Managed Care Insurance and Use of Higher-Mortality Hospitals—Reply

In Reply: Dr Ensor and colleagues misinterpret the mortality rates in Table 1 of our article, which are not adjusted for severity of illness or other preoperative risk factors. These raw mortality rates should not be used to compare outcomes of managed care and FFS-insured patients because the 2 groups of patients are known to differ. Also, while insurers are not the only participants in the choice of hospital, and patient convenience (particularly with respect to travel distance) is also an important factor,¹ it is difficult to imagine how this convenience factor would differ for patients in managed care plans and those with FFS insurance after controlling for travel distance (the "straight-line" distance method we used has been shown to correlate highly with actual travel times).² There is little reason to believe that patients with managed care insurance would have a great deal more difficulty with transportation to hospitals than patients with FFS insurance, particularly after controlling for relative affluence.