Checking Up on Managed Care
Are Some Insurance Plans Bypassing the Best
By Jeff Levine
WebMD Washington Bureau Chief
April 18, 2000 -- HMO members who need heart bypass surgery are
far more likely than other patients to have the operation done in
a hospital where the death rate is higher than average, a new
study finds. That's particularly true for those covered by a
Medicare HMO, says a study published in the Journal of the
American Medical Association.
While the research doesn't prove that HMOs are steering heart
patients away from better or costlier care, researcher Lars
Erickson, MD, MPH, tells WebMD that there's a "dramatic
difference" between how HMO patients and so-called fee-for-service
patients (those whose insurance pays for every procedure
separately) are referred for treatment. Erickson is a pediatric
cardiologist at Boston's Children's Hospital.
Erickson and colleagues analyzed the medical records of nearly
59,000 patients in New York state who underwent bypass surgery.
New York, Erickson says, has done a "spectacular job" of
collecting information on hospital death rates in an effort to
show doctors and patients which institutions are doing the best
The hospitals were considered to have lower-than-average
mortality rates if 2.1% or less of all patients admitted during
the three-year study period died there; the rates were considered
higher than average if 3.2% or more of the patients died.
HMO members were 23% less likely to get their heart operation
at one of the hospitals with a lower-than-average death rate,
Erickson says. For those in Medicare HMOs, the chance of getting
into one of these hospitals was 39% less than for patients with
One possible explanation for the discrepancy is that HMOs may
simply be getting a better deal from some hospitals to handle
their bypass surgery patients. Other financial incentives may be
at work; HMOs may give the primary care doctors who are
responsible for managing patients' overall health care costs a
price break for steering bypass patients to particular hospitals.
Dollar considerations may also have affected the Medicare HMO
patients, who were virtually excluded from many of the
low-death-rate hospitals surveyed. Hospitals that required
patients to make a sizable copayment could be dropped from an
HMO's list, Erickson says. He couldn't find any significant
difference among the bypass patients or their doctors that would
account for which hospitals the patients were sent to.
At the very least, the findings suggest that patients and
doctors aren't heeding information about medical quality, even in
a place like New York, where the data are considered top notch. "I
think it's tragic," says Erickson. "If patients really don't
consider that kind of information the most important thing on
their list, I think that's fine, but they should at least be aware
of the fact that the information exists."
In fact, quality isn't necessarily what drives patient choice.
"A number of studies indicate that, in general, patients rank
quality information far behind convenience, coverage, access, and
cost in choosing health plans," Stephen Jencks, MD, of the Health
Care Financing Administration, writes in an editorial accompanying
Interestingly, Erickson's research came to the opposite
conclusion of a study done in California: HMO patients there were
more likely to get bypass surgery in a low-death-rate hospital
than were their fee-for-service counterparts. A possible
explanation, Erickson says, is that in California many hospitals
perform only a small number of bypass operations. Low volume is
often considered a marker for lower quality, and thus HMOs may
choose to avoid doing business with such institutions.
On the other hand, New York requires that all hospitals doing
bypass surgery have a high volume, making it ideal for this type
of study. "I don't particularly think the HMOs are being
malicious. I suspect that their response to this will be to say,
'Hey, this is great. Here's something we can do better,'" Erickson
But Laura Diamond, a spokeswoman for the American Association
of Health Plans, an industry group, tells WebMD that the study is
flawed. Diamond says that since the average death rate in New York
hospitals was just 2.44%, the researchers' designation of high-
and low-mortality hospitals was "arbitrary."
"Given the small difference in mortality rates, it's unlikely
that patient outcomes were affected in a significant manner. It's
also not clear if any of the managed care plans limited their
contracts to either high- or low-mortality centers," Diamond
- HMO patients who need heart bypass surgery are more likely
to have the operation in hospitals that have a
higher-than-average death rate than patients with insurance that
pays for each procedure separately.
- Financial considerations may explain why HMO patients do not
get to use the hospitals with the lowest death rates for bypass
surgery, but this study does not prove that.
- One researcher says that information about health care
quality is available and should be sought by patients.
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