The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction

doi:10.1016/S0002-9343(01)01098-1

The American Journal of Medicine

Volume 112, Issue 3, 15 February 2002, Pages 176-182

https://doi.org/10.1016/S0002-9343(01)01098-1 Get rights and content

Abstract

Purpose

To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction.

Subjects and methods

We examined the care of 112 900 fee-for-service Medicare beneficiaries aged ≥65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share.

Results

After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care.

Conclusions

Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

Section snippets

Patients

We used data from the Cooperative Cardiovascular Project (8), which includes nearly all Medicare fee-for-service beneficiaries with the principal discharge International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis of acute myocardial infarction (code 410.xx), excluding subsequent care (codes 410.x2), during February 1994 to July 1995. Abstractors employed by independent contractors entered demographic, history, physical examination, hospital course, and

Results

The data set used contained information on 161 962 fee-for-service Medicare patients (aged ≥65 years) with documented myocardial infarction. After excluding patients who resided in rural areas (30%), we determined appropriate treatment and mortality in the remaining 112 900 patients. Patients who resided in areas with high managed care activity were slightly older and less likely to be in Killip class 1 on admission than were patients who lived in low managed care areas (Table 1). Areas with

Discussion

We found differences in the treatment of acute myocardial infarction according to the level of managed care market share. Fee-for-service patients who resided in areas with high managed care market share were more likely to have been treated appropriately with aspirin and beta-blockers, but less likely to have received appropriate coronary angiography than were those who resided in areas with low managed care market share.

There are several mechanisms by which managed care activity could

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Each year, the per capita number of hospitals performing CABG and PCI was higher in states without CON (3.7 per 100 000 elderly for CABG, 4.5 for PCI in 2002), compared with CON states (2.5 for CABG, 3.0 for PCI in 2002). Multivariate regressions that adjusted for market and population characteristics found no difference in CABG utilization rates between states with and without CON (P = .7). However, CON was associated with 19.2% fewer PCIs per 1000 elderly (P = .01), equivalent to 322 526 fewer PCIs for 1989 to 2002. Among most states that discontinued CON, the number of hospitals performing PCI rose in the mid 1990s, but there were no consistent trends in the number of hospitals performing CABG or in PCIs or CABGs per capita.
Certificate of Need restricts the number of cardiac facilities, but its effect on utilization rates may vary by procedure.
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^☆: Dr. Heidenreich is supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Service.

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Clinical studyThe relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction☆

Abstract

Purpose

Subjects and methods

Results

Conclusions

Section snippets

Patients

Results

Discussion

J Clin Epidemiol

J Health Econ

J Am Coll Cardiol

Managed care plan performance since 1980. A literature analysis

JAMA

Association of managed care market share and health expenditures for fee-for-service Medicare patients

JAMA

Managed care and technology diffusionthe case of MRI

Health Aff (Millwood)

Managed care and the growth of medical expenditures

The impact of HMO penetration on the rate of hospital cost inflation, 1985-1993

Inquiry

Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs. fee-for-service insurance

Arch Intern Med

HMO vs fee-for-service care of older persons with acute myocardial infarction

Am J Public Health

Improving the quality of care for Medicare patients with acute myocardial infarctionresults from the Cooperative Cardiovascular Project

JAMA

Circulation

Clinical study
The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction☆