Organizational and financial characteristics of health plans: are they related to primary care performance
Department of Quantitative Health Sciences
Medical Subject Headings
Adult; Confounding Factors (Epidemiology); Continuity of Patient Care; Cross-Sectional Studies; Female; Government Agencies; Group Practice, Prepaid; Health Benefit Plans, Employee; Health Maintenance Organizations; Humans; Insurance, Health, Reimbursement; Male; Managed Care Programs; Massachusetts; Middle Aged; Models, Organizational; Primary Health Care; Regression Analysis; State Government
Biostatistics | Epidemiology | Health Services Research
BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data.
OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences.
METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians.
RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05).
CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.
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Citation: Arch Intern Med. 2000 Jan 10;160(1):69-76. Link to article on publisher's site
Safran, Dana Gelb; Rogers, William H.; Tarlov, Alvin R.; Inui, Thomas; Taira, Deborah A.; Montgomery, Jana E.; Ware, John E. Jr.; and Slavin, Charles P., "Organizational and financial characteristics of health plans: are they related to primary care performance" (2000). Quantitative Health Sciences Publications and Presentations. 577.