and Its Measurement - NCBI

Healthcare Organizational Change: Implications for Access to Care and Its Measurement Robert H. Miller Objectives. To summarize evidence from peer-reviewed literature on access to care for vulnerable HMO enrollee populations; to discuss the potential effect of recent HMO and physician organization changes on access to care and its measurement. Study Design. Review and summary of peer-reviewed literature for two HMO populations: those with chronic conditions and diseases, and those subject to discrimination due to income, color, or ethnic background. I also reviewed and summarized literature on three major changes in capitated organizations (HMOs and capitated physician organizations) that could affect access to care for vulnerable populations, and summarized findings from healthcare manager interviews conducted for several recent research projects on health system change. Principal Findings. Although mixed, there are enough negative results to raise some concerns about access to care for HMO enrollees with chronic conditions and diseases. Several emerging organizational changes have the potential to change access to care for the vulnerable HMO enrollees. The shift in cost-cutting from fragmented clinical management of specific services at a point in time toward more integrated clinical management of all services for specific types of patients across time may improve access to care, as may increased efforts to attract and retain HMO enrollees. The increased importance of capitated provider organizations within the health system may restrict access in some ways, and expand access in others. Conclusions. Organizational changes can affect both access to care and its measurement. More research is needed on the effects of these changes on access to care and quality of care. For researchers examining access to care for vulnerable HMO enrollee populations, these changes create challenges to determine the most appropriate measures of access to care, and the most appropriate organizations and organizational characteristics to measure. Relevance to Clinical Practice, Management, and/or Policy. Changes in market competition are leading to organizational changes that affect access to care for vulnerable HMO enrollee populations. Public and/or private policies that improve measurement and reporting can affect market competition and improve access to care. Key Words. Access to care, managed care, capitation, physician organization, organizational charge.

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HSR: Health Services Research 33:3 (August 1998, Part II)

Major health system changes have the potential to affect access to care by vulnerable HMO enrollee populations, including persons with highercost chronic conditions and diseases and those subject to discrimination due to income or color. This article reviews evidence on access to care for HMO enrollees, especially vulnerable populations, and describes changes in several major factors that can affect access to care. These changes include a shift toward HMO capitation of large provider organizations, as well as capitation- and competition-driven efforts to redesign clinical practice and to recruit and retain HMO enrollees. That is, changes in how HMOs and physician organizations assume risk, lower their costs, and increase their revenues potentially can have an important effect on access to care for vulnerable HMO enrollee populations. I also discuss the effects on access to care of different methods of payment to individual physicians, although the direction of change in such methods is not as clear as for other major factors. After discussing market incentive changes needed to improve access to care, I conclude by discussing the implications of organizational changes for measurement of access to care for vulnerable HMO enrollees. Among multiple vulnerable populations in the access to care literature, I focus on two groups: HMO enrollees with chronic conditions and diseases and HMO enrollees subject to discrimination due to income, color, or ethnic background. I do not address access to care issues pertaining to the non-HMO population, insured or uninsured. In part, this article is based on interviews with dozens of HMO, hospital system, and physician organization managers in California and elsewhere, conducted over the past three years for five different research projects examining various aspects of health system change.

BACKGROUND ON RELEVANT HEALTH SYSTEM CHANGES After two rounds of high premium inflation during the 1980s,' the market for health plan coverage became increasingly competitive in the early 1990s. Funding support for this research was from Mathematica Policy Research through its grant with the Robert WoodJohnson Foundation. Address correspondence to Robert H. Miller, Ph.D., Associate Professor of Health Economics in Residence, Institute for Health Policy Studies, Institute for Health & Aging, Department of Social and Behavioral Sciences, University of California, San Francisco, 1388 Sutter St., 11th Floor, San Francisco, CA 94109. This article, submitted to Health Services Research on July 18, 1997, was revised and accepted for publication on March 2, 1998.

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In a fundamental shift in market dynamics, large employers and purchasing coalitions moved toward the purchase of healthcare services on a competitive basis, via health plans (Etheredge 1995). Health plans reacted by competing more vigorously among themselves in an attempt to gain sizable market share in any one market, in part to lower costs through economies of scale and greater bargaining leverage with provider organizations. HMOs exploited substantial excess hospital and specialist physician capacity, spurring greater price competition among providers than in the past and leading to lower (absolute or rate of growth of) payments to hospitals and physician organizations. Faced with greater competition and lower payments, hospitals and physicians reacted by accelerating the pace of consolidation of hospitals into large systems and of physicians into large physician organizations, in order to lower costs and increase bargaining leverage. Both also riveted their attention on reducing clinical utilization and input prices2 (for a summary of these issues, see Miller 1996a). In part, this competition and cost-cutting led to lower growth rates of premiums and healthcare expenditures, as evidence from several sources indicates (Ginsburg and Pickreign 1996). In some cases, HMOs both lowered payments to physician organizations and capitated those organizations. HMOs lowered their costs and made their costs more predictable, while, in return for lower payments, capitated provider organizations kept the fruits of their cost-cutting efforts-if they could lower costs sufficiently. In these cases, as they transferred risk to physician and physician/hospital organizations, HMOs also transferred numerous functions that HMOs had performed, including primary responsibility for clinical management, a key cost-cutting method (Miller 1996a). Moreover, as they cut costs, capitated organizations attempted to increase their revenues through greater efforts to recruit and retain capitated enrollees. A "capitated organization" refers to organizations that assume risk and conduct clinical management, including HMOs and capitated provider organizations that retain some risk for medical services and manage utilization and quality assurance. This increased competition among capitated organizations is driving many organizational changes. Several specific changes can potentially have a major effect on access to care for vulnerable HMO enrollee populations including which capitated organizations assume risk and control care, and how capitated organizations clinically manage care and compete for capitated enrollees. I place special focus on the emergence of large capitated (risk-bearing) provider organizations, because as larger capitated provider organizations

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assume capitation and bear risk, they often assume primary responsibility for managing care, including access to care, for vulnerable HMO enrollees. Capitation of provider organizations already is common on the West Coast (Kerr et al. 1995; Penner 1997), and capitation of larger physician organizations that assume clinical management responsibilities slowly is becoming more prevalent elsewhere. Activity is under way in anticipation of its further growth (see Ernst and Young 1996) and case studies (Ginsburg and Fasciano 1996; Kohn et al. 1997), especially as hospital- and physician practice management company-led delivery systems grow in size and strength.

EVIDENCE ON THE EFFECTS OF HMO ENROLLMENT ON ACCESS TO CARE FOR VULNERABLE POPULATIONS Analyses of evidence from peer-reviewed literature indicate that, compared to traditional insurance/FFS and PPO enrollees, HMO enrollees had fewer hospital admissions and days; less utilization of more costly tests and procedures and home healthcare visits; lower satisfaction with perceived physician interpersonal skills and quality of care but higher satisfaction with finances; and mixed quality of care-that is, some care was better, some was the same (or better and worse), and some was worse (Miller and Luft 1994, 1997). At least four categories of direct and indirect evidence are relevant for access to care for the two vulnerable HMO enrollee populations discussed above.3 Note that in order to focus on more recent experiences, all studies examined here have some data from 1986 forward. 1. Ratings ofAccess to Care by Enrollees with Low Incomes or Chronic Conditions and Diseases Two studies compared ratings of access to care by low-income HMO and traditional insurance enrollees. One study showed mixed results for HMO performance, whereas the other showed better access to care for HMO enrollees, compared to FFS enrollees. * Low-income HMO enrollees had substantially shorter office visit waiting times and travel time to a visit, but longer waiting times to an appointment, compared to low-income traditional insurance enrollees, according to a study using 1994 data (Mark and Mueller 1996). Whereas low-income HMO enrollees had significantly more unmet medical and dental care needs, they had fewer unmet prescription


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drug, eyeglass, and mental health care needs. Low-income HMO enrollees were more likely to have had at least one physician visit, and had substantially more physician visits. Medicaid Aid to Families with Dependent Children HMO enrollees had substantially better access to care compared to Medicaid FFS recipients, according to a study in New York City that used 1994 data (Sisk et al. 1996). Compared to FFS enrollees, HMO enrollees had higher ratings for access to medical care specialists when needed; access to medical care in an emergency; waiting times to get an appointment and see a physician; convenience of location of a doctor's office; having a usual source of care; and seeing the same clinician at the usual source of care. Medicaid HMO and non-HMO enrollees had no significant differences in the likelihood of at least one hospitalization or physician visit, or in the level of use of those services. Two studies compared ratings of access to care by HMO and traditional insurance enrollees with chronic conditions or diseases. One study showed consistently lower ratings by HMO enrollees, whereas the other showed little difference in ratings. In a Medical Outcomes Study that used 1986-1987 data, group/staff model HMO enrollees with chronic conditions (hypertension, diabetes, congestive heart failure, or recent myocardial infarction) had significantly lower ratings for 6 of 12 measures of organizational access to care, compared to traditional insurance enrollees (Safran, Tarlov, and Rogers 1994). However, there were no differences in access to hospital care or to medical specialists. IPA HMO enrollees with chronic conditions had comparable ratings of organizational access to care, and both types of HMO enrollees had higher ratings of financial access to care, compared to their FFS counterparts. * HIV-infected HMO and non-HMO patients had comparable ratings of access to care, according to a study using 1991-1993 data (Katz et al. 1997). One study with 1996 data compared ratings of access to care among subgroups of Medicare HMO enrollees (rather than between Medicare HMO and FFS beneficiaries) (Nelson et al. 1997, 1996). Among users of specialty, inpatient hospital, and home healthcare services, home healthcare users were most dissatisfied with the amount of service received. This is significant because vulnerable HMO enrollees in worse health or with chronic conditions and diseases are disproportionately large users of home health services (Hill et al. 1992). Ofthe 7.5 percent of HMO enrollees that received home health service, 17 percent felt that they did not receive enough service, and

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70 percent of those felt that they had suffered adversely because of that. However, few reported that they needed some home health but did not receive any. Although they had other concerns, Medicare HMO enrollees tended to give good ratings to their HMO plans for access to care.

2. Comparisons of Quality and Utilization for Enrollees with Chronic Conditions and Diseases For persons with chronic conditions and diseases, results were mixed for studies that compared quality of care and service utilization for HMO and traditional insurance enrollees. Two studies on elderly, ill persons show worse quality of care for HMO enrollees combined with lower utilization, which raises concerns about access to care. * According to a Medicare TEFRA evaluation study that used 19891990 data, Medicare HMO enrollees with joint pain and chest pain were as likely to have their symptoms completely eliminated as FFS enrollees, but HMO enrollees with joint pain that remained showed less symptomatic improvement than did non-HMO enrollees (Clement et al. 1994). Utilization results were mixed: although HMO enrollees with joint pain were much less likely to be referred to a specialist, they were more likely to have had a least one physician visit. * Medicare HMO home health users followed over a 12-week period during 1989-1991 had worse health outcomes than did their FFS counterparts (Schlenker, Shaughnessy, and Hittle 1995; Shaughnessy, Schlenker, and Hittle 1994). HMO enrollees had substantially lower home health utilization and expenditures. The study did not examine differences in initial access to home care. Yet several other studies of persons with chronic conditions and diseases and/or lower incomes show comparable or better quality of care HMO performance results, combined with similar or lower utilization. * HMO enrollees with hypertension and non-insulin-dependent diabetes mellitus had health outcomes that were not significantly different from their non-HMO counterparts, according to a Medical Outcomes Study that used 1986-1992 data (Greenfield et al. 1995). Although HMO hypertensives and diabetics were much less likely to have received any subspecialist treatment, there were no significant differences in number of physician visits.


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* HMO enrollees with arthritis received quality of care that was comparable to that of their non-HMO counterparts, during 1982-1994 (Yelin, Criswell, and Feigenbaum 1996). Healthcare utilization levels also were comparable. * Elderly Medicaid HMO enrollees obtained similar or better quality of care than their FFS counterparts. HMO enrollees were less likely to have had at least one hospitalization or physician visit, and used fewer of those services (Lurie et al. 1994). * Children with Medicaid HMO coverage had similar or better quality of care results, compared to their non-HMO counterparts (Buchanan, Leibowitz, and Keesey 1996; Mauldron et al. 1994). HMO children with preexisting conditions were as likely to have had a physician check-up visit as their FFS counterparts, whereas HMO children without preexisting conditions were less likely to have had one. 3. Comparisons of Utilization for Enrollees in Worse Health Limited evidence suggests that HMO enrollees in worse health are subject to the largest utilization reductions (and are the source of many HMO savings), which raises access to care concerns. A Medicare HMO evaluation that used 1989-1990 data (Hill et al. 1992) compared differences in HMO and FFS healthcare utilization for the approximately 6 percent of Medicare beneficiaries who were in poor self-rated health to differences in HMO and FFS utilization for the remaining 94 percent of beneficiaries. HMO enrollees in poor health accounted for a disproportionately large share of HMO utilization savings. Per 1,000 persons in poor health, HMO enrollees had an estimated 878 fewer hospital days, 2,296 fewer SNF days, 1,149 fewer home nurse visits, and 2,355 fewer home aide visits compared to similar FFS enrollees. Per 1,000 persons not in poor health, HMO enrollees had only 271 fewer hospital days, 5 fewer SNF days, 134 fewer home nurse visits, and 101 fewer home aide visits compared to similar FFS enrollees.4 4. Physician Ratings ofAccess to Care for All HMO Enrollees Several recent studies with data from 1994-1997 provide indirect evidence on access to care, through physician opinions on the effects of HMOs or capitation on access to care. While the evidence pertains to all types of enrollees, the results remain relevant for vulnerable populations. Of four studies on physician perceptions about access to care for HMO enrollees, two found substantially negative physician attitudes about the effect of HMOs on access to care.

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* A nationwide study using 1995 data compared physician satisfaction and perception of practice problems in states with high, medium, and low levels of HMO penetration. Compared to physicians in low HMO penetration states, physicians in high HMO penetration states were significantly more likely to have a serious problem with limitations on referring patients to specialists of the physician's choice or to appropriate specialists, and with limitations on ordering diagnostic tests and procedures thought best for patients. They also had more serious problems with patients who should have been referred for medical attention sooner, and with financial incentives to do less for patients than what the physician thought was best (Donelan et al. 1997). * A study using 1995-1996 data examined perceptions of Massachusetts physicians about the effect of gatekeeping on access to care (Halm, Casino, and Blumenthal 1997). The physicians were gatekeepers for an HMO plan who also served traditional insurance patients. Gatekeeping HMO enrollee care is a not an uncommon utilization management method (Franks, Clancy, and Nutting 1992; Remler et al. 1997). Comparing percent negative vs. percent positive responses, physicians felt that gatekeeping had a negative effect on ease of specialist referrals (51 percent negative vs. 5 percent positive), ease of ordering expensive tests or procedures (42 percent vs. 2 percent), and on appropriate use of such resources as hospitalization (27 percent vs. 14 percent), specialists (40 percent vs. 14 percent), and laboratory tests (35 percent vs. 13 percent). * A study of Minneapolis-St. Paul, Minnesota physicians in three HMO plans showed somewhat more favorable results for HMOs (Borowsky et al. 1997). Physicians rated health plan practices that might impede delivery of high-quality care. Many physicians (78 percent) strongly or somewhat agreed that patients who really need to see a specialist are able to see one promptly, while only a relatively small minority felt that deductibles or copayments frequently prevented patients from receiving care that they needed (22 percent) or felt that patients frequently needed care that was not a covered benefit of the plan

(18 percent). * A nationwide study using 1995 data examined physician attitudes toward capitated payment (to the physician individually or to the physician organization) (Cykert et al. 1997). The study found that physicians with capitated patients perceived that capitation only slightly reduced access to care. * One study showed that, in 1995, California physicians in 89 physician groups with capitated contracts were more satisfied with care for


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patients in their overall practice than they were for care for capitated HMO enrollees (Kerr et al. 1997). For their overall practice, only 59 percent of physicians were very or somewhat satisfied with their ability to obtain specialty referrals when they felt that the referrals were necessary, while for their capitated patients, only 50 percent were very or somewhat satisfied. However, satisfaction increased as group size increased. It is difficult to generalize from these mixed results. However, there are enough negative results to raise concerns about access to care for HMO enrollees, especially those with chronic conditions and diseases; one of the negatives, lack of sufficient access to home healthcare, disproportionately affects persons with chronic conditions and diseases. In interpreting these results, it is important to mention at least a few caveats. The lack of standard measures of access to care hampers any review of evidence. Some studies used measures that were not necessarily designed to measure access to care and that did not differentiate between access to initial care for a type of service and the overall amount of care used. Moreover, some utilization and quality measures implied only possible access problems in obtaining initial, and then subsequent, services. In addition, some evidence was based on relatively small sample sizes. Other evidence that was presented as averages derived from many organizations (with a wide range of characteristics that could affect access to care) made it difficult to understand the range of performance results among organizations. Still other evidence that was derived from only a few organizations (that potentially had idiosyncratic characteristics and performance) made it difficult to generalize from the results. Further, much enrollee-based evidence is not as recent as one would like, given rapid health system change.

SELECTED ORGANIZATIONAL FACTORS AND CHANGES THAT CAN AFFECT ACCESS TO CARE Beyond differences in methodologies among studies, the question remains why results are mixed on access to care for vulnerable HMO enrollee populations, and what organizational characteristics or factors may have led to positive or negative results. Some factors with a potentially important effect on access to care for vulnerable HMO enrollee populations are changing, a situation that could lead to a different pattern of results in the future.

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These changes are shifts toward (a) capitation of provider organizations; (b) more complicated forms of clinical management and clinical integration; and (c) more aggressive attempts to recruit and retain HMO enrollees. That is, among basic organizational arrangements or factors that can affect access to care for vulnerable HMO enrollee populations are changes in * which organization controls care and how much potential control that organization has over physician decision making; * how HMOs or capitated physician organizations control care; and * how HMOs or capitated physician organizations compete to attract and retain HMO enrollees.

Obviously, other factors have the potential to affect access to care, such as ownership of the physician organization (e.g., physician practice management company-, hospital system-, insurer-, and physician-owned), benefit coverage, extent of purchaser activism in an area, and history and level of HMO market penetration and competition. Here I focus on the first three factors and changes occurring within each factor. 1. Which Organization Controls Care and How Much Potential Control It Has over Care

Whether or not an HMO pays capitation to an "intermediate" or large physician group or to a physician-hospital organization often determines which organization controls care. Although good data are lacking, case studies and substantial anecdotal evidence indicate that in most markets HMOs commonly retain some "risk" for healthcare services. Although they may pay capitation and share risk with individual physicians and small groups, they often conduct utilization management and quality assurance. In a slow but major change, HMOs are capitating and "passing risk" to more large physician and physician-hospital organizations, and transferring clinical management responsibility to them (Kerr et al. 1996; Kerr et al. 1995; Penner 1997; Robinson and Casalino 1995). For vulnerable HMO enrollee populations, the capitated physician or physician-hospital organization becomes the key organization that controls access to care, not the HMO, which may exercise only weak oversight over care. For example, when a person with a chronic condition or disease wants to see a specialist, it is the provider organization, not the HMO, that often authorizes the visit. Moreover, specialist referral policies will vary among


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capitated provider organizations, even if the same HMO capitates each provider organization. HMO capitation of medical groups increases as medical group size increases. As of 1995, about one-third of physicians worked in practices with capitated contracts,5 and among those, 19 percent of practice revenues were capitated (Simon and Emmons 1997). Yet for groups of 51 physicians or more, 75 percent of physicians were in practices with capitated contracts and 26 percent were in practices with over 75 percent of practice revenues from capitation. HMOs increasingly can "pass risk" and delegate clinical management responsibility due to the emergence of more large physician or physicianhospital organizations that are enhancing their capabilities to manage care for capitated enrollees. Case studies indicate substantial recent growth in large medical groups and IPAs (e.g., see Ginsburg and Fasciano 1996; Kohn et al. 1997), many of which have accepted, are negotiating, or are preparing to accept, capitation payments.6 Capitation of provider organizations is increasing in other ways, including through provider-sponsored HMOs (e.g., see studies in Kohn et al. 1997).7 Arrangements between an HMO and a provider organization that it capitates can vary widely (e.g., see Advisory Board Company 1994; Conrad et al. 1996). In one typical arrangement, an HMO contracts nonexclusively with several medical groups and IPAs whose primary care physicians act as "gatekeepers" or otherwise manage enrollee healthcare services. The HMO capitates each physician organization for all physician services, both primary care and specialist. The HMO establishes a hospital inpatient risk pool with each physician organization, and both HMO and physician organization share savings from the risk pool if hospital days or expenditures per enrollee fall below agreed-on amounts for each type of enrollee (Advisory Board Company 1994; Conrad et al. 1996; Penner 1997). For vulnerable HMO enrollees, capitation of provider organizations potentially can limit choice of provider and thus can affect access to some specialized care. Although an enrollee that joins an HMO often can choose among many provider organizations, once an enrollee has chosen a capitated physician organization, he or she often is restricted to providers that that organization employs or contracts with. Even as an HMO may widen the network of potential organizations that can provide care, enrollees' choice of providers (and potentially, access to care) may narrow, even though many capitated provider organizations have increased their specialist provider network breadth.

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Capitation of physician organizations tends to increase the intermediary organizations' financial leverage with physicians and thus its potential influence over individual physician clinical decision making and access to care. For example, when a solo or small-group physician contracts with ten different HMOs, he or she is subjected to ten different utilization management and physician payment methods. When the physician joins a large medical group, and the group may contract with the ten HMOs, often the physician is subject only to the medical group's utilization management and payment methods. As a result, the medical group has substantially more economic and clinical importance for the physician than was the case for any of the ten HMOs. A capitated IPA that also contracts with some or all of the ten HMOs also obtains increased leverage with the physician. One study provides fragmentary evidence on the effects of large, capitated physician organizations on access to care (Kerr et al. 1997). As the proportion of capitated patients in a practice rose from under 30 percent to over 70 percent, the proportion of physicians who were somewhat satisfied or very satisfied with their ability to obtain specialty referrals for capitated patients rose from 40 percent to 70 percent. This may suggest that organizations with more experience in capitation may figure out ways to provide better access to care, compared to organizations with less experience. 2. How Organizations Control Care and Their Potential Effects on Access to Care HMOs and physician organization managers convey the pressure of their capitated budget constraint to physicians through a wide range of clinical management methods and financial incentives, in order to control utilization and expenditures. How Organizations Manage Clinical Care Obviously Can Directly Affect Access to Care. Lower payments (or their rate of growth) to capitated organizations demands cost-cutting, and how cost-cutting takes place depends heavily on clinical management methods used to lower costs. Different clinical management methods potentially can create different access to care results for vulnerable HMO enrollee populations. In characterizing types of cost-cutting that involve different clinical management methods, some healthcare managers have used the analogy of picking "low-hanging" versus "high-hanging" fruit. * Picking low-hangingfruit: utilization management. Some capitated organizations initially made relatively large cost-cutting gains fairly quickly because the traditional insurance/FFS system tended to provide too


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many services, and at a relatively high price per service. An HMO or PCP-dominated capitated physician organization initially could cut costs by doing many of the same things as in the past, but with fewer resources (e.g., by shortening hospital length of stay), and by lowering both prices to specialists and administrative costs. During this phase, utilization management of specific services (not specific types of enrollees) is a primary method of reducing utilization, especially hospital admissions and length of stay, home healthcare visits, and use of more costly tests and procedures. Utilization management techniques range from a physician calling an anonymous nurse (the infamous "1-800-mothermay-I" number) to internal committees of physicians developing servicespecific guidelines or protocols, reviewing their peers' requests for particular procedures in the light of those guidelines, and explaining their decisions in subsequent conferences with physicians. In 1995, according to a survey of all physicians (including those serving PPO and traditional insurance patients), utilization review was the most commonly used clinical management technique (Remler et al. 1997). Organizations reviewed hospital length of stay for 59 percent of patients, site of care for 45 percent of patients, and treatment appropriateness for 39 percent of patients. Moreover, use of these methods was highly correlated. However, the extent to which utilization review affects care for HMO enrollees is unclear. Physicians indicated that initial denial rates for recommended services were under 6 percent, and final denial rates were under 3 percent. This raises the question of whether utilization review has little effect, or whether it has a deterrent or sentinel effect (Institute of Medicine 1989; Remler et al. 1997) that discourages physicians from recommending care in the first place. Other clinical management techniques were less common, as the average share of patients for whom the physician was subject to protocols was 16 percent, whereas average shares were 16 percent for profiling, 25 percent for being one of a restricted panel, and 20 percent for gatekeeping. The potential impact of this type of cost-cutting on access to care varies. If there is much "fat" in the system, it is possible to reduce hospital and specialist service utilization without a negative effect on care. However, simply doing the same things with fewer resources increases the likelihood that some providers will cut corners on costs, even if most providers are committed to providing good access and quality of care. That is, if nothing else changes, then sooner or later access will diminish, because care will remain reactive and there will be less of it.

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* Picking high-hanging fruit: clinical integration. Another type of costcutting involves the clinical integration of patient care across personnel, services, and operating units (Gillies et al. 1993; Shortell et al. 1996, 1993). Clinical integration also is known as clinical process reengineering and clinical practice redesign. Rather than only undertaking the same clinical activities with fewer resources, organizations also attempt to undertake new activities with fewer resources. New clinical management methods become more important once easier cost-cutting gains have been achieved, and may improve access to care for vulnerable HMO enrollees, especially those with chronic conditions and diseases. Initial clinical integration activities focus on hospital-related episodes of care. In particular, clinicians develop, implement, and monitor critical care pathways for specific types of admissions. More advanced clinical integration emphasizes integration of care and redesign of clinical practice for patients with chronic conditions and diseases, across services and over time, and involves the patient more fully in that care. Organizations may identify patients that require proactive care; systematize the sequencing mix and amount of patient care through implementing disease- or condition-specific clinical guidelines (protocols or pathways); provide physicians with more clinical information at the point of providing services; subsequently provide physicians with detailed clinical performance feedback; and implement provider financial incentives that balance utilization and outcomes targets (e.g., see Wagner, Austin, and Korff 1996). Clinical integration addresses a flaw in the "picking low-hanging fruit" perspective-that is, for HMO enrollees who are high-cost or on the route to being high-cost, less expenditure now can mean much more expenditure later without coordinated, proactive care. Although reducing access to care for higher-cost persons with chronic conditions and diseases increases the likelihood of their disenrollment (and thus can lower costs), many higher-cost persons will remain enrolled. Moreover, if a capitated organization wants sizable HMO enrollment, it can be difficult to recruit large numbers of members if the organization has developed a reputation for denying care to people who potentially are heavier users of care. By identifying persons that are potentially higher cost, and treating them in an aggressive (timely and appropriate) manner, organizations can profit by preventing exacerbation of conditions that could lead to high expenditures, especially hospitalization. In contrast, with simpler forms of clinical management, an organization may wait for patients to be hospitalized, and then attempt to reduce hospital length of stay or subsequent home health visits.

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For vulnerable HMO enrollee populations, this proactive, integrated approach to care can speed access to care at the point of entry to a delivery system when capitated organizations seek out people who need care (e.g., through screening devices that identify new enrollees with clinical problems) and assign them to clinicians for initial evaluation and follow-up, including visits to specialists. The approach also can improve access to subsequent care, for instance, through calling enrollees into clinician offices for visits or tests, reminding enrollees to take medications, or checking an enrollee's weight by phone. One important trend is the emergence of primary care team practice (Donaldson 1996) or "team care," which increases the patient's contact with the health system. Such teams consist of physicians, and some combination of advanced nurse practitioners, nurses, physician extenders, social workers, home care aides, and other non-physician personnel. Over time, these teams care for the same defined group of persons. They may base their activities on clinical guidelines for the care of patient subgroups, including those with specific conditions and diseases such as diabetes, asthma, or chronic obstructive pulmonary disease; that is, some teams engage in "disease management." A study by Rich et al. illustrates this type of condition-specific (versus procedure-specific), multidisciplinary approach to care for congestive heart failure patients, and provides some evidence that reorganized care can lower cost and produce better outcomes.8 However, there is a dearth of information on the prevalence and effects of these new types of care, including their effects on access to care for vulnerable HMO enrollees, and on whether capitating physician organizations increases the likelihood of adopting new clinical care management strategies. Studies by Kerr and others shed some light on the prevalence of standard utilization management (Kerr et al. 1995) and quality assurance methods (Kerr et al. 1996) in capitated physician organizations, but not as much light on newer forms of clinical management. One important caveat is that clinical integration of care is only in its formative stages so that its current effect on access to care is limited. Its progress varies greatly among organizations, including among operating units within the same firm. Even in high HMO-penetration markets on the West Coast, such a clinical focus is not the rule because it can be a long and difficult process to adopt, put in place, and then actually monitor and enforce the guidelines for (Miller, Lipton, and Duke 1997). Note that an organization can "pick" both types of "fruit" at the same time, so that some changes potentially could decrease, whereas others may increase, access to care. Moreover, neither type of clinical management and cost-cutting is likely to have uniformly positive or negative effects on access

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to care. Clearly, more research is needed to understand effects of clinical management methods on access to care and quality of care. How HMOs or Physician Organizations Pay Individual PCPs and Specialists Also CanAffectAccess To Carefor VulnerableHMOEnrollees. An HMO's payment method to a large physician organization can differ substantially from the large physician organization's payment method to an individual physician, and thus the two sets of payment methods need to be discussed separately. Several overview descriptions of payment methods to individual PCPs and specialists, and the potential effects of these methods on access to care and quality of care, can be found elsewhere (e.g., see Berwick 1996; Bodenheimer and Grumbach 1996; Gold et al. 1995; Kongstvedt 1996a,b; Rodeghero 1996). The three major ways that individual physicians are paid create different incentives to provide access to care. When a capitated organization pays individual physicians FFS, the incentive is for the physician to provide more care and possibly better access to care. Alternatively, when a capitated organization pays a salary to its employee physicians, utilization incentives are more neutral, as income may not vary much with utilization. Salary payment is fairly common: a 1995 survey showed that about 34 percent of physicians were on salary, including 43 percent of generalists (Remler et al. 1997). Capitated payment to individual physicians creates concern about access to care because it contains potential incentives for underutilization if an individual physician's income varies inversely with utilization. The extent of capitated payment to individual physicians varies widely. One 1995 survey found that that for the 24 percent of physicians who received some capitation, an average of 30 percent of their patients were capitated (Remler et al. 1997).9 However, simply knowing whether or not a physician is paid capitation may not convey enough information to understand its potential effects on access to care. Only examining the details of risk-sharing arrangements for individual PCPs and specialists, non-utilization compensation,'0 and utilization management and quality assurance methods can determine whether or not access to care concerns are justified. For example, an HMO or physician organization may pay a PCP capitation, but put the PCP in a risk pool with many physicians; allocate risk pool payments based on the performance of all physicians in the pool rather than on the performance of the individual physician; limit the number of services at risk; limit the extent of the PCPs' "downside" risk (for losses); base a minority of pay on enrollee satisfaction; and monitor its physicians for possible under-utilization of services. It also may pay FFS to specialists, which can create incentives for PCPs to increase specialist referrals.


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Evidence on the effects of capitated payment to individual physicians on access to care (Gold et al. 1995; Rice 1997) is difficult to interpret because there are no data on the extent of actuarial risk for individual physicians (Simon and Emmons 1997), and often little is known about utilization management and quality assurance methods and other factors that may balance the financial incentives of capitation. 3. Increased Competition to Recruit and Retain HMO Enrollees As competition has increased in healthcare markets, capitated organizations have placed more emphasis on increasing enrollment-and revenuesthrough attracting new enrollees and retaining existing enrollees. Greater enrollment increases bargaining leverage with payers (and possibly capitated rates), and helps spread fixed costs among more enrollees. Fixed costs, for such expenses as guaranteed physician salaries, paying for and operating facilities, and administration, can be important expenditures for a capitated organization. As a result, when payment for an insured enrollee covers expected variable costs, and makes some contribution to fixed costs, that enrollee can become attractive to a capitated organization. In part, increased emphasis on enrollee retention is due to the potentially high cost of attracting new enrollees, especially in markets with higher rates of HMO market penetration (Advisory Board Company 1997). Some efforts to attract and retain existing enrollees potentially can lead to improved access to care by tempering some cost-cutting methods and discrimination that restricts access to care. * Access to Specialists. Capitated organizations have used easier access to physicians, especially specialists, as a method of attracting and especially retaining enrollees. In some cases, capitated organizations have abandoned prior authorization of many specialist visits and procedures (other than ones that are very expensive), while in other cases they have permitted enrollees to contact certain types of specialists directly, without going through a PCP (Advisory Board Company 1997). In part, these new tactics are due to low rates of denial of recommended care (Remler et al. 1997). Of course, "open access" accompanied by higher enrollee premium payments can mitigate improvement in access to care. * Better GeographicAccess and More Choice ofProviders. In order to improve patient satisfaction (and enrollee retention), some organizations have offered better geographic distribution of providers and facilities.

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* More Focus on Providing Culturally Sensitive Care. In offering more choice of providers, some capitated organizations have acquired or contracted with African American, Asian, and other physician practices that focus on serving minority populations (Miller, Lipton, and Duke 1997). This, too, improves geographic access to care. * Reduced Wait Times. Again, responding in part to marketing efforts, some capitated organizations have attempted to reduce wait time for specialist appointments or tests, or wait time in a clinician's office. Around-the-clock call centers also can provide more immediate access to care, while potentially lowering costs in emergency situations. * More Competition for Poor, Medicaid-insured Enrollees. Where states capitate multiple HMOs and provider organizations for Medicaid enrollees, capitated organizations have an incentive to attract those enrollees through wider choice of provider and better geographic access, as long as Medicaid capitation covers more than variable costs. However, more marketing dollars can mean fewer patient care dollars. Moreover, whether or not access to care is improved depends on the details of each effort, and of utilization management and physician payment methods. For example, providing direct access to specialists could lead to more patients obtaining at least one specialist visit, but accompanying capitation of specialists (without appropriate counterbalances) could create access problems for subsequent care. Once again, there is a dearth of information on the effects of these changes on access to care and quality of care for vulnerable HMO enrollee populations.

STEPS TOWARD OVERCOMING MARKET BARRIERS TO ACCESS TO CARE The changes just discussed are taking place in the context of market "ground rules" that are unfavorable for improving access to care for vulnerable HMO enrollees. 1. Adjusting existing (flat-rate) payment methods for enrollee characteristics could create powerful economic incentives to provide improved access to care. Although some organizations have found that improving clinical processes and programs can lower costs for existing enrollees and improve access to care and quality of care, the same organizations also fear that positive publicity about program successes could attract new, higher-cost enrollees who would raise

Implications ofOrganizational Change

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the organization's overall cost. In effect, the more an organization succeeds in improving access to care and quality of care, the more it could lose financially if that improvement becomes public knowledge. Risk-adjusted capitation rates for vulnerable HMO enrollees with specific conditions and diseases create financial incentives for organizations to compete for such enrollees, specialize in their care, and improve access to care. 2. Much improved consumer information could provide consumers with access to care and quality of care information that they could use to choose health plans or providers. Although little comparable information across organizations is currently available to consumers, measurement and reporting of access to care and quality of care is essential to the functioning of competitive markets. It is a way of keeping capitated organizations "honest" when financial incentives are strong to reduce costs, access to care, and quality of care, and it can reward plans and providers that succeed in improving access or quality. Measurement and reporting is particularly crucial for improvements that may raise overall costs. For capitated organizations, a rule of thumb is that any new clinical activity potentially is worthwhile if it can lower cost and not harm access or quality of care. This facilitates the introduction of new clinical innovations. However, the flip-side is that a new clinical activity that does not lower cost often is not seen as worthwhile, even if that activity improves access and quality of care. Without extensive measurement of processes and outcomes of care, there is no economic incentive to make the improvement, and it can drop down on a manager's priority list of new initiatives. Although the introduction of HEDIS and other measures of access and quality of care is a step forward, more extensive measurement and reporting is needed for consumers to obtain adequate information.

IMPLICATIONS FOR MEASUREMENT OF ACCESS TO CARE Organizational change creates several challenges for measuring and comparing access to care performance among types of healthcare organizations and enrollees.

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1. Determining Measures ofAccess to Care. As clinical integration becomes more widespread, new clinical management methods (especially the shift from a service- or episode-specific focus to a patient-centered, conditionspecific focus) and new methods of attracting and retaining enrollees that focus on improving access can make it difficult to distinguish between some access to care and some quality of care measures. A key question may not be whether capitated organizations provide at least some service to an enrollee that needs a specific service; rather, it may be whether an enrollee gets the appropriate services, in the appropriate amount, at the appropriate time, and in the appropriate location to meet his or her healthcare needs. These are overlapping access and quality of care issues. Moreover, using quantity of care as a proxy for "access to care" becomes increasingly problematic, because clinical integration potentially can lower utilization while improving quality of care. As care becomes more clinically integrated, access to care measures must take into consideration proactive secondary preventive care that may involve telephone communication; nonphysician personnel use; and education, involvement, and support of the patient in self-care-"services" that might substitute for specialist visits or hospital stays that sometimes are markers for access to care. 2. Determining Appropriate Organizations to Measure Performance. Most access to care comparisons were once made for policy purposes, so that comparing all HMO to all FFS enrollees across organizations often was sufficient. As HMO market penetration increases, there is increasing interest in providing consumers and purchasers with information that they can use in choosing among HMOs and delivery systems. As a result, measuring access to care performance differences among HMO plans becomes more important, in addition to measuring differences between HMO and traditional insurance

plans. Moreover, as HMOs capitate provider organizations and delegate clinical management responsibilities to them, measuring access to care performance differences among capitated provider organizations becomes increasing important. Instead of a small group of HMOs each managing (differendy) utilization of services provided by numerous providers in a network, increasingly numerous capitated physician organizations are likely to manage (differendy) those services. As a consequence, results for access at the HMO level increasingly could become an average of the performance of many different capitated provider organizations. Where the same HMOs each capitate the same provider organizations, variability in access to care performance among HMOs could


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decrease because the same physician organizations may serve enrollees from each HMO. Yet variability in access to care performance among capitated physician organizations may be substantial, because physician organizations can vary greatly in characteristics that can affect access to care.11 Recognizing this new reality, the Pacific Business Group on Health recently issued its first "Physician Value Check Survey Report," which included several access to care measures reported by individual physician organizations (Pacific Business Group on Health 1997). 3. DeterminingAppropriate Organizational Characteristics to Measure. Clearly, one challenge facing researchers that use surveys for policy purposes is to determine what organizational characteristics to measure, and how they affect access to care for vulnerable populations. In the past, researchers created groupings or classifications of HMOs based on the type of physician organization or network that provided services and its relationship to the HMO (e.g., group/staff HMO versus IPA HMO versus network HMO). However, as HMOs grow and evolve, "mixed"-model HMOs have become more prevalent, so that comparing group, staff, network, and IPA model HMO performance becomes less meaningful. Moreover, multiple other characteristics of capitated organizations (whether HMOs or capitated physician organizations) can affect access to care, such as methods of clinical management and payment to individual physicians. One approach is to measure each important dimension of a sample of capitated organizations and relate scores on those dimensions to access to care performance. Some work has begun on conceptualization of important dimensions of capitated physician organizations (Conrad et al. 1996; Kralewski et al. 1996). Yet there are numerous measurement and interpretation challenges, including the fact that physician organizations change simultaneously along multiple dimensions. For example, organizations may attempt to mix and match one factor (e.g., type of payment to individual physicians) with another factor (e.g., type of utilization management) to attempt to create a desired effect on utilization and access to care and quality of care. This "bundling" of characteristics (or correlation among them) makes it difficult to determine the independent effects of each dimension on access to care. A longer-term solution to the challenge is to measure and obtain substantial information on each capitated organization's processes and performance. Such data would become the building block for population-based analyses across organizations. Over time in some areas, much improved data collection processes and clinical information systems likely will produce large amounts of comparable, detailed information on a routine basis for each organization

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and thus for all organizations. Consumers would obtain information that they need to choose individual plans and provider organizations, while policymakers would obtain information that they need to formulate policies across plans and provider organizations. Obviously, given the rudimentary state of clinical information systems and reporting by physician organizations, this is not an immediate reality anywhere.

SUMMARY Although results are mixed regarding access to care for vulnerable HMO enrollees, enough of the results are negative to raise some concerns about access to care for HMO enrollees with chronic conditions and diseases. Several emerging organizational changes have the potential to change access to care for the vulnerable HMO enrollees. The shift in cost-cutting from fragmented clinical management of specific types of services at a point in time toward more integrated clinical management of all services for specific types of patients across time may improve access to care, as it increased efforts to attract and retain HMO enrollees. The increased importance of capitated provider organizations within the health system may restrict access in some ways, and expand access in others. More research is needed on the effects of these changes, and of other important organizational characteristics, on access to care and quality of care. For researchers examining access to care for vulnerable HMO enrollee populations, these changes create challenges to determine the most appropriate measures of access to care to use, and the most appropriate organizations and organizational characteristics to measure. Over time, the extent of improvement in access to care will depend on many factors, including changes in market "ground rules" that can provide capitated organizations with more incentives to improve care for vulnerable HMO enrollees. As a result, the pace of access to care improvement will depend heavily on the demands of both purchasers and consumers to effect these market incentive changes.

NOTES 1. Competition within the health system has a relatively short history. The rapid expansion of managed care plans (HMOs and PPOs) began in the early 1980s in response to strong employer reaction to high premium inflation during that


2.

3. 4.

5.

6.

7.

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period. Whereas a burst of competition helped slow high healthcare expenditure growth rates during the mid-1980s, high premium inflation returned in the late 1980s and early 1990s. Employers reacted strongly to that high premium inflation, triggering or hastening a series of health system changes (Miller 1996b). The spread ofMedicare HMOs has reinforced cost-cutting trends for capitated provider organizations, because when Medicare FFS beneficiaries become HMO enrollees, FFS provider income can fall more quickly than capitated revenues rise. HMOs that receive 95 percent of the Adjusted Average Per Capita Cost (AAPCC), keep, for example, 15 percent of that amount, and pay providers the remaining 85 percent, or about 80 percent of the average Medicare FFS expenditure in the county (i.e., the AAPCC). Even with favorable selection, most provider organizations have strong incentives to cut costs in order to profit from capitated Medicare enrollment. Analysis of characteristics and utilization patterns of disenrollees is another potential category of evidence on access to care for vulnerable HMO enrollee populations (e.g., see Cox and Hogan 1997; Morgan et al. 1997). Interpreting some ofthese results is not straightforward. For example, although HMO enrollees in poor health (or those with activity of daily living [ADL] impairments) had fewer hospital days, they had significantly higher admission rates compared to similar FFS enrollees. For those who see admission rates as a measure of access, this suggests that hospital access was similar or better for HMO enrollees in poor health than for a similar group of FFS enrollees. On the other hand, higher admission rates could be a measure of worse quality, if higher admission rates were due to higher readmission rates or to a delay in needed outpatient care. A 1996-1997 survey indicated that 54 percent of physicians were in practices accepting capitation for at least some of their patients (including 70 percent of PCPs and 43 percent of specialists; see Lake and Peter 1997). However, the brief report gave no statistics by size of organization. This growth has been facilitated by hospital systems or physician practice management companies that supply capital for practice acquisition, information systems, and facilities and, to some extent, supply financial and clinical management expertise that previously had been barriers to forming large physician organizations. Moreover, interest in PSOs and direct contracting, methods of accepting capitated payment without HMO status, recently has increased markedly (Cochrane 1997a,b; Grant 1997; Physician Payment Review Commission

1997). 8. For a detailed description of another "team care" approach for HMO enrollees with congestive heart failure, see Brass-Mynderse (1996). 9. Since some capitated practices do not pay individual physicians capitation (Remler et al. 1997), capitated payment to individual physicians would account for less than 10 percent of total physician income in 1995. 10. For the 70 percent of physicians who are not full owners of a solo practice, other

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factors also were considered in determining their compensation in 1996-1997, including patient satisfaction surveys (affecting 23 percent of such physicians), measures of quality of care (18 percent), and practice profiles (16 percent) (Lake and Peter 1997). 11. When a single HMO or capitated delivery system controls several different physician organizations in a geographic area, access to care performance may differ among these organizations. In that case, it becomes important to measure access to care at the delivery system's operating unit (physician organization) level, which often covers a specific local geographic area.

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