Medicaid Managed Care - U.S. Senate Special Committee on Aging

and chest pain sufficient to require hospitalization
(MOS unpublished data).
These preliminary MOS results are consistent
with published studies that have
linked SF-36 health scores to disease
severity and to treatment response, including
severity of soft-tissue injuriesand
changes in hematocrit amongchronic
dialysis patients The SF-36 studies of
outcomes have also linked treatment to
outcomes including drug treatment for
depression among the elderly~n total
knee replacement,n7 heart valve replacement
surgery~i use of aerosol inhalers
in treating asthmas, intermittent
vs maintenance drug therapy for
duodenal ulcer," elective hip arthroplastyi
elective coronary revascularizationa
and various other elective surgical
procedures.' Three dozen such
studies using the SF-S6 are cited elsewhere.n
Identification of the clinical
correlates of changes in physical and
mental health status warrants high priority
in outcomes and effectiveness research."
Future studies should address
whether variations in the quality of care
explain differences in outcomes across
systems. The MOS patients in HMOs
reported fewer financial barriers and
better coordination of services in comparisons
with equivalent FFS patients.'z
Analyses of primary care quslity
criteria indicated that those in FFS
systems experienced shorter treatment
queues and better comprehensiveness
and continuityofeare and rated the quality
of their care more favorablyms Do
such variations in process account for
differences in outcomes? Practice-level
analyses in progress have linked scores
for primary care process indicators' to
4-year health outcomes, as defined here,
supporting this hypothesis. These and
other asosociatios warrant further study
to determine which practice styles and
specific treatments are most likely to
improve health outcomes. Because many
of the structural and process indicators
being relied on to evaluate the quality of
current health care have not been shown
to predict outcomes, targeted monitoring
efforts are required to discern health
outcomes.
The MOS has demonstrated the feasibility
and usefulness of readily available
patient-based assessment tools,
such as the SF-I6 Health Survey, in
monitoring outcomes across diverse patient
populations and practice settings.
The SF-36 summary measures of physicai
and mental health reduce the number
of comparisons necessary to monitor
outcomes while retaining the option
of analyzing the S-scale SF-36 health
profile on which they are based. The
reporting of results in change catego-
1041; JANA, OCICWb 2,19S96-Vo 276, NO. 13
164
ries in terms of better, same, and worse
may simplify the reporting of outeomes
to diverse audiences and may make results
easier for them to understand. More
practical data collection and processing
systems-under development-and advances
in understanding of the specific
treatments that improve health scores
the most and the clinical and social relevance
of those improvements will increase
their usefulness in improving patient
outcomes."
Policy Impllcations
The MOS results reported hem and
previously' for the average chronically
ill patient constitute good news for those
who consider HMOs as a solution to rioing
health care costs. Outcomes were
equivalent for the average patient because
those who were younger, relatively
healthy, and relatively well-off
financially did at least as well in HMO0
as in the FFS plans. However, our results
sound a cautionary note to policymakers
who expect overall experience
to date with HMOs to generalize to specific
subgroups, such as Medicare beneficiaries
or the poor. Patients who were
elderly and poor were more than twice
as likely to decline in health in an HMO
than in an FFS plan (68% declined in
physical health in an HMO vs 27% for
FFS; P