Heterogeneity of Health Maintenance Organizations and Quality of Care

Extract

Medicare beneficiaries have been permitted to enroll in health maintenance organizations (HMOs) ( 1 ) for more than two decades. There are now approximately five million beneficiaries who have enrolled in Medicare HMOs, and the Federal government is exploring new avenues to encourage more of them to join ( 2 ). This effort is principally intended to contain the spiraling costs of the Medicare program. However, there have also been those who have suggested that HMOs may be a more appropriate vehicle than the traditional fee-for-service (FFS) system for delivering health care to the elderly, many of whom find the present system fragmented and uncoordinated. Nonetheless, the merits of managed care for the elderly in either containing costs, or in delivering quality medical care, remain unsettled.

The article by Potosky et al. ( 3 ) in this issue of the Journal examines the process of care and the long-term survival of women with breast cancer in two HMOs and compares them with similar women from the same FFS market areas. The results were notable not only for the comparisons between HMO and FFS care of breast cancer but also for the dissimilarities between the two HMOs. For instance, in San Francisco-Oakland, the 10-year survival rate was substantially better in the HMO than in FFS, while the survival rates were indistinguishable between HMO and FFS in Seattle. Although recommended therapy (i.e., breast-conserving surgery and adjuvant radiotherapy) was more commonly performed in women in both HMOs, the differences were far more dramatic in Seattle. What factors account for these differences in two HMOs with apparently similar roots?