Study: Medicare HMOs discharge to PT less
September 1, 1997 3 minutes read
Study: Medicare HMOs discharge to PT less
Stroke patients in HMOs are discharged to nursing homes more often than fee-for-service stroke patients who tend to be discharged to physical therapy facilities.
That’s the key finding of a recent study comparing about 400 Medicare HMO stroke patients to the same number of fee-for-service patients.1
Whether or not stroke patients in Medicare HMOs receive the physical therapy they need compared to patients in fee-for-service plans is questioned in the study by Sheldon M. Retchin, MD, MSPH, and colleagues. Retchin is a professor at the department of internal medicine at Virginia Commonwealth University in Richmond. Two scientists at Mathematica Policy Research Inc. in Washington, DC, were also on the research team.
In their sample of 402 HMO patients from 12 HMOs and 408 fee-for-service patients in the same geographical area, the research team found that HMO patients were more likely to be discharged to nursing homes and less likely to be sent to physical therapy compared with clinically similar fee-for-service patients following an acute cerebrovascular accident (CVA).
Survival rates were similar in both groups. But the finding raises the question of whether HMO patients are offered resources to improve their quality of life following CVA. Quality of life for stroke patients generally is perceived to be better if they receive physical therapy. Retchin’s study did not measure quality of life but rather basic survival rates.
On the other hand, there is a point at which physical therapy loses its efficacy, which may be why the HMOs reflect this referral pattern, says Wanda Ziemba, senior consultant for Rheinisch Consulting in San Ramon, CA.
"In all sorts of therapy physical, speech, occupational one of the ways you determine whether to refer a patient to therapy is taking a look at how much gain will be realized when the patient undergoes the therapy," Ziemba says. "You don’t put patients in therapy forever. My key question to the insurers whether HMO or fee-for-service is what kind of guidelines do they have for screening the patient for physical therapy. On what do they base their decisions?"
It’s worth watching, experts say, because postacute care for stroke patients can be costly. Given managed care’s incentives to hold down costs, experts need to focus more on whether financial incentives are affecting physical outcomes beyond mortality and toward making improvements in quality of life, Retchin says.
Retchin’s findings do not fit the current situation at St. Jude’s Medical Center in Fullerton, CA. "That hasn’t been our experience across the board at all," says Barry Ross, vice president of rehabilitation and behavioral sciences at the hospital. "We get quite a few referrals from managed care. I think as managed care matures, the insurers have seen the benefits of rehab."
In addition, the hospital is providing an array of community exercise programs to their high-risk insured populations. "We feel if we can stay connected to these people and hear about their problems before they become big, we can save money through preventive measures."
So far, whether it is a matter of maturity in managed care markets as Ross suggests remains to be seen. Prior studies comparing outcomes for patients in HMOs’ care with patients in fee-for-service plans show every range of results from no difference to better outcomes for fee-for-service to better outcomes for HMOs.
Not enough studies have been conducted to draw a firm conclusion, Retchin says. Also, many outcome studies such as his don’t follow patients postoperatively over a long enough period of time and often lack sensitive enough measures to survey the many factors that influence quality of life outcomes.
In addition, the data used in the study came from 1990 medical records. Since then, managed care practices may have changed, the researchers say, although they add that fundamental management principles have not changed. Also, "the findings from this study are consistent with more recent data showing that HMOs provide less home health care and patients fare worse in terms of functional status," the authors write. "The propensity of HMOs to use nursing homes for post-hospital stays is well known, though comparisons with FFS [fee-for-service] settings are scarce."
But St. Jude’s has come a long way toward making rehabilitation in a capitated health care environment a driving influence in Fullerton. "We are working toward establishing a new medical model for the community," says Ross.
Reference
1. Retchin SM, Brown RS, Yeh JS, Chu D, et al. Outcomes of stroke patients in Medicare fee for service and managed care. JAMA 1997; 278:119-124.
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