Elderly patients with congestive heart failure under prepaid care

Because of concern about the quality of care received by Medicare patients in health maintenance organizations (HMOs), the care of patients with congestive heart failure (CHF) in eight HMOs was compared with the care of fee-for-service (FFS) Medicare cases.

We compared the care of 170 patients with CHF enrolled in one of eight Medicare HMOs with the care of 191 similar FFS patients. Panels of expert physicians developed criteria for evaluating quality of care, and specially trained nurse clinicians abstracted medical records.

Outpatient evaluation and management were similar in both settings, although HMO patients were significantly more likely to be advised to restrict salt intake. However, FFS patients with uncontrolled hypertension were more likely to have their medication regimens changed (62% versus 36%, p less than 0.01). Ejection fractions were obtained equally as often, and inpatient management was similar for both groups. Nonetheless, HMO providers scheduled follow-up visits within 1 week of hospital discharge more often (42% versus 27%, p less than 0.01).

This study suggests that financial incentives of prepaid care are not detrimental to most aspects of care for CHF patients. More rapid follow-up after hospital discharge for patients with CHF suggests that HMOs may be more effective in delivering continuity of care for patients with chronic illness.