To the Editor.—Drs Cher and Lenert1use Medicare records for California to examine
the issue of whether health maintenance organizations (HMOs) provide less
potentially ineffective care at the end of life. Unfortunately, the reporting
of Medicare inpatient stay data for HMO enrollees is known to be incomplete,
which puts into doubt the validity of their findings. Care for HMO enrollees
is provided on a capitation basis, rather than fee-for-service (FFS), and,
consequently, hospitals do not have a financial incentive to report information
to the Health Care Financing Administration (HCFA) on stays of HMO enrollees.
Perhaps as many as two thirds of HMO stays are missing from HCFA's inpatient
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