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Studies examine practices of HMO primary care physicians diabetes care

A well-established group model health maintenance organization (HMO) typically serves hundreds of patients and includes several facilities staffed by primary care physicians (PCPs) who often refer patients to the same specialists. Two recent studies show that the PCPs working in HMOs—family practitioners (FPs), general internal medicine physicians (GIMs), and subspecialist internal medicine doctors (SIMs)—provide similar quality of care and differ little in their use of health resources. These studies, which are summarized here, were supported by the Agency for Health Care Policy and Research (HS08269) and led by Joe Selby, M.D., of the Division of Research, Kaiser Permanente, Northern California.

Grumbach, K., Selby, J.V., Schmittdiel, J.A., and Quesenberry Jr., C.P. (June 1999). Health Services Research, 34(2), pp. 485-502. "Quality of primary care practice in a large HMO according to physician specialty."

There are few differences in the quality of primary care delivered by FPs, GIMs, and SIMs, according to this study. Patients were remarkably similar in their ratings of quality of primary care and satisfaction. They rated GIMS higher than FPs on coordination (adjusted mean scores of 68 vs. 58.4) and slightly higher on accessibility and prevention. They rated GIMs more highly than SIMs on comprehensiveness (adjusted mean scores of 76.4 vs. 73.8). There were no significant differences between specialty groups on a variety of measures of patient satisfaction.

In some settings, practice organization may have more influence than physician specialty on the delivery of primary care, conclude the researchers. In 1995, they surveyed 10,608 patients who visited 60 FPs, 245 GIMs, and 55 SIMs at 13 facilities in the Kaiser Permanente Medical Care Program of Northern California.

Overall, physicians scored much higher on procedurally oriented prevention services, such as flu shots and breast exams, than on health promotion counseling. On average, patients recalled discussing only about half of "lifestyle" health promotion items, such as diet and exercise, with their PCPs. Patients recalled discussing even fewer items of a more social nature, such as their emotional health and sexuality.

Selby, J.V., Grumbach, K., Quesenberry Jr., C.P., and others (June 1999). Health Services Research, 34(2), pp. 503-518. "Differences in resource use and costs of primary care in a large HMO according to physician specialty."

SIMs typically use more medical resources than GIMs and FPs. However, when these primary care physicians practice in the same HMO, these specialty differences are small, concludes this study. It may be that within the same HMO medical group, uniform incentives and a common "culture" reduce or eliminate primary care practice differences, explain the researchers.

They compared the use of resources and costs of health care services provided by these three physician specialties to a group of adult primary care patients in 13 HMO facilities of the Kaiser Permanente Medical Care Program in Northern California in 1995 and 1996. The researchers found that hospitalization rates and inpatient days did not differ between patients of FPs and GIMs after adjusting for patient case mix. Patients of SIMs had 33 percent higher hospitalization rates and 23 more hospital days than patients of GIMs. However, there were no differences in outpatient visits for the three types of primary care physicians. Patients of FPs made slightly fewer primary care visits on average than patients of GIMs and 14 percent fewer visits than patients of SIMs. However, patients of FPs made about 19 percent more urgent care visits than did patients of GIMS. Thus, modest savings from a lower use of four specialty areas (dermatology, psychiatry, gynecology, and orthopedics) by patients of FPs were offset by the more frequent use of urgent care and of other specialty care. However, there was little difference in overall health resource use and total costs among the HMO physicians.

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