Ill Elderly and Poor Fare Worse in HMOs, Study Says
The chronically ill elderly and poor do much worse when they are treated in HMOs than in traditional insurance programs, according to a new study that spells controversy over the headlong shift of Americans into private managed care plans.
In the most comprehensive study of its kind, researchers who tracked the health of 2,235 patients with diabetes, high blood pressure, heart problems and other chronic illnesses found that nearly twice as many elderly patients in HMOs said their health declined over a four-year period.
And only one in five poor patients in HMOs reported improved health after four years, compared with more than half of those in traditional plans.
The study by researchers at Boston’s New England Medical Center followed patients from three cities--Los Angeles, Boston and Chicago--from 1986 to 1990. The results appear in today’s Journal of the American Medical Assn.
HMO officials criticized the study’s methodology and called the findings out of date, arguing that many HMOs have improved treatment of the elderly in the 1990s.
Until now, the bulk of medical research on HMOs has focused on broader groups of patients, most of whom were relatively young and healthy. This is the most complete look at how the chronically ill fare in health maintenance organizations versus traditional fee-for-service plans.
“The health outcomes were significantly worse for chronically ill elderly and poor patients treated in HMOs than in fee-for-service,” said the study’s lead author, John E. Ware, a researcher at the New England Medical Center who also teaches at Harvard and Tufts universities.
Medical researchers “have not been looking at the sick, the elderly and the poor. This is the group for whom health care matters the most. . . . These are vulnerable patients for whom less care is not going to produce a better state of health,” Ware said.
Like many earlier studies, the New England Medical Center researchers found that for the vast majority of people, the medical care provided to HMO members is as good as--and sometimes better than--traditional insurance.
Fee-for-service insurance allows patients a much broader choice of doctors and places fewer restrictions on services. But nearly all experts agree that fee-for-service encourages costly over-treatment by doctors.
The findings are sure to intensify the growing national debate over HMOs and their influence over medicine. About 60 million Americans belong to HMOs, which many see as the best bet to rein in the nation’s soaring health care tab.
Critics contend that HMOs provide financial incentives to doctors to limit medical care to save money, posing potential risks for patients. But proponents say managed care not only can save money by limiting access to doctors and other medical services, but also improve treatment by emphasizing preventive care and reducing unnecessary procedures--such as caesarean births--that sometimes harm patients.
Meanwhile, bipartisan support in Congress has emerged for efforts to encourage more recipients of Medicare--the federal medical program for the elderly and disabled--to join private managed care plans. Likewise, California and other states have been encouraging--and often requiring--low-income Medicaid beneficiaries to enroll in HMOs.
“Congress and the Clinton administration are looking toward HMOs to reduce Medicare costs,” said Steven P. Wallace, an associate professor at UCLA’s School of Public Health. “This study provides compelling evidence that the standards of care in HMOs, at least in the late 1980s, were not as good for the health of older people as it was for the general population.”
Managed care industry officials criticized the study’s methodology, which involved asking patients a series of 36 questions about their health in 1986 and again in 1990. Susan Pisano, a spokeswoman for the American Assn. of Health Plans, an HMO trade group, said medical evaluations should have been part of the study. She noted that the study ended in 1990, contending that HMOs have enhanced care for the elderly and poor since then.
But UCLA’s Wallace said the health questionnaire “is a widely used, well-evaluated and quite sophisticated scale” used in medical research. “It is one of the best indicators we have of mortality and disease.”
Ware agreed that some HMOs may have made strides in improving health care for the elderly and poor since 1990. But he added that “the pressure on these organizations to cut costs was only beginning” in 1990, creating ever-greater incentives to limit care.
HMO spokeswoman Pisano said the new study contradicts some earlier studies that found that the chronically ill do as well in HMOs as in traditional insurance plans. Indeed, this week’s Journal of the American Medical Assn. also includes a study that found rheumatoid arthritis patients in Northern California did just as well in managed care as in fee-for-service.
But Ware said nearly all those studies looked at only one or two medical conditions and tracked patients for only a year or two--too short a period for significant health changes to show up.
In the journal study, 54% of patients 65 and older who were treated in HMOs reported a decline in health, contrasted with 28% of those in fee-for-service plans. Thirty-three percent of poor patients said their health had declined after four years, contrasted with 5% with traditional insurance.
Among HMO patients who were both elderly and poor, 68% reported a decline in health, compared to 27% in fee-for-service.
In the journal report, the pattern of worse outcomes for HMO patients was the same for all the medical conditions studied, in all three cities.
The AMA has often been critical of HMO practices, but an association official Tuesday stressed that the association is “not anti-managed care.”
Ware cautioned that the study results were not an “indictment” of managed care but rather of the idea that what works well for younger, healthier, more well-to-do patients will work just as well for the elderly, poor and chronically ill.
The study’s authors said the findings took six years to report because of the complexity of the research analysis and peer review.
Ware said the study did not attempt to draw conclusions about why patients might have done worse in HMOs. However, he said that the study found that the elderly and poor with chronic conditions who belonged to HMOs were less likely to be treated in hospitals or to see physician sub-specialists, spent less time with doctors during office visits, and received less intensive treatment. For example, he said, patients with diabetes in traditional insurance plans were more than twice as likely to see an endocrinologist as those in HMOs.
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