The Quality of Managed Care: Evidence from the Medical Literature

Abstract

I INTRODUCTION The past decade has seen a proliferation of state laws aimed at modifying the function of managed care organizations ("MCOs"). (1) Reaction to the increasing prevalence and novel practices of MCOs has prompted passage of hundreds of state statutes governing everything from direct access to medical specialists, to minimum coverage standards for maternity stays. (2) The federal government has also taken action on such matters, and the competing "patients' bills of rights" under consideration in Congress would all expand federal oversight of managed care activities. (3) Though the true impetus for these legal initiatives is debatable, the proponents of "patient protection" measures often cite concern over the quality--or safety--of managed care as the driving force behind their legislative efforts. (4) Critics contend that MCOs sacrifice high-quality health care for cost savings and provide inferior medical coverage compared to fee-for-service ("FFS") plans. (5) Horror stories about alleged abuse or neglect of p atients by MCOs have gained wide circulation. (6) There are even web sites devoted to the promulgation of such anecdotal evidence. (7) Opponents of managed care have employed these singular tales of terror to advance their legislative agendas. (8) This article examines the empirical evidence, drawn from the medical literature, pertaining to the safety of managed care practices. It seeks to ground the ongoing debate on the medical merits of MCOs in the science of clinical research. The article is divided into three major sections. Part II is a systematic review of recent literature on the overall quality of MCOs relative to FFS plans, focusing on clinically important outcome and process measures. It extends previous such analyses to the present day. Part III surveys articles comparing the performance of generalists and specialists in the latter's fields of expertise. It aims to weigh claims about the alleged risks of "gatekeeping," a traditional feature of managed care that has come under increasing criticism. Part IV analyzes the medical evidence on early postpartum discharge ("drive-through deliveries"), perhaps the most publicized example of the supposed dangers of managed care. Though originating in FFS settings, this practice is associated with MCO s due to their widespread adoption of short maternal stays. Finally, the article renders an evidence-based opinion on the quality of America's major form of private health care coverage. II QUALITY-OF-CARE PERFORMANCE: MANAGED CARE VERSUS FEE-FOR-SERVICE Considerable data on the quality of care in MCOs versus FFS does exist even though it is conspicuously absent from public debates on the safety of managed care and the need for more patient protection laws in the post-FFS era. Robert Miller and Harold Luft have reviewed much of the early research on this subject, and in 1994 published the first of two literature analyses on the topic. (9) Examining studies from 1980 through 1993, the investigators found that MCO members were more likely than FFS plan enrollees to receive recommended preventive health services. (10) They also reported that treatment processes and outcomes for a wide range of medical conditions were roughly comparable between the two types of coverage. In 1997, the authors completed a second narrative review on the subject. (11) Considering studies published since their previous analysis, they concluded that available evidence suggested essentially equivalent quality of care between MCOs and FFS plans. (12) They cautioned, however, that almost none of the papers in their review included primary data past 1992, when cost cutting by MCOs began in earnest. (13) In a recent examination of Miller and Luft's methods, Kip Sullivan criticized their analyses for failing to control for differences in the level of coverage between insurance plans. …