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HEALTH POLICY Fee-for-Service Tops Managed Care for Elders' Heart Attacks Medicare patients enrolled in managed care plans were significantly less likely to receive coronary angiography following a heart attack, even though the procedure is a highly recommended practice, than those with traditional Medicare fee-for-service coverage, according to a study in the Nov. 16 New England Journal of Medicine. Edward Guadagnoli reports in the NEJM that coronary angiography was underprescribed in Medicare patients who had suffered severe heart attacks. Photo by Jeff Cleary "Nearly a fifth of the Medicare population is in a managed care plan," said the study's lead author, Edward Guadagnoli, HMS associate professor of health care policy. "While these numbers are increasing, we've seen a decline in the growth of overall medical expenditures, causing concern about the quality of care provided to managed care enrollees, and particularly the elderly, the most vulnerable patients." Coverage Affects Treatment The study found that of elderly heart attack patients who needed coronary angiography, or Class I patients as defined by the American College of Cardiology and the American Heart Association, a greater proportion who had fee-for-service coverage—46 percent—received the diagnostic procedure than the proportion with a managed care plan—34 percent. Coronary angiography in such patients can lead to interventions that improve long-term health. "This is a significant statistical difference in care quality," said Guadagnoli. "Other studies have also found that patients with managed care received fewer procedures than their fee-for-service counterparts, but our study went a step further: it revealed a difference even when the procedure is highly recommended by current standards of care, which previous studies did not examine." These findings also bear out the underuse of the procedure in general, since 66 percent of patients in managed care plans and 54 percent of patients with fee-for-service coverage did not receive the recommended care. "These data show the need for increased adoption of this important diagnostic procedure in both types of patients," said Guadagnoli. Among both groups of heart attack patients, the study found that the institution where a patient was first admitted was crucial to having coronary angiography. Of those patients who needed the procedure but were admitted to a hospital without an angiography facility, 85 percent with managed care and 69 percent with fee-for-service did not receive it while under the hospital's care; the patients who did were transferred to facilities with a catheterization lab. "A critical part of improving health care quality is understanding whether patients receive the services they need," said John Eisenberg, director of the Agency for Healthcare Research and Quality. "Future research should address the impact of different utilization management techniques on access to health care services as well as plan characteristics that may be responsible for differences among models of managed care." Advancing Age, Declining Care? In addition to enrollment in a managed care plan, the study correlated increasing age with the underuse of angiography. Among patients assigned to Class I in both groups, the rate of angiography declined with increasing age, but a higher percentage of fee-for-service beneficiaries than managed care enrollees underwent angiography in each age group. The investigators believe more recent data will allow evaluation of changes to these findings over time. The study examined patient data records between February 1994 and July 1995. The Medicare managed care study population of 4,732 patients was drawn from 38 managed care plans in Florida, Texas, California, New York, Ohio, Pennsylvania, and Massachusetts by the Health Care Financing Administration's Cooperative Cardiovascular Project in collaboration with the General Accounting Office. These seven states account for over 70 percent of all Medicare beneficiaries enrolled in managed care. The Medicare fee-for-service study population of 46,321 patients was derived from the Cooperative Cardiovascular Project. Patients were classified according to the need for angiography by a panel of physicians using guidelines of the American College of Cardiology and the American Heart Association. Edward Guadagnoli; HMS co-authors Mary Beth Landrum, assistant professor of biostatistics; and Barbara McNeil, professor and chair of health care policy; and co-authors at other institutions were funded by a grant from the Agency for Healthcare Research and Quality. —John Lacey