DIFFERENCES IN 4-YEAR HEALTH OUTCOMES FOR ELDERLY AND POOR, CHRONICALLY ILL PATIENTS TREATED IN HMO AND FEE-FOR-SERVICE SYSTEMS - RESULTS FROM THE MEDICAL OUTCOMES STUDY

Objective.-To compare physical and mental health outcomes of chronical ly ill adults, including elderly and poor subgroups, treated in health maintenance organization (HMO) and fee-for-service (FFS) systems. Stu dy Design.-A 4-year observational study of 2235 patients (18 to 97 yea rs of age) with hypertension, non-insulin-dependent diabetes mellitus (NIDDM), recent acute myocardial infarction, congestive heart failure, and depressive disorder sampled from HMO and FFS systems in 1986 and followed up through 1990. Those aged 65 years and older covered under Medicare and low-income patients (200% of poverty) were analyzed separ ately. Setting and Participants.-Offices of physicians practicing fami ly medicine, internal medicine, endocrinology, cardiology, and psychia try, in HMO and FFS systems of care. Types of practices included both prepaid group (72% of patients) and independent practice association ( 28%) types of HMOs, large multispecialty groups, and solo or small, si ngle-specialty practices in Boston, Mass, Chicago, Ill, and Los Angele s, Calif. Outcome Measures.-Differences between initial and 4-year fol low-up scores of summary physical and mental health scales from the Me dical Outcomes Study 36-item Short-Form Health Survey (SF-36) for all patients and practice settings. Results.-On average, physical health d eclined and mental health remained stable during the 4-year follow-up period, with physical declines larger for the elderly than for the non elderly (P<.001). In comparisons between HMO and FFS systems, physical and mental health outcomes did not differ for the average patient; ho wever, they did differ for subgroups of the population differing in ag e and poverty status. For elderly patients (those aged 65 years and ol der) treated under Medicare, declines in physical health were more com mon in HMOs than in FFS plans (54% vs 28%; P<.001). In 1 site, mental health outcomes were better (P<.05) for elderly patients in HMOs relat ive to FFS but not in 2 other sites. For patients differing in poverty status, opposite patterns of physical health (P<.05) and for mental h ealth (P<.001) outcomes were observed across systems; outcomes favored FFS over HMOs for the poverty group and favored HMOs over FFS for the nonpoverty group. Conclusions.-During the study period, elderly and p oor chronically ill patients had worse physical health outcomes in HMO s than in FFS systems; mental health outcomes varied by study site and patient characteristics. Current health care plans should carefully m onitor the health outcomes of these vulnerable subgroups.