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Health Serv Res. 1998 April; 33(1): 79–99.
PMCID: PMC1070248

How do HMOs achieve savings? The effectiveness of one organization's strategies.

Abstract

OBJECTIVE: To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. DATA SOURCES/STUDY SETTING: A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic's procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible. STUDY DESIGN: Using an explanatory case design, we first compared HMO and FFS rates of resource utilization, in standardized dollars, which measured the impact of organizational strategies to influence patient and provider behavior. We then examined the effect of HMO insurance and organizational measures to explain total outpatient use. Key variables were standardized charges for all outpatient services and the HMO's strategies. PRINCIPAL FINDINGS: Patient and provider behavior responded to organizational strategies designed to achieve savings for HMO patients; for instance, HMO patients used midlevel providers and generalists more often and ER and specialists less often. Overall HMO savings, adjusted for case mix, were explained by the specialty of the physicians the patients first visited and appeared to affect patients with average health more than others. CONCLUSION: Organizational strategies, without resort to differential financial incentives to each provider, resulted in lower rates of outpatient services for HMO patients. Savings from outpatient use, especially for common diseases that rarely require hospitalization, can be substantial.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Bernstein AB, Bernstein J. HMOs and health services research: the penalty of taking the lead. Med Care Res Rev. 1996 Mar;53 (Suppl):S18–S43. [PubMed]
  • Dorsey JL. Use of diagnostic resources in health maintenance organizations and fee-for-service practice settings. Arch Intern Med. 1983 Oct;143(10):1863–1865. [PubMed]
  • Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995 Jan 25;273(4):323–329. [PubMed]
  • Gold M. Effects of hospital-based primary care setting on internists' treatment of primary care episodes. Health Serv Res. 1981 Winter;16(4):383–405. [PMC free article] [PubMed]
  • Gold M, Nelson L, Lake T, Hurley R, Berenson R. Behind the curve: a critical assessment of how little is known about arrangements between managed care plans and physicians. Med Care Res Rev. 1995 Sep;52(3):307–341. [PubMed]
  • Hellinger FJ. The impact of financial incentives on physician behavior in managed care plans: a review of the evidence. Med Care Res Rev. 1996 Sep;53(3):294–314. [PubMed]
  • Hillman AL, Pauly MV, Kerstein JJ. How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations? N Engl J Med. 1989 Jul 13;321(2):86–92. [PubMed]
  • Hlatky MA, Lee KL, Botvinick EH, Brundage BH. Diagnostic test use in different practice settings. A controlled comparison. Arch Intern Med. 1983 Oct;143(10):1886–1889. [PubMed]
  • Hornbrook MC, Hurtado AV, Johnson RE. Health care episodes: definition, measurement and use. Med Care Rev. 1985 Fall;42(2):163–218. [PubMed]
  • Kralewski JE, Wingert TD, Knutson DJ, Johnson CE, Veazie PJ. The effects of capitation payment on the organizational structure of medical group practices. J Ambul Care Manage. 1996 Jan;19(1):1–16. [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]
  • Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health. 1989 Dec;79(12):1628–1632. [PubMed]
  • Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians. JAMA. 1996 Jun 5;275(21):1693–1697. [PubMed]
  • Miller RH, Luft HS. Managed care plan performance since 1980. A literature analysis. JAMA. 1994 May 18;271(19):1512–1519. [PubMed]
  • Stearns SC, Wolfe BL, Kindig DA. Physician responses to fee-for-service and capitation payment. Inquiry. 1992 Winter;29(4):416–425. [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]
  • Wingert TD, Kralewski JE, Lindquist TJ, Knutson DJ. Constructing episodes of care from encounter and claims data: some methodological issues. Inquiry. 1995;32(4):430–443. [PubMed]
  • Wolinsky FD. The performance of Health Maintenance Organizations: an analytic review. Milbank Mem Fund Q Health Soc. 1980 Fall;58(4):537–587. [PubMed]

Articles from Health Services Research are provided here courtesy of Health Research & Educational Trust