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Effects of Cost Containment on the Care of Elderly Diabetics

Effects of Cost Containment on the Care of Elderly Diabetics Abstract Objective. — Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. Design.— — Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. Setting.— The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. Patients. — Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. Results. — Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. Conclusions.—— We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.(Arch Intern Med. 1991;151:2244-2248) References 1. Havlik RJ, Liu MG, Kovar MG, et al, eds. Health statistics on older persons, United States, 1986 . Vital Health Stat 3. June 1987, No. (25) . 2. Weil PA. Comparative costs to the Medicare program of seven prepaid group practices and controls . Milbank Mem Fund Q. 1976;54:339-365.Crossref 3. Greenlick MR, Lamb SJ, Carpenter TM, et al. Kaiser-Permanente's Medicare plus project: a successful medicare prospective payment demonstration. Health Care Financing Rev . 1983;4:85-97. 4. Gillick MR. The impact of health maintenance organizations on geriatric care . Ann Intern Med. 1987;106:139-143.Crossref 5. Iglehart JK. Health policy report: second thoughts about health maintenance organizations for medicare patients . N Engl J Med. 1987;316:1487-1492.Crossref 6. Himmelstein DU, Woolhandler S. The corporate compromise: a marxist view of health maintenance organizations and prospective payment . Ann Intern Med. 1988;109:494-501.Crossref 7. Rossiter LF, Langwell K, Wan TTH, et al. Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations . JAMA. 1989;262:57-63.Crossref 8. Retchin SM, Brown B. The quality of ambulatory care in Medicare health maintenance organizations . Am J Public Health. 1990;80:411-415.Crossref 9. Retchin SM, Brown B. Management of colorectal cancer in Medicare health maintenance organizations . J Gen Intern Med. 1990;5:110-114.Crossref 10. Wilson PWF, Anderson KM, Kannel WB. Epidemiology of diabetes mellitus in the elderly: the Framingham study . Am J Med. 1986;80( (5A) ):3-9.Crossref 11. Harris MI, Hadden WC, Knowler WC, Bennet PH. Prevalence of diabetes and impaired glucose tolerance in U.S. population aged 20-74 years . Diabetes. 1987;36:523-534.Crossref 12. Lipson LG. Diabetes in the elderly: diagnosis, pathogenesis, and therapy . Am J Med. 1986;80( (5A) ):10-21.Crossref 13. Panzam G. Mortality and survival in type 2 diabetes . Diabetologia. 1987;30:123-131.Crossref 14. Agner E, Thorsteinsson B, Eriksen M. Impaired glucose tolerance and diabetes mellitus in elderly subjects . Diabetes Care. 1982;5:600-604.Crossref 15. Leads from the MMWR: premature mortality from diabetes melllitus: use of sentinel health event surveillance to assess causes . JAMA. 1987;257:15-17.Crossref 16. Taylor AK. Medical expenditures and insurance coverage for people with diabetes: estimates from the national medical care expenditure survey . Diabetes Care. 1987;10:87-94.Crossref 17. Kosecoff J, Fink A, Brook RH, et al. General medical care and the education of internists in university hospitals: an evaluation of the Teaching Hospital General Medicine Group Practice Program . Ann Intern Med. 1985;102:250-257.Crossref 18. Fleiss JL. Statistical Methods for Rates and Proportions. New York, NY: John Wiley & Sons Inc; 1981:217-219. 19. Landis RJ, Heyman ER, Koch GG. Average partial association in three-way contingency tables: a review and discussion of alternative tests . Int Stat Rev. 1978;46:237-254.Crossref 20. Diabetes Mellitus, Report of a WHO Study Group . Geneva, Switzerland: World Health Organization; 1985. Technical Report Series, No. 727. 21. Demlo LK, Campbell PM, Brown SS. Reliability of information abstracted from patients' medical records . Med Care. 1978;16:955-1005.Crossref 22. Standards of medical care for patients with diabetes mellitus . Diabetes Care. 1989;12:365-368. 23. Larsen ML, Horder M, Mogensen EF. Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus . N Engl J Med. 1990;323:1021-1025.Crossref 24. Nathan DM, Singer DE, Hurxthal K, Goodson JD. The clinical information value of the glycosylated hemoglobin assay . N Engl J Med. 1984;310:341-346.Crossref 25. Nathan DM. Hemoglobin A1c: infatuation or the real thing? N Engl J Med. 1990;323:1062-1064.Crossref 26. DCCT Research Group. The Diabetes Control and Complications Trial (DCCT): design and methodologic considerations for the feasibility phase . Diabetes. 1986;35:530-545.Crossref 27. Siu AL, Brook RH, Rubenstein LZ. Medicare capitation and quality of care for the frail elderly . Health Care Financing Rev. 1986; (annual suppl):57-63. 28. Hillman AL. Health maintenance organizations, financial incentives, and physician's judgments . Ann Intern Med. 1990;112:891-893.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Effects of Cost Containment on the Care of Elderly Diabetics

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Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1991.00400110094019
Publisher site
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Abstract

Abstract Objective. — Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. Design.— — Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. Setting.— The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. Patients. — Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. Results. — Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. Conclusions.—— We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.(Arch Intern Med. 1991;151:2244-2248) References 1. Havlik RJ, Liu MG, Kovar MG, et al, eds. Health statistics on older persons, United States, 1986 . Vital Health Stat 3. June 1987, No. (25) . 2. Weil PA. Comparative costs to the Medicare program of seven prepaid group practices and controls . Milbank Mem Fund Q. 1976;54:339-365.Crossref 3. Greenlick MR, Lamb SJ, Carpenter TM, et al. Kaiser-Permanente's Medicare plus project: a successful medicare prospective payment demonstration. Health Care Financing Rev . 1983;4:85-97. 4. Gillick MR. The impact of health maintenance organizations on geriatric care . Ann Intern Med. 1987;106:139-143.Crossref 5. Iglehart JK. Health policy report: second thoughts about health maintenance organizations for medicare patients . N Engl J Med. 1987;316:1487-1492.Crossref 6. Himmelstein DU, Woolhandler S. The corporate compromise: a marxist view of health maintenance organizations and prospective payment . Ann Intern Med. 1988;109:494-501.Crossref 7. Rossiter LF, Langwell K, Wan TTH, et al. Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations . JAMA. 1989;262:57-63.Crossref 8. Retchin SM, Brown B. The quality of ambulatory care in Medicare health maintenance organizations . Am J Public Health. 1990;80:411-415.Crossref 9. Retchin SM, Brown B. Management of colorectal cancer in Medicare health maintenance organizations . J Gen Intern Med. 1990;5:110-114.Crossref 10. Wilson PWF, Anderson KM, Kannel WB. Epidemiology of diabetes mellitus in the elderly: the Framingham study . Am J Med. 1986;80( (5A) ):3-9.Crossref 11. Harris MI, Hadden WC, Knowler WC, Bennet PH. Prevalence of diabetes and impaired glucose tolerance in U.S. population aged 20-74 years . Diabetes. 1987;36:523-534.Crossref 12. Lipson LG. Diabetes in the elderly: diagnosis, pathogenesis, and therapy . Am J Med. 1986;80( (5A) ):10-21.Crossref 13. Panzam G. Mortality and survival in type 2 diabetes . Diabetologia. 1987;30:123-131.Crossref 14. Agner E, Thorsteinsson B, Eriksen M. Impaired glucose tolerance and diabetes mellitus in elderly subjects . Diabetes Care. 1982;5:600-604.Crossref 15. Leads from the MMWR: premature mortality from diabetes melllitus: use of sentinel health event surveillance to assess causes . JAMA. 1987;257:15-17.Crossref 16. Taylor AK. Medical expenditures and insurance coverage for people with diabetes: estimates from the national medical care expenditure survey . Diabetes Care. 1987;10:87-94.Crossref 17. Kosecoff J, Fink A, Brook RH, et al. General medical care and the education of internists in university hospitals: an evaluation of the Teaching Hospital General Medicine Group Practice Program . Ann Intern Med. 1985;102:250-257.Crossref 18. Fleiss JL. Statistical Methods for Rates and Proportions. New York, NY: John Wiley & Sons Inc; 1981:217-219. 19. Landis RJ, Heyman ER, Koch GG. Average partial association in three-way contingency tables: a review and discussion of alternative tests . Int Stat Rev. 1978;46:237-254.Crossref 20. Diabetes Mellitus, Report of a WHO Study Group . Geneva, Switzerland: World Health Organization; 1985. Technical Report Series, No. 727. 21. Demlo LK, Campbell PM, Brown SS. Reliability of information abstracted from patients' medical records . Med Care. 1978;16:955-1005.Crossref 22. Standards of medical care for patients with diabetes mellitus . Diabetes Care. 1989;12:365-368. 23. Larsen ML, Horder M, Mogensen EF. Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus . N Engl J Med. 1990;323:1021-1025.Crossref 24. Nathan DM, Singer DE, Hurxthal K, Goodson JD. The clinical information value of the glycosylated hemoglobin assay . N Engl J Med. 1984;310:341-346.Crossref 25. Nathan DM. Hemoglobin A1c: infatuation or the real thing? N Engl J Med. 1990;323:1062-1064.Crossref 26. DCCT Research Group. The Diabetes Control and Complications Trial (DCCT): design and methodologic considerations for the feasibility phase . Diabetes. 1986;35:530-545.Crossref 27. Siu AL, Brook RH, Rubenstein LZ. Medicare capitation and quality of care for the frail elderly . Health Care Financing Rev. 1986; (annual suppl):57-63. 28. Hillman AL. Health maintenance organizations, financial incentives, and physician's judgments . Ann Intern Med. 1990;112:891-893.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 1, 1991

References