Access and outcomes of elderly patients enrolled in managed care

Objective. —To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. Design. —A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. Sample. —Stratified random sample of HMO enrollees (n=6476) and comparable sample of FFS Medicare beneficiaries (n=6381). Access and Outcome Measures. —Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. Results. —After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n=2243) were more likely than nonenrollees (n=2009) to have a physician visit (odds ratio OR, 1.19; 95% confidence interval CI, 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n=556) were less likely than nonenrollees (n=524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). Conclusions. —Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied. (JAMA. 1994;271:1487-1492)