Access to Preventive Health Services Better in HMOs

Cathy Tokarski

July 29, 2003

July 29, 2003 — Individuals with less than a high-school education had better access to preventive health services if they were enrolled in a health maintenance organization (HMO) compared with more highly educated individuals who were not members of an HMO, a new study finds. In particular, HMO enrollees with less than 12 years of education had the highest use of smoking cessation counseling of any cohort, regardless of educational level or HMO membership.

The findings, reported in the July/August 2003 issue of the Annals of Family Medicine, underscore the important role that educational levels play in determining access to healthcare services, according to lead author Kevin Fiscella, MD, MPH. "Our suspicion is that education is a proxy for health literacy," said Dr. Fiscella, a professor in the Departments of Family Medicine and Community Medicine at the University of Rochester in Minnesota. "Within a system where costs are not a primary limiting factor, like a managed care system, we tend to see that education actually is becoming as powerful a factor as income in determining access to healthcare."

And as the federal government works to reduce healthcare disparities as part of its Healthy People 2010 initiative, public and private insurers should "provide incentives to reward HMOs that make progress in reducing disparities," he added.

In a cross-sectional analysis of the 1996-1997 Community Tracking Study Household Survey among adults between 18 and 64 years old with private insurance or Medicaid, researchers examined the interactions between educational levels and HMO membership for six measures. They were (1) having a regular source of care; (2) physician visit in the past year; (3) a mental health visit; (4) a mammogram for women older than 50 years; (5) an influenza vaccine for individuals older than 55 years; and (6) smoking cessation counseling for individuals who smoke.

Overall, patients with less than 12 years of education received better access to preventive care if they were enrolled in an HMO compared with those of the same educational level not in an HMO, the study found. More than half (54.3%) of HMO enrollees received smoking cessation counseling compared with 44.9% of non-HMO enrollees who had less than a high-school education. Among those with more than 16 years of education, 41.9% of those enrolled in an HMO received smoking cessation counseling compared with 46.8% of patients outside of an HMO, the study found.

Yearly influenza vaccinations, another preventive service measured in the study, was also higher for those with less than a high-school education enrolled in an HMO (31.7%) than for those with the same level of education but not in an HMO (25.3%). However, 47.3% of HMO enrollees with more than 16 years of education had a flu vaccine compared with 37% of non-HMO enrollees with the same educational level.

A limitation of the study, the authors note, is its reliance on five-year-old data at a time when the managed care industry has undergone rapid transformation from strict HMO gatekeeper models to less restrictive preferred provider organizations, or PPOs. "We're starting to blur the distinctions between managed care and nonmanaged care," noted Dr. Fiscella. "It's hard to find a true fee-for-service [system] that doesn't make any effort to manage the care of its enrollees," he said.

At the same time, however, the findings underscore the positive value of public reporting of health plan performance on healthcare quality, according to Dr. Fiscella. This effort has been spearheaded by the National Committee for Quality Assurance (NCQA) in Washington, D.C., and endorsed by major business groups like the Leapfrog Group, state Medicaid health plans, and private payers. "Any type of healthcare delivery system that tracks and publicly reports their own performance is likely to do better," Dr. Fiscella said.

NCQA spokesman Barry Scholl agreed with that assessment. "This study validates what NCQA has been saying for the past six years — health plans that make an effort to manage the care of their patients, and that commit themselves to public reporting, can have a significant impact on members' lives," he said.

"The challenge is going to be maintaining public pressure for that kind of accountability as     health plan models become less managed," Mr. Scholl added.

Ann Fam Med. 2003;1(2):90-96

Reviewed by Gary D. Vogin, MD


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