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May 18, 1994, Vol 271, No. 19 >
ARTICLE | May 18, 1994

Managed Care Plan Performance Since 1980: Title and subTitle BreakA Literature Analysis FREE

Robert H. Miller, PhD; Harold S. Luft, PhD
[+] Author Affiliations

Reprint requests to University of California—San Francisco, Institute for Health & Aging, Box 0646, Laurel Heights, San Francisco, CA 94143 (Dr Miller).


JAMA. 1994;271(19):1512-1519. doi:10.1001/jama.1994.03510430066037
Text Size: A A A
Published online
Article
References

Objective.  —To compare the health care utilization, expenditure, quality of care, and satisfaction since 1980 of enrollees in managed care and indemnity plans.

Data Sources and Study Selection.  —Studies selected met the following criteria: data from 1980 forward, private insurance or Medicare enrollees, a comparison group, a reasonable attempt at statistical adjustment for noncomparable managed care and indemnity plan enrollees, and peer-reviewed findings (with two exceptions). Few studies on preferred provider organization plan performance met the selection criteria.

Data Synthesis.  —Compared with indemnity plans, health maintenance organization plans had somewhat lower hospital admission rates, 1% to 20% shorter hospital length of stay, the same or more physician office visits per enrollee, less use of expensive procedures and tests, greater use of preventive services, mixed results on outcomes, and somewhat lower enrollee satisfaction with services but higher satisfaction with costs. The evidence does not support the hypothesis that prepaid group practice or staff model health maintenance organizations are more effective than individual practice association or network model health maintenance organizations.

Conclusions.  —Although this literature analysis found several clear patterns of results, several factors, including unmeasured selection bias, diverse and rapidly changing health plans and local market conditions, and relatively few research results, suggest that generalizations must be made with caution.(JAMA. 1994;271:1512-1519)

REFERENCES

1 +
Luft HS. Health Maintenance Organizations: Dimensions of Performance . New York, NY: John Wiley & Sons Inc; 1981;.
2 +
Manning WG, Leibowitz A, Goldberg GA, Rogers WH, Newhouse JP.  A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med . 1984;;310:1505-1510.
3 +
Carey T, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: effects on preventive health care. J Clin Epidemiol . 1990;;43:1213-1220.
4 +
Carey TS, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: lack of effect on pregnancy outcomes and prenatal care. Health Serv Res . 1991;;26:165-181.
5 +
Krieger JW, Connell FA, LoGerfo JP.  Medicaid prenatal care: a comparison of use and outcomes in fee-for-service and managed care. Am J Public Health . 1992;;82:185-190.
6 +
Hurley RE, Freund DA, Paul JE. Managed Care in Medicaid: Lessons for Policy and Program Design . Ann Arbor, Mich: Health Administration Press; 1993;.
7 +
Martin DP, Diehr P, Price KF, Richardson WC.  Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health . 1989;;79:1628-1632.
8 +
Clement DG, Retchin SM, Stegall MH, Brown RS. Evaluation of Access and Satisfaction With Care in the TEFRA Program . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
9 +
Hill J, Brown R, Chu D, Bergeron J. The Impact of the Medicare Risk Program on the Use of Services and Costs to Medicare . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
10 +
Brown RS, Bergeron JW, Clement DG, Hill JW, Retchin SM. The Medicare Risk Program for HMOs: Final Summary Report on Findings From the Evaluation . Princeton, NJ: Mathematica Policy Research Inc; 1993;.
11 +
Brown RS, Hill J. Does Model Type Play a Role in the Extent of HMO Effectiveness in Controlling the Utilization of Services? Princeton, NJ: Mathematica Policy Research Inc; 1993;.
12 +
Retchin SM, Brown R, Cohen R, et al. The Quality of Care in TEFRA HMOs/CMPs: Final Version . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
13 +
Newcomer R, Harrington C, Preston S. Satisfaction in the Social/Health Maintenance Organization: A Comparison of Members, Disenrollees, and Those in Fee for Service . San Francisco, Calif: Institute for Health and Aging, University of California—San Francisco; 1993;.
14 +
Greenfield S, Nelson EC, Zubkoff M, et al.  Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA . 1992;;267:1624-1630.
15 +
Johnson AN, Dowd B, Morris NE, Lurie N.  Differences in inpatient resource use by type of health plan. Inquiry . 1989;;26:388-398.
16 +
Stafford RS.  Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health . 1990;;80:313-315.
17 +
Stafford RS.  The impact of nonclinical factors on repeat cesarean section. JAMA . 1991;;265:59-63.
18 +
Retchin SM, Brown B.  The quality of ambulatory care in Medicare health maintenance organizations. Am J Public Health . 1990;;80:411-415.
19 +
Hlatky MA, Lee KL, Botvinick EH, Brundage BH.  Diagnostic test use in different practice settings: a controlled comparison. Arch Intern Med . 1983;;143:1886-1889.
20 +
Young GJ, Cohen BB.  Inequities in hospital care: the Massachusetts experience. Inquiry . 1991;; 28:255-262.
21 +
Cummings SR, Stein MJ, Hansen B, Richard RJ, Gerbert B, Coates TJ.  Smoking counseling and preventive medicine: a survey of internists in private practices and a health maintenance organization. Arch Intern Med . 1989;;149:345-349.
22 +
Bredfeldt RC, Brewer ML, Junker JA.  Influences upon reported health promotion by family physicians. Fam Pract Res J . 1990;;9:85-94.
23 +
Tarlov AR, Ware JE Jr, Greenfield S, Nelson ED, Perrin E, Zubkoff M.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA . 1989;;262:925-930.
24 +
Kravitz RL, Greenfield S, Rogers W, et al.  Differences in the mix of patients among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA . 1992;;267:1617-1623.
25 +
McCusker J, Stoddard AM, Sorensen AA.  Do HMOs reduce hospitalization of terminal cancer patients? Inquiry . 1988;;25:263-270.
26 +
Wolfe F, Kleinheksel SM, Spitz PW, et al.  A multicenter study of hospitalization in rheumatoid arthritis: effect of health care system, severity, and regional difference. J Rheumatol . 1986;;13:277-284.
27 +
Yelin EH, Shern MA, Epstein WV.  Health outcomes for a chronic disease in prepaid group practice and fee-for-service settings. Med Care . 1986;; 24:236-246.
28 +
Welch WP.  Health care utilization in HMOs: results from two national samples. J Health Econ . 1985;;4:293-308.
29 +
Braveman PA, Egerter S, Bennett T, Showstack J.  Differences in hospital resource allocation among sick newborns according to insurance coverage. JAMA . 1991;;266:3300-3308.
30 +
Arnould RJ, Debrock LW, Pollard JW.  Do HMOs produce specific services more efficiently? Inquiry . 1984;;21:243-253.
31 +
Stern RS, Juhn PI, Gertler PJ, Epstein AM.  A comparison of length of stay and costs for health maintenance organizations and fee-for-service patients. Arch Intern Med . 1989;;149:1185-1188.
32 +
Bradbury RC, Golec JH, Stearns FE.  Comparing hospital length of stay in independent practice association HMOs and traditional insurance programs. Inquiry . 1991;;28:87-93.
33 +
Rapoport J, Gehlbach S, Lemeshow S, Teres D.  Resource utilization among intensive care patients: managed care vs traditional insurance. Arch Intern Med . 1992;;152:2207-2212.
34 +
Fitzgerald JF, Moore PS, Dittus RS.  The care of elderly patients with hip fracture: changes since implementation of the prospective payment systern. N Engl J Med . 1988;;319:1392-1397.
35 +
Dowd B, Feldman R, Cassou S, Finch M.  Health plan choice and the utilization of health care services. Rev Econ Stat . 1991;;73:85-93.
36 +
Lubeck DP, Brown BW, Holman HR.  Chronic disease and health system performance: care of osteoarthritis across three health services. Med Care . 1985;;23:266-277.
37 +
Norquist GS, Wells KB.  How do HMOs reduce outpatient mental health care costs? Am J Psychiatry . 1991;;148:96-101.
38 +
Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM.  Comparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann Intern Med . 1991;;327:424-429.
39 +
Szilagyi PG, Roghmann KJ, Foye HR, et al.  The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice. JAMA . 1990;;263:2198-2203.
40 +
Wells KB, Hosek SD, Marquis MS.  The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups. Med Care . 1992;;30:412-427.
41 +
Garnick DW, Luft HS, Gardner LB, et al.  Services and charges by PPO physicians for PPO and indemnity patients: an episode of care comparison. Med Care . 1990;;28:894-906.
42 +
Wouters AV.  The cost of acute outpatient primary care in a preferred provider organization. Med Care . 1990;;28:573-585.
43 +
Retchin SM, Brown B.  Management ofcolorectal cancer in Medicare health maintenance organizations. J Gen Intern Med . 1990;;5:110-114.
44 +
McCloskey L, Petitti DB, Hobel CJ.  Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care . 1992;;30:126-135.
45 +
Lessler DS, Avins AL.  Cost, uncertainty, and doctors' decisions: the case of thrombolytic therapy. Arch Intern Med . 1992;;152:1665-1671.
46 +
McCombs JS, Kasper JD, Riley GF.  Do HMOs reduce health care costs? a multivariate analysis of two Medicare HMO demonstration projects. Health Serv Res . 1990;;25:593-613.
47 +
Zwanziger J, Auerbach RR.  Evaluating PPO performance using prior expenditure data. Med Care . 1991;;29:142-151.
48 +
Palsbo SJ, Gold MR. HMO Industry Profile, Volume 3: Financial Performance, 1988 . Washington, DC: Group Health Association of America; 1990;.
49 +
McLaughlin CC.  The effect of HMOs on overall hospital expenses: is anything left after correcting for simultaneity and selectivity? Health Serv Res . 1988;;23:421-442.
50 +
McLaughlin CG.  HMO growth and hospital expenses and use: a simultaneous-equation approach. Health Serv Res . 1987;;22:183-205.
51 +
Hadley J, Swartz K.  The impacts on hospital costs between 1980 and 1984 of hospital rate regulation, competition, and changes in health insurance coverage. Inquiry . 1989;;26:35-47.
52 +
Friedman B, Shortell S.  The financial performance of selected investor-owned and not-for-profit system hospitals before and after Medicare prospective payment. Health Serv Res . 1988;;23:237-267.
53 +
Robinson JC.  HMO market penetration and hospital cost inflation in California. JAMA . 1991;; 266:2719-2723.
54 +
Melnick GA, Zwanziger J.  Hospital behavior under competition and cost-containment policies. JAMA . 1988;;260:2669-2675.
55 +
Hay/Huggins Co. 1992 Hay/Huggins Benefits Report: Executive Summary . Philadelphia, Pa: Hay/ Huggins Co Inc; 1993;.
56 +
KPMG Peat Marwick. Health Benefits in 1992 . Newark, NJ: KPMG Peat Marwick; 1992;.
57 +
Sullivan CB, Miller M, Feldman R, Dowd B.  Employer-sponsored health insurance in 1991. Health Aff . 1992;;11:172-185.
58 +
Foster Higgins. Foster Higgins Health Care Benefits Survey, Report 1: Medical Plans . Princeton, NJ: A. Foster Higgins; 1992;.
59 +
Feldman R, Dowd B, Gifford G.  The effect of HMOs on premiums in employment-based health plans. Health Serv Res . 1993;;27:779-812.
60 +
Gabel J, Formisano R, Lohr B, DiCarlo S.  Tracing the cycle of health insurance. Health Aff . 1991;; 10:48-61.
61 +
Gabel JR.  Perspective: a look at insurance data. Health Aff . 1992;;11:186-190.
62 +
Short PF.  Trends in employee health insurance benefits. Health Aff . 1988;;7:186-196.
63 +
Bernstein AB, Thompson GB, Harlan LC.  Differences in rates of cancer screening by usual source of medical care: data from the 1987 National Health Interview Survey. Med Care . 1991;;29:196-209.
64 +
Ornstein SM, Garr DR, Jenkins RG, et al.  Compliance with five health promotion recommendations in a university-based family practice. J Fam Pract . 1989;;29:163-168.
65 +
Retchin SM, Brown B.  Elderly patients with congestive heart failure under prepaid care. Am J Med . 1991;;90:236-242.
66 +
Retchin SM, Preston J.  Effects of cost containment on the care of elderly diabetics. Arch Intern Med . 1991;;151:2244-2248.
67 +
Retchin SM, Clement DG, Rossiter LF, et al.  How the elderly fare in HMOs: outcomes from the Medicare Competition Demonstration. Health Serv Res . 1992;;27:651-670.
68 +
Preston, JA, Retchin SM.  The management of geriatric hypertension in health maintenance organizations. J Am Geriatr Soc . 1991;;39:683-690.
69 +
Vernon SW, Hughes JI, Heckel VM, Jackson GL.  Quality of care for colorectal cancer in a fee-for-service and health maintenance organization practice. Cancer . 1992;;69:2418-2425.
70 +
Carlisle DM, Siu AL, Keeler EB, et al.  HMO vs fee-for-service care of older persons with acute myocardial infarction. Am J Public Health . 1992;;82: 1626-1630.
71 +
Miller NA.  An evaluation of substance misuse treatment providers used by an employee assistance program. Int J Addict . 1992;;27:533-559.
72 +
MurrayJP, Greenfield S, Kaplan SH, Yano EM.  Ambulatory testing for capitation and fee for service patients in the same practice setting: relationship to outcomes. Med Care . 1992;;30:252-261.
73 +
Wells KB, Hays RD, Burnam MA, Rogers W, Greenfield S, Ware JE Jr.  Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study. JAMA . 1989;;262:3298-3302.
74 +
Rogers WH, Wells KB, Meredith LS, Sturm R.  Burnam MA. Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Arch Gen Psychiatry . 1993;;50:517-525.
75 +
Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware JE Jr.  Patients' ratings of outpatient visits in different practice settings: results from the Medical Outcomes Study. JAMA . 1993;;270:835-840.
76 +
Rossiter LF, Langwell K, Wan TT, Rivnyak M.  Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations: results from the National Medicare Competition Evaluation. JAMA . 1989;;262:57-63.
77 +
Luft HS.  How do health maintenance organizations achieve their 'savings'? rhetoric and evidence. N Engl J Med . 1978;;298:1336-1343.
78 +
Luft HS.  Trends in medical care costs: do HMOs lower the rate of growth? Med Care . 1980;;18:1-16.
79 +
Newhouse JP, Schwartz WB, Williams AP, Witsberger C.  Are fee-for-service costs increasing faster than HMO costs? Med Care . 1985;;23:960-966.
80 +
Ware JE, Brook RH, Rogers WH, et al.  Comparison of health outcomes at a health maintenance organization with those of a fee-for-service care. Lancet . 1986;;1:1017-1022.
81 +
Sloss EM, Keeler EB, Brook RH, et al.  Effect of a health maintenance organization on physiologic health: results from a randomized trial. Ann Intern Med . 1987;;106:130-136.
82 +
Lichtenstein R, Thomas JW, Watkins B, et al.  HMO marketing and selection bias: are TEFRA HMOs skimming? Med Care . 1992;;30:329-346.
83 +
Riley G, Lubitz J, Rabey E.  Enrollee health status under Medicare risk contracts: an analysis of mortality rates. Health Serv Res . 1991;;26:137-163.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Luft HS. Health Maintenance Organizations: Dimensions of Performance . New York, NY: John Wiley & Sons Inc; 1981;.
2 +
Manning WG, Leibowitz A, Goldberg GA, Rogers WH, Newhouse JP.  A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med . 1984;;310:1505-1510.
3 +
Carey T, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: effects on preventive health care. J Clin Epidemiol . 1990;;43:1213-1220.
4 +
Carey TS, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: lack of effect on pregnancy outcomes and prenatal care. Health Serv Res . 1991;;26:165-181.
5 +
Krieger JW, Connell FA, LoGerfo JP.  Medicaid prenatal care: a comparison of use and outcomes in fee-for-service and managed care. Am J Public Health . 1992;;82:185-190.
6 +
Hurley RE, Freund DA, Paul JE. Managed Care in Medicaid: Lessons for Policy and Program Design . Ann Arbor, Mich: Health Administration Press; 1993;.
7 +
Martin DP, Diehr P, Price KF, Richardson WC.  Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health . 1989;;79:1628-1632.
8 +
Clement DG, Retchin SM, Stegall MH, Brown RS. Evaluation of Access and Satisfaction With Care in the TEFRA Program . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
9 +
Hill J, Brown R, Chu D, Bergeron J. The Impact of the Medicare Risk Program on the Use of Services and Costs to Medicare . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
10 +
Brown RS, Bergeron JW, Clement DG, Hill JW, Retchin SM. The Medicare Risk Program for HMOs: Final Summary Report on Findings From the Evaluation . Princeton, NJ: Mathematica Policy Research Inc; 1993;.
11 +
Brown RS, Hill J. Does Model Type Play a Role in the Extent of HMO Effectiveness in Controlling the Utilization of Services? Princeton, NJ: Mathematica Policy Research Inc; 1993;.
12 +
Retchin SM, Brown R, Cohen R, et al. The Quality of Care in TEFRA HMOs/CMPs: Final Version . Princeton, NJ: Mathematica Policy Research Inc; 1992;.
13 +
Newcomer R, Harrington C, Preston S. Satisfaction in the Social/Health Maintenance Organization: A Comparison of Members, Disenrollees, and Those in Fee for Service . San Francisco, Calif: Institute for Health and Aging, University of California—San Francisco; 1993;.
14 +
Greenfield S, Nelson EC, Zubkoff M, et al.  Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA . 1992;;267:1624-1630.
15 +
Johnson AN, Dowd B, Morris NE, Lurie N.  Differences in inpatient resource use by type of health plan. Inquiry . 1989;;26:388-398.
16 +
Stafford RS.  Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health . 1990;;80:313-315.
17 +
Stafford RS.  The impact of nonclinical factors on repeat cesarean section. JAMA . 1991;;265:59-63.
18 +
Retchin SM, Brown B.  The quality of ambulatory care in Medicare health maintenance organizations. Am J Public Health . 1990;;80:411-415.
19 +
Hlatky MA, Lee KL, Botvinick EH, Brundage BH.  Diagnostic test use in different practice settings: a controlled comparison. Arch Intern Med . 1983;;143:1886-1889.
20 +
Young GJ, Cohen BB.  Inequities in hospital care: the Massachusetts experience. Inquiry . 1991;; 28:255-262.
21 +
Cummings SR, Stein MJ, Hansen B, Richard RJ, Gerbert B, Coates TJ.  Smoking counseling and preventive medicine: a survey of internists in private practices and a health maintenance organization. Arch Intern Med . 1989;;149:345-349.
22 +
Bredfeldt RC, Brewer ML, Junker JA.  Influences upon reported health promotion by family physicians. Fam Pract Res J . 1990;;9:85-94.
23 +
Tarlov AR, Ware JE Jr, Greenfield S, Nelson ED, Perrin E, Zubkoff M.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA . 1989;;262:925-930.
24 +
Kravitz RL, Greenfield S, Rogers W, et al.  Differences in the mix of patients among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA . 1992;;267:1617-1623.
25 +
McCusker J, Stoddard AM, Sorensen AA.  Do HMOs reduce hospitalization of terminal cancer patients? Inquiry . 1988;;25:263-270.
26 +
Wolfe F, Kleinheksel SM, Spitz PW, et al.  A multicenter study of hospitalization in rheumatoid arthritis: effect of health care system, severity, and regional difference. J Rheumatol . 1986;;13:277-284.
27 +
Yelin EH, Shern MA, Epstein WV.  Health outcomes for a chronic disease in prepaid group practice and fee-for-service settings. Med Care . 1986;; 24:236-246.
28 +
Welch WP.  Health care utilization in HMOs: results from two national samples. J Health Econ . 1985;;4:293-308.
29 +
Braveman PA, Egerter S, Bennett T, Showstack J.  Differences in hospital resource allocation among sick newborns according to insurance coverage. JAMA . 1991;;266:3300-3308.
30 +
Arnould RJ, Debrock LW, Pollard JW.  Do HMOs produce specific services more efficiently? Inquiry . 1984;;21:243-253.
31 +
Stern RS, Juhn PI, Gertler PJ, Epstein AM.  A comparison of length of stay and costs for health maintenance organizations and fee-for-service patients. Arch Intern Med . 1989;;149:1185-1188.
32 +
Bradbury RC, Golec JH, Stearns FE.  Comparing hospital length of stay in independent practice association HMOs and traditional insurance programs. Inquiry . 1991;;28:87-93.
33 +
Rapoport J, Gehlbach S, Lemeshow S, Teres D.  Resource utilization among intensive care patients: managed care vs traditional insurance. Arch Intern Med . 1992;;152:2207-2212.
34 +
Fitzgerald JF, Moore PS, Dittus RS.  The care of elderly patients with hip fracture: changes since implementation of the prospective payment systern. N Engl J Med . 1988;;319:1392-1397.
35 +
Dowd B, Feldman R, Cassou S, Finch M.  Health plan choice and the utilization of health care services. Rev Econ Stat . 1991;;73:85-93.
36 +
Lubeck DP, Brown BW, Holman HR.  Chronic disease and health system performance: care of osteoarthritis across three health services. Med Care . 1985;;23:266-277.
37 +
Norquist GS, Wells KB.  How do HMOs reduce outpatient mental health care costs? Am J Psychiatry . 1991;;148:96-101.
38 +
Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM.  Comparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann Intern Med . 1991;;327:424-429.
39 +
Szilagyi PG, Roghmann KJ, Foye HR, et al.  The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice. JAMA . 1990;;263:2198-2203.
40 +
Wells KB, Hosek SD, Marquis MS.  The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups. Med Care . 1992;;30:412-427.
41 +
Garnick DW, Luft HS, Gardner LB, et al.  Services and charges by PPO physicians for PPO and indemnity patients: an episode of care comparison. Med Care . 1990;;28:894-906.
42 +
Wouters AV.  The cost of acute outpatient primary care in a preferred provider organization. Med Care . 1990;;28:573-585.
43 +
Retchin SM, Brown B.  Management ofcolorectal cancer in Medicare health maintenance organizations. J Gen Intern Med . 1990;;5:110-114.
44 +
McCloskey L, Petitti DB, Hobel CJ.  Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care . 1992;;30:126-135.
45 +
Lessler DS, Avins AL.  Cost, uncertainty, and doctors' decisions: the case of thrombolytic therapy. Arch Intern Med . 1992;;152:1665-1671.
46 +
McCombs JS, Kasper JD, Riley GF.  Do HMOs reduce health care costs? a multivariate analysis of two Medicare HMO demonstration projects. Health Serv Res . 1990;;25:593-613.
47 +
Zwanziger J, Auerbach RR.  Evaluating PPO performance using prior expenditure data. Med Care . 1991;;29:142-151.
48 +
Palsbo SJ, Gold MR. HMO Industry Profile, Volume 3: Financial Performance, 1988 . Washington, DC: Group Health Association of America; 1990;.
49 +
McLaughlin CC.  The effect of HMOs on overall hospital expenses: is anything left after correcting for simultaneity and selectivity? Health Serv Res . 1988;;23:421-442.
50 +
McLaughlin CG.  HMO growth and hospital expenses and use: a simultaneous-equation approach. Health Serv Res . 1987;;22:183-205.
51 +
Hadley J, Swartz K.  The impacts on hospital costs between 1980 and 1984 of hospital rate regulation, competition, and changes in health insurance coverage. Inquiry . 1989;;26:35-47.
52 +
Friedman B, Shortell S.  The financial performance of selected investor-owned and not-for-profit system hospitals before and after Medicare prospective payment. Health Serv Res . 1988;;23:237-267.
53 +
Robinson JC.  HMO market penetration and hospital cost inflation in California. JAMA . 1991;; 266:2719-2723.
54 +
Melnick GA, Zwanziger J.  Hospital behavior under competition and cost-containment policies. JAMA . 1988;;260:2669-2675.
55 +
Hay/Huggins Co. 1992 Hay/Huggins Benefits Report: Executive Summary . Philadelphia, Pa: Hay/ Huggins Co Inc; 1993;.
56 +
KPMG Peat Marwick. Health Benefits in 1992 . Newark, NJ: KPMG Peat Marwick; 1992;.
57 +
Sullivan CB, Miller M, Feldman R, Dowd B.  Employer-sponsored health insurance in 1991. Health Aff . 1992;;11:172-185.
58 +
Foster Higgins. Foster Higgins Health Care Benefits Survey, Report 1: Medical Plans . Princeton, NJ: A. Foster Higgins; 1992;.
59 +
Feldman R, Dowd B, Gifford G.  The effect of HMOs on premiums in employment-based health plans. Health Serv Res . 1993;;27:779-812.
60 +
Gabel J, Formisano R, Lohr B, DiCarlo S.  Tracing the cycle of health insurance. Health Aff . 1991;; 10:48-61.
61 +
Gabel JR.  Perspective: a look at insurance data. Health Aff . 1992;;11:186-190.
62 +
Short PF.  Trends in employee health insurance benefits. Health Aff . 1988;;7:186-196.
63 +
Bernstein AB, Thompson GB, Harlan LC.  Differences in rates of cancer screening by usual source of medical care: data from the 1987 National Health Interview Survey. Med Care . 1991;;29:196-209.
64 +
Ornstein SM, Garr DR, Jenkins RG, et al.  Compliance with five health promotion recommendations in a university-based family practice. J Fam Pract . 1989;;29:163-168.
65 +
Retchin SM, Brown B.  Elderly patients with congestive heart failure under prepaid care. Am J Med . 1991;;90:236-242.
66 +
Retchin SM, Preston J.  Effects of cost containment on the care of elderly diabetics. Arch Intern Med . 1991;;151:2244-2248.
67 +
Retchin SM, Clement DG, Rossiter LF, et al.  How the elderly fare in HMOs: outcomes from the Medicare Competition Demonstration. Health Serv Res . 1992;;27:651-670.
68 +
Preston, JA, Retchin SM.  The management of geriatric hypertension in health maintenance organizations. J Am Geriatr Soc . 1991;;39:683-690.
69 +
Vernon SW, Hughes JI, Heckel VM, Jackson GL.  Quality of care for colorectal cancer in a fee-for-service and health maintenance organization practice. Cancer . 1992;;69:2418-2425.
70 +
Carlisle DM, Siu AL, Keeler EB, et al.  HMO vs fee-for-service care of older persons with acute myocardial infarction. Am J Public Health . 1992;;82: 1626-1630.
71 +
Miller NA.  An evaluation of substance misuse treatment providers used by an employee assistance program. Int J Addict . 1992;;27:533-559.
72 +
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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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