Research in Action
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The face of America's medical systems has changed dramatically in
the last decade as private
market forces have transformed how health care is provided and
purchased. Largely in reaction to
spiraling costs, managed care is becoming the dominant health
care delivery system. The number
of Americans in health maintenance organizations (HMOs) is rising
fast, from 15 million in 1984
to more than 50 million today.
Managed care—interdependent systems that integrate the financing
and delivery of health care
services—differ in how they deliver care, ease of access to
care, flexibility in physician choice, and
services covered. Much remains to be learned about the long-term
effects of managed care on
access, cost, and quality of care.
AHCPR—Catalyst for Change
The Agency for Health Care Policy and Research (AHCPR) actively
supports studies of these
rapid changes and is working with the private sector to reach a
consensus on how to increase
quality and accountability in health care.
By providing information on the effectiveness of alternative
systems and management practices
and by spotlighting both successes and problems, AHCPR will help
improve the health care
marketplace. AHCPR is the only Federal agency looking at what
works and what doesn't in the
real world—and at the quality of care received for the almost $1
trillion dollars spent on health
care each year.
Recent AHCPR-supported research provides important insights:
- HMO doctors spent more time with their patients in
one study than fee-for-service
doctors, and their patients received more preventive care, asked
more questions, and were
more involved in treatment planning. Family physicians were
studied at a large HMO and
three fee-for-service groups.
- Managed care patients spent 2 fewer days in an
intensive care unit (ICU) than patients
with fee-for-service health insurance, with the average stay for
managed care patients
costing $8,000 less. There was no difference in mortality or ICU
readmission between the
two groups. Patients were treated in the same teaching hospital
by the same ICU
- HMO patients were hospitalized 40 percent less than
patients with fee-for-service plans
and treated in solo practices. The study of 20,000 persons
examined variations in health
care delivery systems. Patient outcomes findings will be
- Fewer low birthweight infants and cost savings
resulted from a self-help smoking
cessation program for prenatal care patients of Maxicare Health
Plans, a large HMO.
Women in the program were 45 percent less likely to give birth to
low birthweight infants.
More than $3 in medical costs were saved for every $1 spent.
- Group practice outpatient clinic patients had shorter
stays and incurred lower costs at
a Cleveland hospital, but received the same quality of care as
traditional clinic patients at
- Chronically ill patients in managed care plans had
better access to care than patients in
fee-for-service plans, but their care was not as comprehensive,
they waited longer for care,
and physician-patient continuity was less in a study of 1,200
patients in three cities.
Research Under Way
AHCPR is studying issues critical to finding out what works
- Switching Medicaid beneficiaries to managed care and
the effect on access to health
services is being studied in Washington State. The number of
Medicaid recipients in
managed care plans doubled in 1994.
- Impact of continuous quality improvement on delivery
of preventive services at
primary care clinics is being investigated at two managed care
organizations in Minnesota.
- Effect of specialty training on primary care
practice is being studied at Kaiser
Permanente of Northern California. Factors being studied include
the number of tests
ordered and other services used, patient outcomes, and
- Adequacy of followup of patients with abnormal
screening mammograms is being
studied at the Henry Ford Health System in Detroit.
- Compliance with guidelines for pediatric preventive
care and cancer screening and the
impact of incentives are being investigated in two studies at a
Medicaid HMO in
- Methods of pain management of primary care doctors
are being studied to determine
if they are associated with different risks of dysfunctional
chronic pain among patients
with back pain and headache at Group Health Cooperative of Puget
New Rural Research
By many measures, rural populations are in poorer health than
most nonrural groups. In a major
initiative, AHCPR has awarded five grants to support innovative
demonstrations of health care
delivery in five States. Many important innovations—such as
managed care—are often unavailable
in rural areas:
Goals of the initiative include:
- Promoting establishment of managed care institutions
and development of rural health
networks. These efforts should lay groundwork for planning future
statewide or regional
managed care systems to enhance access to rural health
- Demonstrating how to improve rural care through
innovations in the organization,
financing, and delivery of health care services. In a project
with a rural hospital alliance,
participants may use the Oklahoma Telemedicine Network and its
center to improve access to health care services.
- Implementation of AHCPR guidelines is being studied
at HMOs in Oregon and
Washington State. Studies are assessing the effectiveness of
working with clinical opinion
leaders and of continuous quality improvement as interventions
that may promote
incorporation of guidelines into daily practice.
- Scripps Clinic, an integrated medical network, gives
the Consumer Version of
AHCPR's acute pain management guideline to elective surgery
patients. Each year 2,000
patients are trained to use the guideline's pain intensity scale,
which helps staff manage
postsurgical pain effectively.
Studying health care markets is a major focus of AHCPR
- A year-long AHCPR nationwide survey will estimate health
care and out-of-pocket family
costs for persons with managed care plans. The Third National
Survey will also estimate how many people have managed care
- Analyses that examine how changes in market structures have
affected the way health care
providers produce and market care and the price, distribution,
and quality of services
available will be supported by a new initiative. Collaborative
research with managed care
organizations is encouraged.
- Appropriate use of specialists by managed care
organizations will be the subject of a
conference now being planned.
Kaiser Permanente (Anaheim) drew directly on an AHCPR
guideline when revising its pain
management practices. Referring to surgery patients below age 5
who benefit from the
recommended preventive approach of pain management, Kaiser
anesthesiologist Dr. Nathan
Mann says, "The children are not crying and screaming in agony
Intermountain Health Care tested the AHCPR pressure ulcer
prevention guideline in 1 of its
24 hospitals for 6 months and found it reduced the incidence of
pressure ulcers significantly,
saving the system $240,000. The Salt Lake City-based health care
system is implementing the
guideline in its 23 other hospitals.
AHRQ, a part of the Department of Health and Human Services, is
the lead agency charged with
supporting research designed to improve the quality of health
care, reduce its cost, and broaden
access to essential services. AHRQ's broad programs of research,
clinical guideline development,
and technology assessment bring practical, science-based
information to medical practitioners and
to consumers and other health care purchasers.
AHCPR Publication No. 96-P045
Current as of June 1996