Managed Care Features and Chronic Conditions

Effects on Quality of Care and Patient Outcomes

Millions of chronically ill Americans depend on managed care plans for their care. Seven research teams have been awarded grants to investigate features of managed care that may affect the quality, outcomes and satisfaction with care for chronic conditions.

Millions of chronically ill Americans depend on managed care plans for their care. Seven research teams have been awarded grants to investigate features of managed care that may affect the quality, outcomes and satisfaction with care for chronic conditions.

Introduction

In 1998, the Agency for Healthcare Research and Quality (AHRQ), the American Association of Health Plans Foundation (AAHPF), and the Health Resources and Services Administration (HRSA) awarded seven research teams over $10 million to investigate the effects of various features of managed care on the outcomes of care and satisfaction with care for chronically ill patients. These features included:

  • Protocols governing the referral of patients to medical specialists.
  • Arrangements for paying physicians.
  • The use of guidelines for effective care.

The 7 teams based their research on new survey data and patient records from physicians, mangers and patients in 32 health plans, including industry giants such has United Healthcare, Kaiser Permanente and Harvard Pilgrim Health Plan. Government-sponsored programs in 5 states and 50 medical group practices affiliated with Pacific Business Group on Health participated in the studies.

Research Teams and Projects

Principal Investigator: Jose Escarce, M.D., Ph.D.
Institution: RAND, Santa Monica, CA.
Project Description: Examine the care given to working-age members of seven United Health Care plans in different parts of the country for diabetic retinopathy and open-age glaucoma—two leading causes of blindness.

Principal Investigator: Edward Guadagnoli, Ph.D.
Institution: Harvard Medical School, Cambridge, MA.
Project Description: Examine care for diabetic and hypertensive patients enrolled in three large heath plans with numerous medical clinics and offices in the Minneapolis-St.Paul area.

Principal Investigator: Katherine Kahn, M.D.
Institution: University of California, Los Angeles
Project Description: Analyze quality of care provided to patients with chronic heart and lung diseases by 58 group practices serving companies who belong to the Pacific Business Group on Health.

Principal Investigator: Tracy Lieu, M.D.
Institutions: Harvard Pilgrim Health Plan and Harvard University, Cambridge, MA.
Project Description: Examine the quality of care given to asthmatic children enrolled in Medicaid managed care plans in California, Massachusetts, and Washington State.

Principal Investigator: Barbara McNeil, M.D.
Institution: Harvard Medical School, Cambridge, MA.
Project Description: Focus on members of four large health plans after hospital treatment for heart attack, congestive heart failure or hypertension.

Principal Investigator: Elizabeth Shenkman, Ph.D.
Institution: University of Florida, Gainesville, FL.
Project Description: Study the quality of care for low-income children in Florida's Healthy Kids Program who suffer from asthma, diabetes or other chronic diseases. Participating groups include the Health Insurance Plan of Florida, Health Option/Blue Cross-Blue Shield of Florida, Humana, Florida Health Care Plans, Florida First, Physicians' Corporation of America-Family, Jackson Memorial Trust Plan of Florida, Av-Med Health Plan and Physicians' Health Plan.

Principal Investigator: Bruce Stuart, Ph.D.
Institution: University of Maryland, Baltimore, MD.
Project Description: Assess changes in treatment and outcomes for asthmatic children covered by Medicaid after statewide mandatory enrollment in managed care plans began in 1998.

These studies are part of a broad AHRQ effort to build a foundation of scientifically sound evidence that can be tapped to inform public policy and system decisions related to the quality of care.

Publications and Findings

Authors: Jensvold NG, Lieu TA, Chi FW, Capra AM, Sisk C.
Title: Strategies for surveying families of Medicaid-insured children by telephone.
Publication: J Health Care Poor Underserved 14:17-22.
Date: 2003.

Authors: Farber HJ, Capra AM, Finkelstein JA, Lozano P, Quesenberry CP, Jensvold NG, Chi FW, Lieu TA.
Title: Misunderstanding of asthma controller medications: Association with nonadherence.
Publication: J Asthma 40(1):17-25.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Lieu TA, Lozano P, Finkelstein JA, Chi FW, Jensvold NG, Capra AM, Quesenberry CP, Selby JV, Farber HJ.
Title: Racial/ethnic variation in asthma status and management among children in managed Medicaid.
Publication: Pediatrics 109(5):857-65.
Date: 2002.
Abstract: Select for PubMed® abstract.

Authors: Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA.
Title: Underuse of controller medications among Medicaid-insured children with asthma.
Publication: Arch Pediatr Adolesc Med 156(6):562-7.
Date: 2002.
Abstract: Select for PubMed® abstract.

Authors: Dudley RA, Landon BE, Rubin HR, Keating NL, Medlin C, Luft HS.
Title: Assessing the relationship between quality of care and the characteristics of health care organizations.
Publication: Med Care Res Rev 57(Suppl 2):116-35.
Date: 2000.
Abstract: Select for PubMed® abstract.

The following articles were published in a special section of Health Services Research in December 2003:

Authors: Luft HS, Dudley RA.
Title: Measuring quality in modern managed care.
Publication: Health Services Research 38(6 Part 1):1373-79.
Date: 2003.

Authors: Keating NL, Landrum MB, Landon BE, Ayanian JZ, Borbas C, Guadagnoli E.
Title: Measuring the quality of diabetes care using administrative data: is there bias?
Publication: Health Services Research 38(6 Part 1):1529-45.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Stuart B, Singhal PK, Magder LS, Zuckerman IH.
Title: How robust are health plan quality indicators to data loss? A Monte Carlo simulation study of pediatric asthma treatment.
Publication: Health Services Research 38(6 Part 1):1547-61.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Lozano P, Grothaus LC, Finkelstein JA, Hecht J, Farber HJ, Lieu TA.
Title: Variability in asthma care and services for low-income populations among practice sites in managed Medicaid systems.
Publication: Health Services Research 38(6 Part 1):1563-78.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Kahn KL, Liu H, Adams JL, Chen WP, Tisnado DM, Carlisle DM, Hays RD, Mangione CM, Damberg CL.
Title: Methodological challenges associated with patient responses to follow-up longitudinal surveys regarding quality of care.
Publication: Health Services Research 38(6 Part 1):1579-98.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Shenkman E, Wu SS, Nackashi J, Sherman J.
Title: Managed care organizational characteristics and health care use among children with special health care needs.
Publication: Health Services Research 38(6 Part 1):1599-624.
Date: 2003.
Abstract: Select for PubMed® abstract.

Authors: Adams JL, Wickstrom SL, Burgess MJ, Lee PP, Escarce JJ.
Title: Sampling patients within physician practices and health plans: multistage cluster samples in health services research.
Publication: Health Services Research 38(6 Part 1):1625-40.
Date: 2003.
Abstract: Select for PubMed® abstract.

Topics Under Investigation and Contacts

In addition to the work completed, each research team continues to produce findings. For more information about ongoing work, see contact information below.

Effect of Health Plans on Hypertension and Diabetes Care

This project examines the association between the features of three health plans (Allina, U-Plan, and Preferred One) in the Twin Cities area of Minneapolis/St. Paul and the quality of care provided to patients with hypertension and diabetes. Some plans have multiple product lines and the study will make use of the actual coverage for each patient studied. The investigators have identified four broad features of managed care for study: financial arrangements for providers; care management strategies; care delivery methods; and cost-sharing by patients. Researchers are conducting analyses to identify relationships between plan characteristics, provider group characteristics, and quality of care.

Contact: Edward Guadagnoli, Ph.D.
Institution: Harvard Medical School
E-mail: guadagnoli@hcp.med.harvard.edu

Quality of Care Under Varying Features of Managed Care Organizations

This study supplements three existing sources of data due to previous work of the project team with the Pacific Business Group on Health (the 1996 baseline Physician Value Check Survey, the 1998 followup Physician Value Check Survey, and the 1996 baseline Medical Groups/IPA Survey). Two new sources of data are the 1998 Medical Group/IPA Survey and the 1999 Medical Record Abstraction. There are about 58 medical groups participating in this study. Based on patient self-reports at the baseline survey, four health conditions (selected from hypertension, diabetes, heart disease, chronic lung disease, extremity use limitations, or chronic back pain) are targeted. Researchers are examining seven general hypotheses about the relationships between patient and medical group characteristics and patient and medical group processes and outcomes.

Contact: Katherine L. Kahn, M.D.
Institution: University of California-Los Angeles
E-mail:kkahn@mednet.ucla.edu

Quality of Chronic Eye Care Under Managed Care

This study deals with care for working age patients with diabetic retinopathy (DR) and primary open angle glaucoma (POAG). DR and POAG are the leading causes of blindness among working-age people. Researchers are studying the following features of managed care organizations: patient cost sharing, type of eye provider, provider payment method, practice arrangement, and use of quality assurance techniques. The hypotheses of the study deal with the impact of plan features on the process of care in relation to The American Academy of Ophthalmology guidelines, intermediate outcomes, visual performance, quality of life, patient satisfaction, and utilization.

Contact: Jose Escarce, Ph.D, M.D.
Institution: RAND
E-mail: escarce@rand.org

Financial Incentives and Care of Chronic Cardiac Patients

This study merges information collected from an ongoing AHRQ-funded study to develop new performance measures for patients with acute myocardial infarction, congestive heart failure, and hypertension with additional information about financial incentives and managerial practices of the medical groups caring for same patients. The study involves patients enrolled in large health plans in six different sites in the U.S. The three aims of the project are to:

  • Develop an approach for characterizing the influence of financial incentives on clinical decisionmaking.
  • Develop an approach for characterizing the impact on clinical decisions of two management strategies (use of information [e.g., guidelines, physician profiles] and use of clinical teams and adjunct clinical personnel).
  • Determine the extent to which financial incentives and management strategies influence accepted patterns of care, as measured by specific clinical performance measures.

Contact: Barbara McNeil, M.D.
Institution: Harvard Medical School
E-mail: mcneil@hcp.med.harvard.edu

Quality of Care for Children with Special Needs in Managed Care

The primary focus of this study is on children with special health care needs (CSHCN) enrolled in nine managed care organizations that are participating in the Florida Healthy Kids Program, a statewide initiative designed to provide coverage to uninsured children who are not Medicaid eligible and whose parents cannot afford private insurance. Secondarily, researchers are assessing the processes and outcomes of care for CSHCN who are enrolled in the Florida Medicaid Program or in one of five different commercial managed care organizations.

Contact: Elizabeth Shenkman, Ph.D.
Institution: University of Florida
E-mail: eas@ichp.edu

Quality of Care for Children with Special Needs in Managed Care

This is a multi-site study of the quality of care delivered to asthmatic children (ages 2 to 17 years) who are enrolled in Medicaid managed care programs in California, Massachusetts, and Washington. Three major provider organizations are involved: Kaiser Permanente, Harvard Pilgrim Health Care and Group Health Cooperative of Puget Sound. Researchers are studying children with asthma prospectively for 1 year. The features of the nine managed care organization sites within these three provider organizations enrolling these children include organizational model, empanelment, financial incentives or penalties, provider payment system, barriers to specialty services, provider feedback, and use of disease management programs.

Relevant meeting abstracts:

Authors: Bonomi AE, Lozano P, Hecht J, Grothaus L, Jensvold NG, Capra AM, Lieu TA
Title: Do Medicaid-insured teens and parents agree on health status and quality of care for asthma?
Publication: Pediatr Res 51:178A.
Date: 2002.

Authors: Farber HJ, Lieu TA, Lozano P, Capra AM, Chi F, Jensvold NG, Finkelstein JA.
Title: Parent misunderstanding of role of asthma medication in a Medicaid managed care population.
Publication: Pediatr Res 47:477A.
Date: 2000.

Contact: Tracy A. Lieu, M.D.
Institution: Harvard Pilgrim Health Care
E-mail: tracy_lieu@harvardpilgrim.org

Impact of Managed Care Organization Policy on Quality of Pediatric Asthma Care

This study investigates the impact of selected managed care organizational policies on the quality of treatment and health outcomes for Medicaid-enrolled children with asthma in the state of Maryland. The study sites include nine managed care organization plans that participate in the Maryland Medicaid HealthChoice Program, which was implemented in November 1997. The managed care organizations vary in terms of policies whose effect may be to either enhance or impede the delivery of high-quality care for this population group. The aims of the study are:

  • To determine the impact that transition from fee-for-service to managed care has on quality of asthma treatment.
  • To assess the specific impact of exposure to restrictive and enabling managed care organization policies on pediatric asthma patients.

Relevant meeting abstract:

Authors: Zuckerman IH, Stuart B, Magder LS, Bollinger ME, Weiss SR.
Title: Adherence to asthma treatment guidelines among children in the Maryland Medicaid program.
Publication: Current Therapeutic Research, Clinical and Experimental 61:912-24.
Date: 2000.

Contact: Bruce Stuart, Ph.D.
Institution: University of Maryland, Baltimore.
E-mail: Bstuart@rx.umaryland.edu

Current as of May 2004
Internet Citation: Managed Care Features and Chronic Conditions: Effects on Quality of Care and Patient Outcomes. May 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/managed/mcofeat/index.html