Selection Bias in HMOs: A Review of the Evidence

Hellinger, Fred J.; Wong, Herbert S.

doi:10.1177/107755870005700402

Cited by 81 publications

(68 citation statements)

References 20 publications

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“…9 Patient selection may also account for the higher turnover rate by HMO enrollees, because patients who have formed strong relationships with their physicians are less likely to join a managed care plan. 39 These findings are largely consistent with other local and regional studies that compare the primary care experience of HMO and FFS users. Using a random sample of consumers in a defined geographic area of Washington, DC, Starfield et al found that comprehensiveness as measured by services available was reported to be significantly better by consumers associated with facilities that were primarily capitated than by consumers whose facilities were primarily FFS.…”

Section: Discussionsupporting

confidence: 81%

“…20,22 While an HMO improves access to care for those previously without it, [41][42][43] HMO enrollees have greater difficulty gaining access to care than enrollees in traditional FFS health plans. 39 Safran et al 22 also found diminished organizational access for HMO patients. The organizational barrier could be the result of oversubscription by the physicians or of negative incentives to see capitated patients.…”

Section: Discussionmentioning

confidence: 99%

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Type of health insurance and the quality of primary care experience

Shi

2000

Am J Public Health

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OBJECTIVES: This study examined the association between type of health insurance coverage and quality of primary care as measured by its distinguishing attributes--first contact, longitudinality, comprehensiveness, and coordination. METHODS: The household component of the 1996 Medical Expenditure Panel Survey was used for this study. The analysis primarily focused on subjects aged younger than 65 years who identified a usual source of care. Logistic regressions were used to examine the independent effects of insurance status on primary care attributes while individual sociodemographic characteristics were controlled for. RESULTS: The experience of primary care varies according to insurance status. The insured are able to obtain better primary care than the uninsured, and the privately insured are able to obtain better primary care than the publicly insured. Those insured through fee-for-service coverage experience better longitudinal care and less of a barrier to access than those insured through health maintenance organizations (HMOs). CONCLUSIONS: While expanding insurance coverage is important for establishing access to care, efforts are needed to enhance the quality of primary health care, particularly for the publicly insured. Policymakers should closely monitor the quality of primary care provided by HMOs.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Type of health insurance and the quality of primary care experience

Shi

2000

Am J Public Health

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“…We adjusted mortality rates for age, sex, and comorbidity, however, and patients belonging to an HMO were usually found to be healthier than patients with FFS insurance. 42,43 We found, though, that patients with commercial HMO insurance and those with commercial FFS insurance had similar measures on the Charlson-Deyo comorbidity index. We did not have detailed information on the specific types or intensities of treatments received, nor on the overall quality of care rendered, so it is also possible that the health care that FFS and HMO patients received differed in other important ways not captured by our study.…”

Section: Discussionmentioning

confidence: 58%

Effects of health insurance and race on colorectal cancer treatments and outcomes

Roetzheim

Pal²,

Gonzalez³

et al. 2000

Am J Public Health

214

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OBJECTIVES: We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer. METHODS: We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n = 9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality. RESULTS: Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR = 1.44; 95% CI = 1.06, 1.97; P = .02), and uninsured (RR = 1.41; 95% CI = 1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR = 1.18; 95% CI = 1.01, 1.37; P = .04) than non-Hispanic Whites. CONCLUSIONS: Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among non-Hispanic African American patients.

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“…As a result, this plan may have been more attractive to those SSI beneficiaries who had been using specialty providers in the past or who anticipated needing easy access to such providers in the future. Numerous studies have found that plans with rigid gatekeeping systems have favorable selection (Hellinger 1995).…”

Section: Factors Likely Affecting Choice and Risk Selectionmentioning

confidence: 99%