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Health Serv Res. 1998 February; 32(6): 759–774.
PMCID: PMC1070232

A longitudinal study of hospitalization rates for patients with chronic disease: results from the Medical Outcomes Study.


OBJECTIVE: To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. DATA SOURCE/STUDY SETTING: Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. STUDY DESIGN: A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. DATA COLLECTION/EXTRACTION METHODS: Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. PRINCIPAL FINDINGS: Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. CONCLUSIONS: PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system.

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Selected References

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  • Batalden PB, Nelson EC, Roberts JS. Linking outcomes measurement to continual improvement: the serial "V" way of thinking about improving clinical care. Jt Comm J Qual Improv. 1994 Apr;20(4):167–180. [PubMed]
  • Clement DG, Retchin SM, Brown RS, Stegall MH. Access and outcomes of elderly patients enrolled in managed care. JAMA. 1994 May 18;271(19):1487–1492. [PubMed]
  • Dowd BE, Johnson AN, Madson RA. Inpatient length of stay in Twin Cities health plans. Med Care. 1986 Aug;24(8):694–710. [PubMed]
  • Ellwood PM, Jr, Lundberg GD. Managed care: a work in progress. JAMA. 1996 Oct 2;276(13):1083–1086. [PubMed]
  • Experton B, Ozminkowski RJ, Branch LG, Li Z. A comparison by payor/provider type of the cost of dying among frail older adults. J Am Geriatr Soc. 1996 Sep;44(9):1098–1107. [PubMed]
  • Francis AM, Polissar L, Lorenz AB. Care of patients with colorectal cancer. A comparison of a health maintenance organization and fee-for-service practices. Med Care. 1984 May;22(5):418–429. [PubMed]
  • Gravdal JA, Krohm C, Glasser M. Payment mechanism and patterns of use of medical services: the example of hypertension. J Fam Pract. 1991 Jan;32(1):66–70. [PubMed]
  • Greenfield S, Nelson EC, Zubkoff M, Manning W, Rogers W, Kravitz RL, Keller A, Tarlov AR, Ware JE., Jr Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992 Mar 25;267(12):1624–1630. [PubMed]
  • Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA. 1995 Nov 8;274(18):1436–1444. [PubMed]
  • Kravitz RL, Greenfield S, Rogers W, Manning WG, Jr, Zubkoff M, Nelson EC, Tarlov AR, Ware JE., Jr Differences in the mix of patients among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992 Mar 25;267(12):1617–1623. [PubMed]
  • Luft HS. How do health-maintenance organizations achieve their "savings"? N Engl J Med. 1978 Jun 15;298(24):1336–1343. [PubMed]
  • Manning WG, Leibowitz A, Goldberg GA, Rogers WH, Newhouse JP. A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med. 1984 Jun 7;310(23):1505–1510. [PubMed]
  • Miller RH, Luft HS. Managed care plan performance since 1980. A literature analysis. JAMA. 1994 May 18;271(19):1512–1519. [PubMed]
  • Retchin SM, Brown B. Elderly patients with congestive heart failure under prepaid care. Am J Med. 1991 Feb;90(2):236–242. [PubMed]
  • Retchin SM, Preston J. Effects of cost containment on the care of elderly diabetics. Arch Intern Med. 1991 Nov;151(11):2244–2248. [PubMed]
  • Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware JE., Jr Patients' ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study. JAMA. 1993 Aug 18;270(7):835–840. [PubMed]
  • Stern RS, Juhn PI, Gertler PJ, Epstein AM. A comparison of length of stay and costs for health maintenance organization and fee-for-service patients. Arch Intern Med. 1989 May;149(5):1185–1188. [PubMed]
  • Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA, Ware JE., Jr Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA. 1989 Aug 18;262(7):907–913. [PubMed]
  • Sturm R, Jackson CA, Meredith LS, Yip W, Manning WG, Rogers WH, Wells KB. Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the Medical Outcomes Study. Health Serv Res. 1995 Jun;30(2):319–340. [PMC free article] [PubMed]
  • Tarlov AR, Ware JE, Jr, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA. 1989 Aug 18;262(7):925–930. [PubMed]
  • Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM. Comparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann Intern Med. 1991 Sep 1;115(5):394–400. [PubMed]
  • Ware JE, Jr, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the Medical Outcomes Study. JAMA. 1996 Oct 2;276(13):1039–1047. [PubMed]
  • Ware JE, Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995 Apr;33(4 Suppl):AS264–AS279. [PubMed]
  • Yelin EH, Criswell LA, Feigenbaum PG. Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings. JAMA. 1996 Oct 2;276(13):1048–1053. [PubMed]
  • Yelin EH, Henke CJ, Kramer JS, Nevitt MC, Shearn M, Epstein WV. A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee-for-service practices. N Engl J Med. 1985 Apr 11;312(15):962–967. [PubMed]
  • Yelin EH, Shearn MA, Epstein WV. Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis. Med Care. 1986 Mar;24(3):236–247. [PubMed]

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