Chronically ill patients who are elderly or poor have worse physical health outcomes in HMO's than in fee-for-service systems.

That is one dramatic conclusion from a study of differences in health outcomes among 2,235 patients treated in 1986 and followed through 1990 in HMO's and in fee-for-service systems in three different cities.

Results for mental health outcomes were mixed, varying by study site and patient characteristics.

John Ware, Ph.D., lead author of the article, told Psychiatric News in an interview that for all patients in the study and in both systems, mental health remained stable.

Any improvement over time among patients with a DSM-IV diagnosis of major depression was entirely among nonpoor patients, he said.

The poor did not improve, but remained stable or declined, Ware said.

Nonpoor depressed patients in HMO's improved over the four-year period, though Ware said that this was the result of especially good outcomes in one of the sites.

"One plan in one site really stood out," he said.

Overall mental health outcomes for elderly patients were also better in HMO's than in fee-for-service systems_due entirely, again, to the better performance of HMO's in one of the three study sites.

At the other two sites, mental health outcomes were worse in HMO's for elderly patients than in fee-for-service systems, the authors stated in their article.

The study by Ware and colleagues at the Health Institute of the New England Medical Center appeared in the October 2 Journal of the American Medical Association. Results were drawn from the Medical Outcomes Study (MOS), a four-year observation of variations in practice styles and outcomes for chronically ill patients treated in HMO's and fee-for-service systems in Boston, Chicago, and Los Angeles.

Other studies drawing on the MOS have appeared in the medical literature previously, but the study by Ware and colleagues was the first to analyze outcomes separately for patients 65 or older covered by Medicare and patients who were at or below 200 percent of the federal poverty level.

The results are striking: physical health of poor and elderly patients was more than twice as likely to decline in an HMO than in a fee-for-service system, the authors say.

"[O]ur results sound a cautionary note to policymakers who expect overall experience to date with HMO's to generalize to specific subgroups, such as Medicare beneficiaries or the poor," the authors say.

"An implication for future evaluations of changes in health care policies is that high-risk groups, including the elderly and poor who are chronically ill, should be oversampled when outcomes are monitored to achieve the statistical precision necessary to rule out harmful health effects."

APA President Reacts

APA President Harold Eist, M.D., cited the JAMA study as another indication_"one of many," he said_of the poorer quality of care delivered by HMO's.

Eist said he believes HMO's "cherry pick" and "cream skim," predominantly treating the healthy.

For this reason, he said, HMO's in the past have been able to demonstrate outcomes comparable to those in fee-for-service.

He hailed the study by Ware and colleagues for showing that subgroups such as the elderly and the poor may be vulnerable in HMO's.

Patients included in the study were those with hypertension, non-insulin-dependent diabetes mellitus, recent acute myocardial infarction, congestive heart failure, and depressive disorder. Physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry were included. Types of practice included both prepaid group and independent practice association types of HMO's, large multispecialty groups, and solo or small, single-specialty practices.

Applicable Today?

Are the four-year follow-up results from the study by Ware and colleagues applicable to health policy decisions today?

"If cost-containment pressures have increased since MOS data collection ended in the early 1990's, high-risk patient groups may be at an even greater risk today," the authors say.

However, "[i]f information systems for monitoring and improving the quality of care are better now and if health promotion and disease prevention initiatives are more successful in HMO's, MOS results may not apply to current health care."

Yet Ware and colleagues emphasize that their study adds an important dimension to outcomes research by focusing on specific, potentially vulnerable patient groups rather than drawing conclusions from overall averages.

"The contrast between results reported here for high-risk patients versus results reported previously for the average patient underscores the hazard in generalizing about outcomes on the basis of averages," Ware and colleagues say. "Patient-based assessments of outcomes are likely to add significantly to the evidence used in informing the public and policymakers regarding which health care plans perform best_not just in terms of price, but in overall quality and effectiveness."

"The Public Must Decide. . ."