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Access Equal In For-Profits, Not-For-Profits?

MANAGED CARE February 2004. © MediMedia USA
News and Commentary

Access Equal In For-Profits, Not-For-Profits?

MANAGED CARE February 2004. ©MediMedia USA

Scientific studies sometimes produce surprising conclusions, and one published last month in the New England Journal of Medicine, indicating that for-profit health plans involved in Medicare+Choice provide just as much access to high-cost medical procedures as not-for-profit competitors, certainly did.

The lead author himself was caught off-guard.

"We actually didn't believe it when we first saw the unadjusted numbers," Eric C. Schneider, MD, of the Harvard School of Public Health, tells the Wall Street Journal. "That's why we went to relatively great lengths to prove to ourselves that it wasn't some sort of statistical artifact."

In fact, because their data — derived from HEDIS information on 3.7 million Medicare beneficiaries who were enrolled in 254 health plans in 1997 — held up, health plans may reap some benefit.

One of the goals of the Medicare amendments passed last year is to encourage beneficiaries, as well as health plans, to participate in the program.

The study's findings suggest that beneficiaries could be lured by assurances that they won't get less care by selecting a for-profit insurer.

The authors compared for-profit and not-for-profit rates of cardiac catheterization, coronary-artery bypass graft, percutaneous transluminal coronary angioplasty, carotid endarterectomy, reduction of femur fracture, total hip replacement, total knee replacement, partial colectomy, open cholecystectomy, closed cholecystectomy, hysterectomy, and prostatectomy.

The data were adjusted for sociodemographic case mix and for characteristics of the health plans other than their tax status, including the plans' location.

The authors discovered that the for-profit plans had significantly higher rates than the not-for-profit plans for 2 of 12 procedures — closed cholecystectomy and partial colectomy — and lower rates for none.

The news immediately reverberated through the system because the findings challenge conventional wisdom.

"Fears that for-profit ownership of health plans will lead to unreasonable restrictions on high-cost procedures may not be justified," Schneider suggests.

"On the other hand, our results also raise questions about whether for-profit health plans will be any more effective than not-for-profit plans at controlling health care spending."