Since the early 1970s, Medicare beneficiaries have been permitted to enroll in health maintenance organizations (HMOs). Increasing numbers of seniors have been doing so because participation reduces out-of-pocket expenses. The federal government views HMOs as a way to contain Medicare costs.

A study in the Journal of the American Medical Association. concludes that Medicare health maintenance organization patients treated for stroke are significantly less likely to be discharged to a rehabilitation hospital or return home than clinically similar patients treated in a fee-for-service (FFS) setting, implying that some HMO patients may be denied optimal care as a result of their payer status.

The study was based on a sample of Medicare patients in 12 states hospitalized for stroke in 1989. Researchers controlled for age, marital status, do-not-resuscitate orders and characteristics of dependency at discharge. They found that:

• About 42 percent of HMO patients were sent to nursing homes after a stroke, whereas only 28 percent of FFS patients went into nursing homes.

• But about 23 percent of FFS patients were discharged to rehabilitation hospitals or units, whereas only 16 percent of HMO patients received this type of care.

Other data on patients' status at discharge suggested that HMO enrollees had a higher prevalence of unresolved neurologic deficits. And the HMO patients had a shorter length of stay in hospitals, 8.6 days compared to FFS patients' 10.5 days.

Although at follow-up no significant differences in relative risk of dying were found between HMO and FFS groups, the authors of the study say that stroke patients admitted to rehabilitation hospitals have a higher likelihood of return to the community and improved functional status.

However the study did not determine whether or not the differences in care represent a judicious use of expensive resources or a withholding of necessary care.

Source: Sheldon Retchin et al., "Outcomes of Stroke Patients in Medicare Fee for Service and Managed Care," Journal of the American Medical Association, July 9, 1997.