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Impact of Managed Care on the Treatment, Costs, and Outcomes of Fee-for-Service Medicare Patients with Acute Myocardial Infarction


  • M. Kate Bundorf,

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    • Address correspondence to M. Kate Bundorf, Ph.D., M.B.A., M.P.H., Stanford University School of Medicine, HRP Redwood Building, Room 257, Stanford, CA 94305-5405. Kevin A. Schulman, M.D., Judith A. Stafford, M.S., and James G. Jollis, M.D., are with Duke University Medical Center. Darrell Gaskin, Ph.D., is with Johns Hopkins Bloomberg School of Public Health in Baltimore. José J. Escarce, M.D., Ph.D., is with the David Geffen School of Medicine at UCLA and RAND Health Program.

  • Kevin A. Schulman,

  • Judith A. Stafford,

  • Darrell Gaskin,

  • James G. Jollis,

  • José J. Escarce

  • We gratefully acknowledge financial support from the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization initiative.

  • This work was also supported by contract 500-96-P623, sponsored by the Delmarva Foundation for Medical Care, Inc., and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), U.S. Department of Health and Human Services, both in Baltimore. The contents of this publication do not necessarily reflect the views of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care.


Objective. To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients.

Data Sources/Study Setting. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996.

Study Design. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics.

Data Collection/Extraction Methods. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital.

Principal Findings. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets.

Conclusions. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.