Managed care for congestive heart failure: Influence of payer status on process of care, resource utilization, and short-term outcomes, ,

Background Although health maintenance organizations (HMO) are insuring an increasing number of Americans, there are concerns that cost-reduction strategies may limit access to medical care or jeopardize its quality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among patients hospitalized for congestive heart failure (CHF). Methods and Results Administrative information on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of CHF in the principal diagnosis position were obtained from the Statewide Planning and Research Cooperative System database. The following were compared among patients with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-for-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF readmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive procedures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjustment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital charges, the latter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, and highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups. Conclusions Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study. (Am Heart J 1998;136:553-61.)