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Medicare managed care plans provide no benefit to patients undergoing carotid endarterectomy, study finds

Friday, December 12 2008 | Comments

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What's This? Medicare managed care (MC) plans appear to have had no beneficial impact on procedure appropriateness, referral to high-volume providers or clinical outcomes in Medicare beneficiaries undergoing carotid endarterectomy (CEA), researchers report.

Medicare MC plans were developed with the goal of controlling health care costs while improving the quality of health care, the authors noted, adding that the plans have both financial and quality of care incentives to prevent overuse of procedures and poor surgical outcomes. They sought to determine whether Medicare patients enrolled in Medicare MC plans had lower rates of inappropriate CEAs, operations performed more frequently by high-volume surgeons or hospitals or better perioperative outcomes relative to patients enrolled in fee-for-service (FFS) Medicare.

For the study, the medical records of 897 patients with Medicare Choice MC plans who underwent CEA were compared with those of 8,691 similar patients with traditional fee-for-service (FFS) Medicare coverage. CEA appropriateness was based on an analysis of the risks and benefits of the procedure in individual patients, as measured by the RAND appropriateness method.

There were no significant differences in the rates of inappropriate surgery between the FFS (8.6 percent) and MC groups (8.4 percent). In addition, the reasons for inappropriate CEA in the FFS and MC groups were also similar.

The likelihood of being operated on by a vascular or general surgeon (the two most common types of surgeons performing CEA) was similar between the two groups. However, the FFS patients were significantly more likely to be operated on in higher volume hospitals than were the MC patients (109.9 cases/year vs. 89.8 cases/year, respectively), while a significantly greater proportion of the MC patients underwent CEA in cities with 1 million residents or more (87.9 percent) compared with the FFS patients (64 percent).

There were no differences in unadjusted rates of the combined endpoint of perioperative death or nonfatal stroke between the FFS (4.2 percent) and MC patients (4.4 percent). Both groups were similar in terms of the rates of death, nonfatal stroke and myocardial infarction and risk-adjusted rates of death or stroke.

"[W]hile MC plans had the time, opportunity, evidence-based guidelines and financial and quality incentives to rationalize the use of CEA, they did not have a positive impact on inappropriateness, referral to high-volume providers or clinical outcomes," the researchers concluded. "Whether these findings reflect the fact that MC plans tried to exert such influence but failed or did not try at all is a worthy subject for future research."

The study appeared in the November/December issue of the American Journal of Medical Quality.

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