Quality in managed care: promise versus reality

More than 1 million Americans will have an acute myocardial infarction this year. Although we have learned a great deal about different treatments that can reduce mortality after myocardial infarction (1), every year thousands of patients are discharged without receiving optimal treatment (2). The data describing these shortcomings in treatment are based primarily on patients being cared for in a traditional fee-for-service environment. Would care for these patients be better or worse if they were enrolled in managed care plans? That is the question addressed by Seddon et al (3) in this issue of The American Journal of Medicine. Previous studies comparing quality of care in managed care and fee-for-service environments have shown mixed results (4,5). In general, simple preventive services, such as immunizations and mammograms, are delivered at higher rates in a managed care environment. Enrollees in managed care plans report less satisfaction with care, however, and experience more difficulty in accessing specialized services. Elderly, poor, and chronically ill enrollees are more likely to experience functional decline. During the past 20 years, we have seen major changes in our health care delivery system. Not only are more people enrolled in managed care plans, but also the nature of managed care plans has evolved. It is imperative that we examine the effects these changes in the health care system have on the care of patients with life-threatening conditions such as myocardial infarction. In this issue, Seddon et al (3) compared treatment for Medicare fee-for-service patients with treatment for similar patients enrolled in Medicare managed care plans. They examined the use of aspirin, angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, and cardiac rehabilitation for patients after myocardial infarction. They found that quality of care, based on drug utilization, was similar in managed care and fee-for-service environments, but patients in managed care were much less likely to receive cardiac rehabilitation. Both of these findings are disconcerting. There is every reason to expect that drug utilization after a myocardial infarction can be better in a managed care setting than in the fee-for-service system. The payment mechanisms in managed care offer the possibility of developing new models of care that can improve the use of effective treatments. Disease management, case management, telephone follow-up, and standardized risk assessments are well suited for managed care but difficult to organize in a fragmented fee-for-service system. The potential for these models to improve care for patients with myocardial infarction was clearly demonstrated in a randomized trial in the Kaiser-Permanente system. In this study, patients enrolled in a case management system had higher rates of smoking cessation, greater exercise capacity, and better control of lipid levels (6). Similar systems are effective for the care of patients with diabetes (8) or heart failure (9). Given the potential for managed care to organize care delivery for high-risk patients, it is disappointing that the managed care organizations in the Seddon study had not found a better way to manage the use of beta-blockers, aspirin, and lipid-lowering agents after myocardial infarction. Unfortunately, we do not know how many, if any, of the 32 managed care organizations participating in the Seddon study had implemented plans to improve care for patients with myocardial infarction. Since 1996, when this study was conducted, there has been substantial growth in the number of managed care organizations implementing disease management programs. Further studies will be needed to determine if these programs enable the managed care industry to address problems that the fee-for-service system has been unable to fix. Since this study was conducted, the managed care industry has faced additional pressures to improve drug use after myocardial infarction. In 1996, the National Committee for Quality Assurance began examining the use of beta-blockers after myocardial infarction as part of its Health Plan Employer Data and Information Set (HEDIS). Between 1996 and 1999, HEDIS reports have documented the increased use of beta-blockers from 62% to 85% among these patients (9). Nevertheless, there is still substantial variation in the use of beta-blockers among health plans. It is unlikely that formulary restrictions would have influenced use of the medications in the Seddon study, because any managed care formulary would make at least one agent available from each of the drug classes included in this study. On the other hand, insurance coverage of medications could have a major effect on drug use. At the time of this study, many Medicare managed care organizations included at least a small pharmacy benefit. One might postulate that drug coverage included in managed care plans would increase the use of beta-blockers and lipid-lowering agents, but the majority of Medicare recipients in the fee-for-service setting also receive pharmaceutical benefits, primarily through plans sponsored by Am J Med. 2001;111:75–76. From the Departments of Preventive Medicine and Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas. Requests for reprints should be addressed to Edward F. Ellerbeck, MD, MPH, Department of Preventive Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, Kansas 661607313.