April 2002

Grant Results

SUMMARY

From 1997 to 2000, researchers from the University of California, Los Angeles, School of Medicine conducted a study to compare the care received by Medicare patients with diabetes in fee-for-service to that received by patients in managed care health plans.

Investigators focused on differences in the quantity and quality of care received and whether differing financial arrangements between physicians and health plans influenced the kind of care patients receive.

Key Results
Based on unpublished analyses, the investigators concluded that:

  • There were few differences in quality of care between Medicare patients with diabetes in fee-for-service and those in managed care plans.
  • There were no differences between the two groups in the frequency of blood sugar measurement and eye and foot examinations.
  • Managed care patients, however, were less likely than fee-for-service patients to have had their cholesterol measured.
  • Within managed care, certain vulnerable groups — including persons over 75 years of age, women and those with lower incomes — were less likely to receive needed care and indicated medications.
  • Among the physician groups surveyed, financial and organizational structures varied widely, with capitated contracts being most common in Northern California and least common in the Pacific Northwest.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $162,084.

 See Grant Detail & Contact Information
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THE PROJECT

Little is known about the impact of managed care on Medicare patients, particularly those with chronic health conditions.

Under this grant, the investigators examined whether there are differences in the quantity and quality of care received by Medicare patients with diabetes in fee-for-service and for those in managed care plans that reimburse physicians through capitated payments (a fixed fee for each patient in the plan, regardless of the care provided). They also examined whether differing financial arrangements between physicians and health plans influence the kind of care patients receive.

The study built upon another RWJF-supported study (under the Generalist Physician Faculty Scholars Program, ID# 029250) by the principal investigator, which examined access to vision services among Medicare patients in fee-for-service and managed care plans. That study found that the overall rate of geriatric eye care is lower than national guidelines for both fee-for-service and managed care Medicare patients. But fee-for-service Medicare patients had significantly more dilated eye exams, better visual functioning, and a more favorable perception of care than did managed care Medicare patients.

In the study funded under this grant, investigators aimed to:

  1. Determine whether Medicare patients with diabetes have different rates of access to and use of medical services in fee-for-service plans and managed care plans.
  2. Compare markers of the quantity of care, such as frequency of blood sugar monitoring, and quality of care, such as the proportion of patients with good blood sugar control.
  3. Assess whether persons with diabetes in capitated plans have greater visual disability because of lack of cataract treatment.
  4. Determine whether race, ethnicity, or socioeconomic status are independently associated with care and functional status in capitated and fee-for-service settings.

The investigators interviewed by telephone 494 managed care and 230 fee-for-service Medicare patients with diabetes and conducted clinical examinations of 306 patients in the managed care group and 106 patients in the fee-for-service group. They also surveyed 54 out of 57 medical directors in physician groups that provide the majority of managed care in California and the Pacific Northwest.

The survey examined the structural characteristics and financial arrangements between primary care physicians, specialists, and health plans to assess their effects on the content and quality of care provided to diabetics.

Other support for the study came from the RWJF Generalist Physician Faculty Scholars Program Award (ID# 029250, mentioned above) to Dr. Mangione, an RWJF Minority Medical Faculty Development Program award (ID# 038561) and an Agency for Healthcare Research and Quality National Research Service Award to co-investigator Arleen F. Brown, M.D., Pacific Business Group on Health, a non-profit employer health care coalition based in San Francisco, Calif., funded the fielding of the physician survey.

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RESULTS

Data analysis was still underway as of late 2000, but the investigators have reported the following results to RWJF:

  • There was no difference in quality of care for patients with diabetes between managed care and fee-for-service in five of the six quality indicators evaluated. In the year before the study interviews were conducted, managed care and fee-for service patients were equally likely to receive blood sugar tests and eye and foot examinations. In addition, both groups had about the same proportions of patients with good blood pressure and blood sugar control. Managed care patients, however, were less likely than fee-for-service patients to have had their cholesterol measured.
  • Among Medicare managed care patients, race and education were not associated with differences in quality of care, but other non-clinical factors may influence the quality of care received. People over age 75, women, and those with lower incomes were significantly more likely than other groups not to receive needed care for their diabetes.
  • Among Medicare managed care patients, there were differences in the use of indicated medications by age, sex, income, and education. Women received cholesterol-lowering medications more often than men did. Older persons, poorer persons, and those with less education were less likely to receive cholesterol-lowering medications, aspirin, and angiotension converting (ACE) inhibitors.
  • Physician group financial and organizational structures varied widely. Capitated contracts were most common in Northern California and least common in the Pacific Northwest. In the Pacific Northwest, the dominant form of compensation to primary care physicians was some form of fee-for-service; in Northern California, capitation payments were almost twice as common as salary. In Southern California, capitation and salary were almost equally common. Linking these characteristics to patient data will be critical in determining whether physician group characteristics are associated with variations in the quality and outcomes of care.

Communications

The investigators presented abstracts of the study's results at the annual meetings of the Society of General Internal Medicine and the Association for Health Services Research in 1999 and 2000; and at the Hartford Summer Research Program in Aging and the National Research Service Award Trainees Research Conference, both in 1999. (See the Bibliography for details.) They are preparing two manuscripts for publication.

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LESSONS LEARNED

  1. Researchers must rethink how they approach and recruit patients because former methods do not appear to be as effective in the current environment. In earlier studies, investigators succeeded in recruiting a representative sample of older persons by using Medicare claims and enrollment data from the federal Health Care Financing Administration. In the current study, investigators were unable to contact 28 percent of fee-for-service patients identified as potentially eligible for the study, and overall, 33 percent of those contacted declined to participate in the study. The researchers believe two trends contributed to their recruitment difficulties:
    • An increasing proportion of older adults with unlisted phone numbers.
    • The public's heightened concerns about privacy issues.

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AFTER THE GRANT

The investigators continue to analyze the data, including evaluating outcomes such as patient satisfaction and quality of care for subgroups of patients (for example, patients with diabetes-related retinal or peripheral nerve damage), and comparing data from the earlier vision services study against data from this study. Co-investigator Arleen F. Brown, M.D. is using study results in her dissertation. Drs. Mangione and Brown are also co-investigators in a five-year, six-site study of the quality, cost, and outcomes of care received by diabetes patients in managed care, sponsored by the Centers for Disease Control and Prevention.

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GRANT DETAILS & CONTACT INFORMATION

Project

Study of Risk-Sharing's Effect on Access and Quality of Care for Medicare Managed Care Patients with Diabetes

Grantee

University of California, Los Angeles, School of Medicine (Los Angeles,  CA)

  • Amount: $ 162,084
    Dates: November 1997 to January 2000
    ID#:  032072

Contact

Carolyn Mangione, M.D.
(310) 794-7280
cmangione@mednet.ucla.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books and Reports

Mangione CM, Damberg C, Horst M, Castles A and Kahn K. UCLA/PBGS Medical Group and IPA Survey of Financial and Organizational Structure: Final Report. San Francisco, Calif.: Pacific Business Group on Health, March 2000. 60 copies distributed.

Survey Instruments

"UCLA/PBGH Medical Group and IPA Survey of Financial and Organizational Structure." University of California, Los Angeles, PBGH Medical Group, and IPA, fielded July–November 1998.

Presentations and Testimony

AF Brown, "Use of Standardized Questions to Identify Diabetic Persons with Peripheral Neuropathy," at the Annual Meeting of the Association for Health Services Research, June 27–29, 1999, Chicago, Ill.

AF Brown, "Use of Standardized Questions to Identify Diabetic Persons with Peripheral Neuropathy," at the Annual Meeting of the Society of General Internal Medicine, April 29–May 1, 1999, San Francisco, Calif.

AF Brown, "Use of Standardized Question to Identify Diabetic Persons with Peripheral Neuropathy," at the National Research Service Award Trainees Research Conference, June 26, 1999, Chicago, Ill.

AF Brown, "Age- and Gender-Related Differences in the Use of Cardiovascular Evidence-Based Therapies in Older Persons with Diabetes," at the Hartford Summer Research Program in Aging, August 3, 1999, Los Angeles, Calif.

AF Brown, RS Starr, PG Gutierrez, J Adams, RH Brook, MF Shapiro and CM Mangione, "The Influence of Sociodemographic Characteristics on Quality of Care for Medicare Beneficiaries with Diabetes in Managed Care," at the 23rd Annual Meeting of the Society of General Internal Medicine, May 4–6, 2000, Boston, Mass.

AF Brown, AG Gross, PG Gutierrez, J Adams, MF Shapiro and CM Mangione, "Sociodemographic Differences in the Use of Evidence-based Therapies in Medicare Beneficiaries with Diabetes in Managed Care," at the 23rd Annual Meeting of the Society of General Internal Medicine, May 4–6, 2000, Boston, Mass.

CM Mangione, C Damberg, M Horst, A Castles, PR Gutierrez, AF Brown, M Spar, D Carlisle and K Kahn, "Variation by region in the financial and organizational structure of physician groups in California and the Pacific Northwest," at the 23rd Annual Meeting of the Society of General Internal Medicine, May 4–6, 2000, Boston, Mass.

AF Brown, RS Starr, PG Gutierrez, J Adams, RH Brook, MF Shapiro and CM Mangione, "The Influence of Sociodemographic Characteristics on Quality of Care for Medicare Beneficiaries with Diabetes in Managed Care," at the 60th Scientific Sessions of the American Diabetes Association, June 9–13, 2000, San Antonio, Texas.

AF Brown, RS Starr, PG Gutierrez, J Adams, RH Brook, MF Shapiro and CM Mangione, "The Influence of Sociodemographic Characteristics on Quality of Care for Medicare Beneficiaries with Diabetes in Managed Care," at the Association for Health Services Research, June 25–27, 2000, Los Angeles, Calif.

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Report prepared by: Lori De Milto
Reviewed by: Richard Camer
Reviewed by: Janet Heroux
Program Officer: Seth L. Emont

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