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We agree with Dr Schiff that our finding of a reduced rate of nondiscretionary medical admissions in the HMO should not be ignored. However, possible explanations for the result similarly should not be ignored. As we report in our article, we tried to identify why there were fewer nondiscretionary hospitalizations in the HMO. One striking result was that the HMO sample did not have any hospitalizations for chemotherapy. The HMO may have substituted ambulatory services (eg, chemotherapy) for some of the hospitalizations that were considered nondiscretionary by our physician reviewers. Other explanations are discussed in the original article.On the other hand, we found that the HMO did not reduce the rate of nondiscretionary surgical admissions. Dr Schiff suggests that this may have been because the need for emergency surgery (eg, trauma-related or acute abdominal surgery) was beyond the control of the HMO. We found, however, that only
Siu AL, Brook RH, Leibowitz A, Newhouse JP. Use of the Hospital in a Randomized Trial of Prepaid Care-Reply. JAMA. 1988;260(3):338. doi:10.1001/jama.1988.03410030054015