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Letters
August 16, 2000

Managed Care Insurance and Use of Higher-Mortality Hospitals

Author Affiliations
 

Stephen J.LurieMD, PhD, Contributing EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(7):829-831. doi:10.1001/jama.284.7.827

To the Editor: Dr Erickson and colleagues1 concluded that patients with managed care insurance were less likely than those with fee-for-service (FFS) insurance to undergo coronary artery bypass grafting (CABG) at hospitals with lower mortality rates. However, the data in Table 1 of their article provide evidence that CABG inpatient mortality rates among patients enrolled in managed care plans are equal to or better than mortality rates among those in non–managed care plans. The authors minimize this central finding because they focus on the likelihood of using "lower-mortality hospitals," a very difficult metric to interpret.

Hospital use does not necessarily represent insurer contracting decisions. Indeed, Erickson et al did not determine which hospitals managed care organizations did or did not typically contract with. Rather, they contrasted hospital choices of physicians for very dissimilar patient populations. Given the lower mortality rates among individuals in managed care organizations compared with those with FFS insurance, it is apparent that the hospitals used for CABG were very effective for managed care patients but not as effective for patients with FFS insurance.

A survey of more than 2000 consumers conducted by the Kaiser Family Foundation and the Agency for Health Care Policy and Research found that a majority of consumers (72%) would choose a hospital that is familiar to them over a hospital rated higher in quality by experts.2 The same survey concluded that an individual's regular physician has the most influence over the patients' choice of hospital. Patients choose local practitioners for convenience, and those practitioners have privileges at local hospitals.

Erickson et al did not consider several confounding variables for the classification of hospitals as high or low mortality. However, the demographic compositions of managed care and non–managed care populations were quite different based on the criteria used in the model. It is likely that additional confounding variables were overlooked. For example, Erickson et al acknowledge that patients in the study were more likely to choose a hospital they classified as a "higher-mortality hospital." In addition, the methods used to control for travel distance to hospitals were inadequate.

References
1.
Erickson  LCTorchiana  DFSchneider  ECNewburger  JWHannan  EL The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery.  JAMA. 2000;283:1976-1982.Google Scholar
2.
 Consumers value information on quality when selecting doctors and health plans.  Med Practice Communicator. 1997;4:3.Google Scholar
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