Care of Stroke Patients in HMOs and Fee-for-Service Systems


Synopsis: Stroke patients in Medicare HMOs are more likely to be discharged to nursing homes and less likely to go to rehabilitation facilities.

Source: Retchin SM, et al. JAMA 1997;278:119-124.

Numerous studies have evaluated the process of care for patients cared for under HMOs compared to fee-for-service (FFS) payment systems. In general, the results have been mixed. For some conditions, and particularly for more affluent and educated patients, HMOs provide as good or better care. However, the Medical Outcomes Study found that the elderly and poor had poorer outcomes under HMOs.1 Universally, the HMO patients spend less time in hospitals than in FFS.

Few studies have evaluated care to the Medicare beneficiaries enrolled in HMOs. Given the rapid growth in Medicare HMOs and the recent Congressional budget agreement, such studies are critical to informed decision-making. Retchin and colleagues have performed the majority of such studies of patients from the mid-1980s to early 1990s. Their most recent work addresses the care of stroke patients under the two payment systems.

In this detailed (and expensive) study, patient charts from about 400 each HMOs and FFS were audited. Only four of the 19 HMOs studied were staff-model, and 50% of the patients were from California or Florida. Patients enrolled in HMOs were less likely to be discharged to rehabilitation units (17% vs 23% ) and more likely to be sent to nursing homes (40% vs 29%). HMOs had a shorter hospital length of stay (8.6 vs 10.5 days). These differences persisted after adjusting for clinical differences at presentation. Survival was similar for the two groups after those patients with DNR orders were excluded.


This study is important since it addresses a high-frequency, high-cost event in a vulnerable population. Given that the HMOs studied included nine independent practice associations, six group model plans, and only four staff model plans, I believe the source of the differences are the organizational barriers or incentives from the HMOs and not the practice style or culture of the physicians. At the time of this study, whether using rehabilitation units was a judicious use of expensive resources was uncertain. However, given the recent study showing improved outcomes after hip fractures and strokes associated with the use of rehabilitative services, HMOs should be under scrutiny to change their care.2


1. Ware JE, et al. JAMA 1996;276:1039.

2. Kramer AM, et al. JAMA 1997;277:396.