Tài liệu Differences in 4-Year Health Outcomes for Elderly and Poor, Chronically III Patients

Reprinted from JAMA @ The Journal of the American Medical Association October 2, 1996 Volume 276 Copyright 1996, American Medical Association

Original Contributions

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

John E. Ware, Jr, PhD; Martha S. Bayliss, MSc; William H. Rogers, PhD; Mark Kosinski, MA; Alvin R. Tarlov, MD

Objective.-To compare physical and mental health outcomes of chronically ill

adults, including elderly and poor subgroups, treated in health maintenance orga￾nization (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), re￾cent 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, in￾ternal medicine, endocrinology, cardiology, and psychiatry, in HMO and FFS sys￾tems of care. Types of practices included both prepaid group (72% of patients) and

i ndependent 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-Item 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, de￾clines 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.

JAMA, October 2, 1996-Vol 276, No. 13

JAMA. 1996;276:1039-1047

ENROLLMENTS in health mainte￾nance organizations (HMOs) have in￾creased nearly 10-fold since 1976, and in

some regions of the country, half of pri￾vately insured Americans are enrolled

in HMOs! Policies at the state and fed￾eral levels seek to affect a similar shift

for those who are publicly insured, in￾cluding both Medicare and Medicaid.

Congress has signed legislation that will

give Medicare patients strong financial

incentives to enroll in managed care

plans. Yet, as documented in a recent

literature analysis,' little is known about

health outcomes in HMOs for the elder￾ly and the poor, who have historically

tended to favor fee-for-service (FFS)

over HMO systems.

The Medical Outcomes Study (MOS)

was fielded to compare 4-year health

outcomes for chronically ill patients

treated in well-established HMOs and

FFS plans serving the same "medical

marketplaces" in 3 cities.' To increase

the generalizability of results, adults

with 4 physical conditions (hypertension,

non-insulin-dependent diabetes mellitus

[ NIDDM], recent acute myocardial in￾farction, and congestive heart failure)

and 1 mental condition (depressive dis￾From The Health Institute, New England Medical

Center (Drs Ware, Rogers, and Tarlov, Ms Bayliss, and

Mr Kosinski), Tufts University School of Medicine (Drs

Ware and Tarlov), and Harvard School of Public Health

( Drs Ware and Tarlov), Boston, Mass.

Reprints: John E. Ware, Jr, PhD, The Health Institute,

New England Medical Center, Box 345, 750 Washington

St, Boston, MA 02111 ( e-mail: [email protected])

Chronically III Elderly and Poor Patients-Ware et al 1039