PRIMARY-CARE PERFORMANCE IN FEE-FOR-SERVICE AND PREPAID HEALTH-CARE SYSTEMS - RESULTS FROM THE MEDICAL OUTCOMES STUDY

Objective.-To examine differences in the quality of primary care deliv ered in prepaid and fee-for-service (FFS) health care systems. Study D esign.-Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance or ganization (HMO). Both IPA and HMO represent prepaid care systems. Pat ient- and physician-provided information was obtained by self-administ ered questionnaires. Setting.-A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. Outcomes Measures.-Seven indicators of primary care quality-accessibility (financial and organ izational), continuity, comprehensiveness, coordination, and accountab ility (interpersonal and technical) of care. Performance on each was e valuated in FFS, IPA, and HMO settings. Analyses controlled for patien t and physician characteristics. Results.-Financial access was highest in prepaid systems. Organizational access, continuity, and accountabi lity were highest in the FFS system. Coordination was highest and comp rehensiveness was lowest in HMOs. Conclusions.-The results mark notabl e differences in core dimensions of primary care quality in each of th ree payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delive ry reform climate, these findings call for consideration of the relati ve strengths and weaknesses of each system. We suggest strategies for elevating performance in each.