conditions). With respect to continuity, the results showed some overlap on scores on the high end among the three types of plans studied, but showed that the prepaid plans produced a range of scores that extended much lower than those for the fee-for-service plans. The lower comprehensiveness of care4 score for HMOs may reflect "organizational access barriers and/or HMO referral practices" (p. 1584). The authors suggest that HMO patients may opt to see other providers rather than wait to see their own providers. Also, HMOs rely on primary care providers more than IPAs or fee-for-service plans do. Thus, in that study HMO patients were less likely than their IPA and fee-for-service counterparts to see a specialist for primary care. (Less than 5 percent of HMO patients received primary care from a specialist.5

Shaughnessy and colleagues (1994) found most home health care outcomes in fee-for-service plans to be better than those in HMOs. (There were no differences in outcomes for wound patients and patients receiving intravenous therapy.) Schlenker (forthcoming) found that HMO home health care costs are "significantly lower" than those in fee-for-service plans, even after controlling for case mix, demographic characteristics, region, and agency factors. Despite reduced expenditures for home health care, HMOs did not substitute other services for home health care services. Shaughnessy and colleagues (1994) observed that "relative to the fee-for-service sector, it appears that HMOs tend to approach some aspects of home health care with more of a 'maintenance' philosophy than a rehabilitative or restorative philosophy" (p. 219). If true, this would have enormous implications for the vulnerable populations under discussion here, whose very quality of life could depend on achieving or maintaining maximum function. Shaughnessy and colleagues noted that the findings were most pronounced among HMO patients whose care was contracted out to home health agencies. Thus, the ways in which managed care plans organize the provi-


Comprehensiveness" measured the total number of health care visits and the number of visits during the preceding 6 months.


Some analysts believe that primary care provided by primary care physicians rather than specialists improves continuity and comprehensiveness and does not compromise quality of care or outcomes (Franks et al., 1992).

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