staff model health maintenance organizations (HMOs) to loosely organized preferred provider organizations (PPOs). Today, more than 50 million Americans are enrolled in some type of HMO.

Changes in our health care system are occurring in response to market forces to control costs, regulatory initiatives on cost and quality, and consumer demands for quality care and greater flexibility in provider choice. Other factors causing change are the increasing domination of for-profit ownership and the rapidly increasing number of public beneficiaries, particularly Medicaid recipients. Because these changes occurred so rapidly and extensively, little is known about the long-term effects of managed care on access to care, cost, and quality of care. If policy makers, purchasers, and consumers are to make thoughtful and reasonable decisions, we need to know what works and how much it costs.

The Agency for Health Care Policy and Research (AHCPR) is the lead Federal agency charged with supporting health services research. These studies are designed to produce information that, ultimately, will improve consumer choice, improve the quality and value of health care services, and support and improve the marketplace. The vast majority of research on managed care has been conducted in HMOs, the prototypic managed care organization. Examples of AHCPR-supported research are presented in the following categories:

· Factors affecting costs, premiums, and employee choice of health plan.

· Interventions to increase value.

· The HMO as laboratory for clinical and effectiveness research.

· HMOs and managed care in rural areas.

 

Factors Affecting Costs, Premiums, and Employee Choice of Health Plan

As the share of the health marketplace occupied by managed care has increased, policy makers, purchasers, and consumers have become more interested in the effects of managed care organizations on costs, premiums, and enrollee satisfaction. A number of issues are of particular interest, including whether and to what extent lower premiums reflect favorable selection, what factors are important to consumers in choosing health plans, the effectiveness of interventions in decreasing unnecessary utilization of services, and methods to compensate appropriately those HMOs with enrollees who have high rates of illness.

Effects of Managed Care on Physicians and Their Practices. Jack Hadley, Principal Investigator. This project examines physician involvement with managed care plans: whether they have formal contracts and whether they have formal "gatekeeper" responsibilities, the methods of payment, the extent of risk-taking, and financial incentives. The project is examining changes in practice size and composition, in affiliation and ownership, and changes in operations (for example, satellite offices and extended hours). Other factors being studied include hours worked, number of patients seen, patient mix by insurance and socioeconomic status, fees charged, and physician satisfaction. (Project dates: 9/30/95-9/29/97)

Effects of Managed Care on Hospital and Physician Integration. Michael Morrisey, Principal Investigator. To understand better how physicians and hospitals respond to managed care in local markets, the investigators are studying measures of physician-hospital integration from a 1993 national survey of 1,500 U.S. community hospitals that was designed to learn about hospital-physician relationships. The survey contains facts on physician participation in hospital management, on organizational and financial arrangements between hospital and physician, and on physician relations in teaching hospitals and in multihospital systems, and on hospital revenues. (Project dates: 9/30/95-3/31/97)

Impact of HMOs on Integrated Networks and Services. Lawton Burns, Principal Investigator. This study is estimating the impact of HMO market structure on the development of integrated networks among physicians and hospitals (both horizontal and vertical integration). The project is estimating the effects of HMO market structure and integrated networks on hospital costs and is providing evidence on whether integrated provider networks augment or moderate the impact of HMO market structure on HMO premiums charged in local markets. (Project dates: 9/30/95-3/30/97)

Impact of Managed Care on Physician Markets. William White, Principal Investigator. To examine patterns of compensation, location, and use of primary care and specialist physicians, this project is using physician-level data and measures of managed care penetration. The study is assessing the effects of managed care on the number, incomes, hours, hourly compensation, and type of care provided by primary care physicians, relative to specialty physicians. Information from this project will address issues useful in evaluating workforce policies designed to address imbalances between primary care physicians and specialists. (Project dates: 9/30/95-9/29/96)

Impact of Changing Markets on Rural Health Care Providers. Keith Mueller, Principal Investigator. This project is assessing the pace of market changes in rural areas and the involvement of rural providers and community leaders in changes that are occurring. Informants (including health care providers, insurers, State offices of rural health, consumer representatives, public health, community health centers, employers, and public health agencies) will be used to assess provider participation in market-driven changes. Knowledge gained from this project will be disseminated directly to policymakers as well as to academics and other researchers. (Project dates: 9/30/95-9/29/97)

Efficiency in Hospitals: Do HMOs and PPOs "Buy Right?" Jose Escarce, Principal Investigator. This project is determining whether patients of HMOs and PPOs tend to use more efficient, higher quality and lower cost hospitals, respectively, than nonmanaged care patients. The study will control for important correlated factors such as distance of patients to the hospital. (Project dates: 9/30/95-9/29/97)

Effects of Horizontal Hospital Mergers on Efficiency, Profitability, and Consumer Prices. Robert Connor, Principal Investigator. This project is addressing such questions as: Do hospital mergers reduce costs? Are savings passed on to consumers as lower prices or are they retained by hospitals as higher profits? Does market concentration affect merger-related changes in cost or price inflation? Is there an optimal level of hospital market concentration for the most efficient provision of hospital services? Does HMO market penetration affect hospital costs or price inflation? Also being examined are the relevance of merged hospitals' relative size, proximity, and similarity in services for the outcomes of mergers. (Project dates: 9/30/95-12/31/96)

Health Care Markets, Managed Care, and Hospital Performance. Glenn Melnick, Principal Investigator. Three linked markets (hospitals, physicians, and insurance) are being examined. The study will describe how managed care penetration and competition among providers and insurance companies affects hospital utilization, costs, revenues, and uncompensated care. This study will broaden previous work on hospital competition and managed carewhich is regional in natureto the national scene. It will focus on interdependencies between markets and effects on hospital performance. (Project dates: 9/30/95-9/29/98)

The determinants of HMO efficiency from 1985 to 1994. Douglas Wholey, Principal Investigator. This project is developing reliable efficiency measures of firm-level HMO efficiency by using two different methodologies and comparing the measures for consistency. Questions to be addressed include: Do HMOs become more efficient over time? Is increasing efficiency due to the failure of less efficient HMOs? Is it due to enrollment growth and achieving economies of scale? Is it due to mergers leading to larger, more efficient HMOs? Is it due to HMO adaptation, holding HMO scale economies constant? Do more competitive markets lead to greater HMO efficiency increases? How do State regulations affect the evolution of HMO efficiency? (Project dates: 9/30/95-12/31/96)

The Performance of Strategic Hospital Collectives. Roice Luke, Principal Investigator. Strategic hospital collectives (SHCs), consisting of two or more hospitals in the same metropolitan statistical area that are in the same system or network, are important examples of the integration of health services organizations. The project will present empirical evidence on how performance is related to market structure, local environment, and the organizational characteristics (hospital or SHC). Market structure is being measured by concentration in the hospital market, HMO penetration, and the presence of large purchasers. (Project dates: 9/30/95-9/29/96)

For more information on the above projects, contact:

Michael Hagan

Agency for Health Care Policy and Research

2101 East Jefferson Street

Rockville, MD 20852

(301) 594-1410, ext. 1503

mhagan@po3.ahcpr.gov

Factors Affecting Premium and Employee Choice of Health Plan. Bryan E. Dowd, Principal Investigator. In studying the strategy of managed competition, the project found that employees switch plans when faced with higher out-of-pocket premiums. Using data on Minnesota State employees from 1988 to 1993, the project established that high-cost plans lost market share while the lowest cost plan dramatically increased its market share. A second study, among five large Minnesota employers, indicated a high degree of consumer sensitivity to out-of-pocket premiums. (Project dates: 4/1/93-5/31/93)

Design of a Survey to Monitor Consumers' Access to Care, Use of Health Services, Health Outcomes, and Patient Satisfaction. James Lubalin, Principal Investigator. Through this contract with the Research Triangle Institute, AHCPR has developed survey modules designed to collect key information on consumers' attitudes about access to health care, use of specific services, health outcomes, perceived quality of care, and satisfaction with care. One goal was to design a survey that could yield comparative data across types of health benefits plans (such as managed care versus fee-for-service). This effort built on the experience of the health care industry, managed care, and other users. (Project dates: 9/30/94-3/30/95)

HMO Cost Performance: A Simultaneous Equations Approach. Dana P. Goldman, Principal Investigator. This study examined the impact of reforms to reduce the costs of federally insured health care on the demand for medical services. Two experiences were analyzed: the Department of Defense (DoD) effort to reduce health care costs for its civilian employees and a Robert Wood Johnson Foundation-funded demonstration of prepaid managed health care enrollment for Medicaid eligibles. These analyses revealed that in the DoD experience, the generosity of benefits and lower prices expanded managed care participants' use of ambulatory services; in the Medicaid reforms, the HMO did not significantly reduce expenditures. (Project dates: 9/1/92-8/31/94)

Medicaid Managed Care and Access to Health Services. P.J. Gibson, Principal Investigator. Across the United States, managed care systems are replacing fee-for-service systems in providing Medicaid services. Because the effect of this switch on access is unclear, this study is examining how access to medical services for Medicaid clients is affected by the change from a fee-for-service system to a capitated, gatekeeper system. Results from this study will be used to help guide future State health reform measures and guide improvements to the Medicaid system. (Project dates: 9/30/94-9/29/95)

Competition and Health Plan Premium Determination. Randall P. Ellis, Principal Investigator. This project is examining how competition influences the determination of health plan premiums by identifying the rate-setting mechanisms and market structures where competition seems to work well. Rate-setting mechanisms and market structures that will be examined include community rating, experience rating, competitive bidding, negotiated rate setting, government formulas, payment by the employer of a fixed amount or a fixed proportion toward the plan, number of plans offered, exit and entry of health plans, and the market share of HMOs. (Project dates: 8/1/94-3/31/96)

A Comparison of S/HMO and TEFRA HMO Enrollees. Bryan E. Dowd, Principal Investigator. This study compared cost, use of health care services, and health and functional status measures for enrollees in a social HMO (S/HMO) and a TEFRA-risk Medicare HMO. The study concluded that people enrolled in the S/HMO had higher expenditures overall than those in the TEFRA-risk Medicare HMO. Specifically, the S/HMO group had higher expenditures for nursing home services but lower expenditures for inpatient care. There were no differences between the two groups by two measures of functional status. (Project dates: 7/1/92-6/30/94)

Cost Containment and Group Health Insurance Benefit Growth. Douglas C. Coate, Principal Investigator. In this study, investigators evaluated the effectiveness of managed care cost containment strategies in the group health benefit plans of private- and public-sector employers in the United States. Data were used from the Foster Higgins annual Health Care Benefit Surveys for 1986-92. Results suggest that group health plans in which all enrollment is in one type of plan (traditional indemnity, PPO, or HMO) are about 6 percent less costly than plans that allow employee choice between different plans. For employers who offer multiple health plan choices, increased enrollment of employees in HMOs was associated with higher overall costs. However, HMOs were the least costly option for employers offering only one choice for health coverage. (Project dates: 9/1/92-8/31/94)

Self-Selection into Medicaid Managed Care. Teresa M. Herbert, Principal Investigator. The objective of this study is to analyze data on children ages 1-19 who are enrolled in either fee-for-service Medicaid (FFSM) or Medicaid managed care (MMC) to determine the direction and strength of the association between self-selection into an MMC program and prior utilization of health care services and health status. Because MMC and FFSM enrollees are likely to be different, policy makers will need these data to predict future utilization if MMC becomes the standard for Medicaid-eligible children. (Project dates: 9/1/94-8/31/95)

Adverse Selection and Risk Rating in Insurance Markets. James C. Robinson, Principal Investigator. In this study, investigators used 1985-89 personnel data and medical care claims from a large employer to develop a method for measuring and compensating for adverse selection among fee-for-service and HMO health insurance plans competing with each other. Diagnostic information from the claims data was used to identify particularly high-risk individuals most likely to be the objects of risk selection strategies. Special techniques were developed to risk-adjust employer contributions for these individuals. Investigators analyzed both predicted and actual expenditures for individuals switching from the fee-for-service plan to an HMO or from one HMO to another and compared these with predicted and actual expenditures for individuals continuously enrolled in particular plans. The comparison was found to overestimate the degree of favorable selection enjoyed by HMOs, because employees who anticipate the need for maternity services were more likely to switch to an HMO. (Project dates: 2/1/91-1/31/94)

Risk Adjusters for Pediatric Populations. Elizabeth J. Fowler, Principal Investigator. Over the past decade, risk assessment and risk adjustment strategies have received increased attention. This interest has accompanied a growing concern over the need to control selection bias in the health care marketplace. Through prospective risk adjustment models, insurers and health plans can use current information to predict future use of health care services for enrolled populations. Risk adjusters also have been identified as valuable tools for activities such as quality assurance and utilization review. Using utilization and expenditure data from two pediatric populations, this study is testing the predictive performance of two risk adjustment methodsa case-mix method and a demographic model based on the AAPCC methodology. The results of this study will fill a gap in existing knowledge, since previous research on risk adjusters has focused primarily on elderly and employed populations. A Maryland Medicaid program and a private, non-profit Minneapolis HMO are providing the data for the study. (Project dates: 9/30/94-9/29/95)

Direct Medical Costs of Preclass IV HIV Care in an HMO. Jenifer Ehreth, Principal Investigator. In studying the 1990-92 direct medical care costs and utilization of some 250 patients who were preclass IV HIV positive (not full-blown AIDS), investigators explored the impact that patients with HIV infection have on health service delivery systems. All patients were actively being treated at the Group Health Cooperative of Puget Sound. Findings show that having preclass IV HIV infection increased a person's annual health care costs an average of $3,818 and a diagnosis of AIDS increased those costs by $15,077. The greatest increase in demand due to preclass IV HIV infection was for pharmacy and laboratory services. AIDS patients mainly affected demand for home health/hospice; respiratory, physical, and occupational therapy; and inpatient services. (Project dates: 9/1/93-8/31/94)

The Effect of Selective Contracting on Physician Pricing. Jack Zwanziger, Principal Investigator. Currently, very little is known about the effect on physician fee schedules of health insurance plans that contract selectively. This study is examining the relationship between the physician fees derived from charge data, "usual, customary, and reasonable" (UCR) rates, and the market share of HMO/PPO plans in the area; the study is also comparing the growth of UCR rates with growth of to negotiated fees. In addition, the study is testing whether the negotiated fee structure is converging to Medicare physician fees resulting from the Resource-Based Relative Value Scale. Study results will provide insight into the effectiveness of selective contracting plans in reducing the rate of growth of physician fees. (Project Dates: 9/1/93-2/28/96)

Interventions to Increase Value

The early successes of HMOs in containing costs and utilization, as compared with fee-for-service plans, have long stimulated interest in understanding more precisely how HMOs effectively match intensity of services with patients' needs and preferences. The increased demands for proof of cost-effective service delivery, along with the evolution of newer HMO organizational models, have intensified interest in "what works." Studies examining the implementation of clinical practice guidelines and interventions that encourage cost-effective prescribing practices are of particular interest.

Measurement Typology Project (Phase I). R. Heather Palmer and Benjamin Duggar, Principal Investigators. This project collected and organized examples of 40 clinical performance measure sets used by private and public health care providers and organizations to assess the quality of clinical care. The project developed a typology or framework for evaluating the characteristics of these clinical performance measures so that persons trying to identify clinical quality indicators can assess their appropriateness for particular uses. Phase I was conducted with the Center for Health Policy Studies of Columbia, Maryland, and the Center for Quality of Care Research and Education at the Harvard School of Public Health. (Project dates: Completed 1/31/95)

Measurement Typology Project (Phase II). R. Heather Palmer, Principal Investigator. Phase II is refining and validating the typology developed in phase I. Developers of clinical quality measures are reviewing the classification of their measures and ensuring that the typology correctly assesses characteristics of measures and measure sets. Characteristics being reviewed include whether measures were tested for reliability and validity, the settings and populations to which the measures apply, and the clinical conditions addressed by each measure. Phase II will also incorporate information from AHCPR-supported guidelines to help users interpret measures. Information on the measures is being summarized in four related databases that will be a prototype for a national information source on clinical quality measures. The typology databases will be produced on diskette with a user manual. (Project dates: 4/1/95-12/22/95)

Practice Guidelines in Primary Care. W.S. Schroth, Principal Investigator. Many groups are actively developing clinical guidelines for primary care clinicians, although it remains unclear to what extent primary care physicians will accept and follow such guidelines. In addition, the most effective methods for disseminating and implementing clinical guidelines in primary care settings have not been established. In this study, investigators are determining the effect of a clinical guideline for the treatment of acute low back pain, a common condition associated with wide variations in evaluation and treatment. The effect of patient education with or without guideline implementation is being assessed. A formal cost analysis of the implementation methods is also being undertaken. The study is also evaluating alternative guideline implementation methods in a controlled comparison of primary care clinician practice groups in an HMO setting. The impact of guidelines on clinician practices, utilization of medical resources, patient satisfaction, and functional outcomes are the endpoints of interest in this study. (Project dates: 7/1/93-12/31/95)

Individualized Feedback to Implement Clinical Guidelines. E.A. Balas, Principal Investigator. The aim of this project is to assist health care providers in translating accepted guidelines and practice variation data into measurable individual quality improvement objectives and to assess the clinical effect of this intervention on clinical practice patterns in diverse areas of primary care. The outpatient centers of Humana Health Care Plans in Kansas City are the sites for this randomized controlled clinical trial. Forty-three physicians and 13 nurse practitioners have been randomly assigned to participate in the new quality management program that gives feedback on quality. This new quality management intervention and the results of the controlled trial should have practical application in a wide variety of managed health care organizations. (Project dates: 1/1/94-12/31/95)

Implementation of Guidelines in a Large Group-Model HMO. Jonathan B. Brown, Principal Investigator. In this project, investigators are collaborating with AHCPR and an HMO at several sites to demonstrate evaluation strategies for implementing clinical guidelines for hypertension and depression in large prepaid group practices using guidelines. Medical records, clinical databases, accounting records, an ongoing medical visit survey, and a special follow-up survey are providing data to ascertain the primary outcome measures of changes in blood pressure and depression. (Project dates: 9/30/92-9/29/95)

Evaluation of Guidelines in Large Group Practices. Harold I. Goldberg, Principal Investigator. This randomized controlled trial is comparing alternative strategies for implementing national guidelines on hypertension and depression at the largest HMO in western Washington (Group Health Cooperative) and at two hospitals affiliated with the University of Washington. Twelve small groups of primary care physicians have been assigned to either standard care or two intervention arms that use strategies for implementing guidelines. The trial will help us understand which organizational strategies are most effective in ensuring that guideline implementation is translated into improved quality of care. (Project dates: 12/1/92-12/31/95)

Pediatric Preventive Care Incentives in a Medicaid HMO. Alan L. Hillman, Principal Investigator. This randomized controlled trial is assessing the impact of a system of periodic feedback and financial incentives on compliance with pediatric preventive care clinical guidelines in HealthPASS, a mandatory Medicaid HMO in Philadelphia. The study is investigating whether the provision of detailed feedback reports to sites every 6 months, linked with a financial bonus program specifically tied to preventive care, improves the HMO's currently observed pediatrics standards compliance rate of 60 percent. (Project dates: 4/1/93-9/30/95)

Cancer Prevention for Minority Women in a Medicaid HMO. Alan L. Hillman, Principal Investigator. In this randomized controlled trial, investigators are assessing the impact of a system of periodic feedback and financial incentives on physician compliance with cancer screening guidelines in HealthPASS, Philadelphia's Medicaid HMO. The study is investigating whether providing feedback to primary care sites and a financial bonus program improves primary care provider attention to cancer prevention for women ages 50 and over. (Project dates: 9/30/93-3/31/96)

Effect of Specialty on Primary Care Practice in an HMO. Joseph V. Selby, Principal Investigator. Three groups are usually thought of as primary care providersfamily physicians, general internists, and subspecialty internists. Previous studies suggested that the level of training received by primary care physicians has a marked impact on practice style, resource utilization, and costs of care, with subspecialty internists using more medical resources than general internists or family physicians. This will be the first study that can assess the independent effect of physician training on the cost and quality of primary care. To examine differences in resource utilization and total costs for 1 year for patients of these three groups of primary care physicians, this prospective study is using the automated data systems of the Kaiser Permanente Medical Care Program of Northern California. (Project dates: 9/1/94-12/30/96)

Consumer Comprehension of Quality-of-Care Indicators. Judith H. Hibbard, Principal Investigator. The managed competition approach to heath care reform relies, in part, on consumer choice to improve the performance of health care markets and health care delivery systems. This study is using a focus group methodology and content analysis to examine the degree to which consumers understand managed care and quality-of-care indicators, and the extent to which they find these indicators useful in making health care choices. The results of the study will be used to ensure that quality indicators are accessible and useful to consumers. The results may help the development of educational efforts for assisting consumers, including newly insured consumers, in the transition to managed care. (Project dates: 7/1/94-12/31/95)

Managed Care, Physician Referral, and Medical Outcomes. David E. Grembowski, Principal Investigator. Efforts to control health care costs include constraints on physician referrals. However, these efforts may have adverse consequences for access and quality, and little is known about the influence of managed care on physician referral behavior and health outcomes. This study is examining the effect of managed care on physician referral behavior and health outcomes among patients suffering from pain and depression by determining the effect of managed care on the probability of referral among these patients and by determining the effect of managed care on health outcomes of both referred and nonreferred patients. (Project dates: 5/1/95-10/31/98)

Multi-Institutional Test Bed for Clinical Vocabulary. Christopher G. Chute, Principal Investigator. The advent of electronic medical records promises rapid and accurate conduct of clinical epidemiologic research. A major difficulty in realizing the full potential of electronic records is the absence of robust clinical terminologies. Using the combined clinical environments of the Mayo Foundation and Kaiser Permanente, project investigators are developing, evaluating, maintaining, and implementing standard medical terminologies. This environment will be a controlled test bed, resembling in miniature the national environment of care delivery. The relative merits of terminology additions and changes are being measured as they affect guideline development and patient data retrieval. The impact of terminology variants on physician practice and satisfaction is also being evaluated. (Project dates: 9/30/94-9/29/97)

The Detection and Treatment of Depression in a Large HMO. Gregory A. Nichols, Principal Investigator. This study is exploring differences between internal medicine and family practice physicians in detecting and treating patients with major depression. The specific aims of this study are to compare differences in detection rates of depression between the two types of physicians, compare treatment methods between the two groups, compare health care resource use by depressed patients of these two groups, and compare health care resource use of detected versus nondetected depressed patients within and between the two groups of physicians. (Project dates: 8/1/93-7/31/95)

Improving Disease Prevention in Primary Care. Leif I. Solberg, Principal Investigator. This study is testing the hypothesis that by promoting preventive services and by implementing continuous quality improvement (CQI), two HMO's—Blue Plus and HealthPartnerscan stimulate contracted primary care clinics to routinely deliver the medical preventive services outlined in the Healthy People 2000 goals. These services include breast exams and mammograms in women 50 and over, Pap smears in women 20 and over, tobacco cessation efforts, and hypertension and high cholesterol identification and treatment. This study also aims to show that implementing these processes will improve overall quality of care for all clinic patients, including those who are not enrolled in the HMOs. Investigators are also measuring the developmental and operating costs for the HMOs, clinics, and patients and are assessing the potential for other clinics and HMOs to adopt a similar program. (Project dates: 7/1/93-6/30/97)

Doctor/Patient/System Relationship and Perception of Quality. Roy Penchansky, Principal Investigator. From five HMOs, investigators examined undesirable outcomes and other functions that influence the possibility of a malpractice claim. Analysis showed that injury and the doctor-patient relationship were more important than patient or provider attributes. The widespread perception among providers that Medicaid and minority patients are more litigious was not supported. A low-cost way of identifying critical occurrences and incidents in ambulatory care that affect the probability of malpractice claims (hospitalization with selected combinations of diagnoses and procedures) was found, permitting risk management activities to be focused. (Project dates: 4/1/90-2/28/94)

Pharmacy-Based Patient Monitoring in an IPA HMO. L.D. Ried, Principal Investigator. The feasibility of modifying physician prescribing has not been clearly shown in a network-style HMO. This study will evaluate the effectiveness of providing pharmaceutical information about asthma treatment to community practitioners in an individual practice association (IPA). Results will be valuable to IPA HMO drug benefit administrators in determining whether they can manage the cost and care of their patients in ways similar to staff model HMOs. (Project dates: 4/1/95-10/31/96)

Record Linkage and Outcomes of Drug Therapy. Richard Platt, Principal Investigator. This investigation is assessing the usefulness of an automated record linkage system in the Harvard Community Health Plan that contains pharmacy dispensing data as well as ambulatory and inpatient clinical data for studying the indications for, outcomes of, and resource utilization associated with prescribed drug therapy. A major aim is to determine whether either prescribing or dispensing data are a sufficiently accurate measure of drug exposure to allow the data to be used for investigation of several aspects of drug therapy. Investigators are studying hypertension therapy because it is a common indication for medical care and the principal outcome, blood pressure, must be assessed in ambulatory records. This approach may also provide a model for investigating drug therapy of other conditions, such as diabetes or depression. (Project dates: 8/1/93-7/31/97)

Pharmaceutical Care and Pediatric Asthma Outcomes. Andreas S. Stergachis, Principal Investigator. Asthma is the most common chronic condition in children and is a common reason for pediatrician visits. Asthma-related health services utilization and cost have been increasing. Although studies suggest that asthma education programs may improve knowledge and short-term outcomes, there have been no assessments of the impact on long-term outcome. This study is assessing the changes in disease control, functional status, and cost associated with the introduction and delivery of a structured program of pharmaceutical care for pediatric and adolescent asthma patients. This randomized, controlled study is being conducted in the general community, including the Medicaid and King County, Washington, HMO setting, and will demonstrate the effect of pharmacists' cognitive services on the health outcomes and cost of care of this patient population. (Project dates: 3/1/93-2/28/97)

Assessing Recall Accuracy for Prescription Medications. Suzanne L. West, Principal Investigator. Drug utilization review (DUR) programs, which are conducted to improve the effectiveness of drug use, often require respondents to recall previous drug use. Because little was known about the validity of patient recall of prior drug exposures, a telephone survey was conducted of 480 persons enrolled for 12 years or more in the Group Health Cooperative of Puget Sound. Respondent recall of prior exposures to nonsteroidal anti-inflammatory drugs and estrogen was compared with the computerized pharmacy database maintained by the HMO. Respondents had tremendous difficulty remembering the specifics of their drug use. Results indicate that questionnaire-derived data on drug use may be of low quality, and the quality is affected by respondent age, recall intervals, and the specifics involved (drug name, dose, and start and end dates). (Project dates: 9/1/91-2/28/93)

HMO as Laboratory

HMOs have long served as real-world laboratories for clinical and effectiveness research because they offer the advantage of a defined population and often have an administrative infrastructure that facilitates identification of eligible cohorts of patients and/or practitioners. Several HMOs have served as laboratories to test the feasibility of translating AHCPR's clinical practice guidelines into medical review criteria. A number of AHCPR's Patient Outcomes Research Teams have used HMOs for research.

Develop, Apply, and Evaluate Review Criteria and Education Programs Based upon Practice Guidelines. Carole J. Magoffin, Principal Investigator. The Center for Clinical Quality Evaluation (formerly the American Medical Review Research Center) developed quality and utilization review criteria and clinical practice guidelines based on three AHCPR-supported clinical practice guidelines. As part of this project, review criteria and performance measures based on the guideline Benign Prostatic Hyperplasia: Diagnosis and Treatment were tested for use in two staff model HMOs (Geisinger Medical Center in Danville, Pennsylvania, and Henry Ford Health Systems in Detroit, Michigan) and in two multispecialty clinics (Lahey Clinic in Burlington, Massachusetts, and Jackson Hospital and Clinic in Montgomery, Alabama). (Project dates: 9/30/91-7/1/95)

Back Pain Outcome Assessment Team. Richard A. Deyo, Principal Investigator. Back problems result in frequent hospitalizations, surgery, and use of expensive diagnostic tests; wide geographic variations in the use of these services are well documented. One site for this study of low back pain was the Group Health Cooperative of Puget Sound. Investigators found no evidence that spinal fusion—one of the most common operations for low back problems—is superior to other surgical procedures for common degenerative conditions of the spine, but they did find more complications with spinal fusion. Evidence was also found to be growing against bed rest as therapy (even for 1-2 weeks) and against conventional spinal traction for treatment of sciatica or herniated disks. (Project dates: 9/7/89-2/28/95)

Videodisc for Back Surgery Decisions: A Randomized Trial. Richard A. Deyo, Principal Investigator. Investigators are using study subjects drawn from a closed-panel HMO and a fee-for-service academic surgical practice to evaluate the impact of a new educational program using interactive media (both computer and videodisc) to help patients with low back disorders make informed decisions about undergoing back surgery. The study will compare the interactive program with written materials and will evaluate the impact of this program on patient satisfaction with medical care; health perceptions and functioning; knowledge of low back problems relevant to informed decisionmaking; the proportion of patients selecting surgical therapy; and health care utilization. Because of the different practice sites used in the study, the results should be widely generalizable. (Project dates: 9/1/94-8/31/97)

Chiropractic Versus Physical Therapy—A Randomized Trial. Daniel C. Cherkin, Principal Investigator. Using subjects recruited from two primary care clinics in a large HMO, this study is comparing the effectiveness of two popular and expensive nonsurgical treatments for low back pain: spinal manipulation performed by chiropractors versus the McKenzie method of physical therapy. The results of this study will provide patients, physicians, managed health care systems, and insurers with valuable information on the relative benefits and costs of these commonly used treatments for patients with low back pain. (Project dates: 8/1/93-7/31/96)

Medical Care Use and Costs for Adults with Sleep Apnea. Dennis G. Fryback, Principal Investigator. Using study subjects from one of four HMOs in Madison, Wisconsin, this study is investigating the health status and health care costs associated with undiagnosed sleep apnea. The recently established high prevalence of undiagnosed sleep apnea has raised concerns about the public health burden and health care costs associated with this condition. Using cost and service delivery data obtained from the HMO, investigators will be able to compare patterns of health care utilization and estimated costs among persons with sleep apnea versus those of persons without the disorder. (Project dates: 7/1/94-6/30/96)

Lipid-Lowering Medications and Risk of Injury. Viktor E. Bovbjerg, Principal Investigator. Trials of lipid-lowering drugs have not demonstrated overall reductions in mortality because reductions in fatal cardiac deaths are offset by deaths from other causes. In this study, using Group Health Cooperative (GHC) enrollees with at least one total cholesterol measurement at or above 200 mg/dL, investigators are examining the relationships between use of lipid-lowering medication and injury. Injury cases will be identified using GHC computerized hospitalization files and death tapes; GHC pharmacy and laboratory data will be used to collect information on exposure to lipid-lowering agents. The study will also examine the utility of large HMO databases for the postmarketing surveillance of adverse drug effects. (Project dates: 9/1/94-8/31/95)

Health Care Utilization and Recurrence of Abdominal Pain. Alan M. Adelman, Principal Investigator. Although abdominal pain is one of the most common reasons for visiting a physician, little is known about it as a reason for a doctor's visit. Using subjects selected from the rosters of a large HMO, this study provided descriptive information on the natural history of abdominal pain; assessed factors associated with the recurrence and resolution of abdominal pain; assessed factors associated with seeking medical care for the problem; and described the health utilization patterns of these patients. (Project dates: 5/1/90-4/30/94)

HMOs and Managed Care in Rural Areas

Whether the achievements of HMOs or delivery models derived from comparable principles can be replicated in rural areas with relatively low population density has been a challenge for policy makers and providers. In a recent major initiative, AHCPR awarded five demonstration grants to promote the establishment of managed care approaches to health care delivery in rural areas.

Arizona Rural Managed Care Center. Andrew W. Nichols. Principal Investigator. In this 5-year project, the University of Arizona Rural Health Office is working cooperatively with AHCPR to develop and manage an AHCPR Rural Center that will plan, initiate, and monitor demonstration projects for the expansion and promotion of managed care in rural Arizona. The goal of the project is to increase access to primary care and preventive clinical services for 95 percent of those Arizona residents who are currently uninsured and/or not receiving needed medical services. (Project dates: 9/30/94-9/29/99)

Program of Rural Health Demonstration Activities. Keith J. Mueller, Principal Investigator. The Nebraska Center for Rural Health Research is establishing a Program for Rural Demonstration Activities, which will be responsible for designing activities to improve the practice of managed care in rural communities in Nebraska and Iowa. Primary care practitioners will be targeted in each of the activities. A consortium of the Nebraska Center for Rural Health Research, the University of Iowa Graduate Program in Hospital and Health Administration/Center for Health Services Research, the Nebraska Office of Rural Health, and the Iowa Office of Rural Health has responsibility for this project. (Project dates: 9/30/94-9/29/99)

West Virginia Rural Managed Care Demonstration Center. Hilda R. Heady, Principal Investigator. The West Virginia University Robert C. Byrd Health Sciences Center will create a Rural Managed Care Demonstration Center through a statewide consortium led by its Office of Rural Health. This managed care demonstration center will build on two existing managed care projects in the State by supporting activities that promote the delivery of cost-effective, quality care while promoting competition among rural, regional networks. (Project dates: 9/30/94-9/29/99)

The Maine AHCPR Rural Center. David Hartley, Principal Investigator. The Maine AHCPR Rural Center is a consortium of health sciences and State health policy organizations that will assist two rural, underserved regions in Maine to develop strategies for responding to changing local conditions and broader State and Federal health reform initiatives. The project will link community- and provider-stimulated initiatives already underway in these rural areas with research and practice findings regarding successful models of rural heath care delivery, network development, and managed care. The Rural Center will strengthen the capacity of local leaders and procure additional resources and expertise to fully design and implement a vertically integrated network approach for the delivery of managed health care services to rural populations. (Project dates: 9/30/94-9/29/99)

Oklahoma Rural Managed Care Demonstration Center. Edward N. Brandt, Principal Investigator. The Center for Health Policy Research and Development established the Oklahoma Rural Research Center, a multidisciplinary collaborative center, to analyze and evaluate effective characteristics of public-private partnerships that can create and sustain rural health primary care networks. Faculty members of the Center are working with collaborating partners and community demonstration sites to disseminate and apply primary care network principles to improve primary care access for rural Oklahomans. (Project dates: 9/30/94-9/29/99)

For more information, contact:

Carolyn Clancy, MD

Agency for Health Care Policy and Research

2101 East Jefferson Street

Rockville, MD 20852

(301) 594-1357, ext. 1338

cclancy@po3.ahcpr.gov

To obtain a published copy of this document, call 800-358-9295 toll-free or write to:

AHCPR Publications Clearinghouse

P.O. Box 8547

Silver Spring, MD 20907

AHCPR Publication No. 96-0020

January 1996

Source: AHCPR Research About Managed Care Organizations. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. AHCPR Pub. No. 96-0020, Jan. 1996. AHCPR Web Site http://www.ahcpr.gov

Reprinted with permission.

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