A new study suggests that between 1998 and 1999, Medicare managed-
care plans did not have a positive effect on the appropriate use of
carotid endarterectomy (CEA) or outcomes, failing to deliver on
their promise, the researchers say.

"We were surprised that Medicare patients with managed-care
insurance didn't seem to have any benefit as far as lower rates of
overuse of carotid surgery or better outcomes, and in fact, it
looked like they were less likely to be referred to high-volume
providers," lead author Ethan A. Halm, MD, from the Mount Sinai
School of Medicine, in New York, told Medscape Neurology &
Neurosurgery.

"The managed-care plans had the motive, the means, and the
opportunity to try to prevent overuse and selectively refer to high-
quality providers, but they didn't do it," he said.

Their analysis appears in the December issue of the American Journal
of Medical Quality.

CEA a Good Marker

Managed care became the dominant form of healthcare insurance during
the 1990s, with advocates saying that these organizations would
improve quality of care and outcomes while reducing costs. The
improvements would be obtained by, among other interventions,
precertifying elective procedures for their appropriateness and
selective referral of patients to high-quality doctors and
hospitals.

In this analysis, Dr. Halm and colleagues looked to see whether the
promise of managed care had been fulfilled by focusing on its effect
on the use of CEA among Medicare beneficiaries in New York State
between January 1, 1998 and June 30, 1999.

"One of the reasons that we thought this was a good procedure to
look at the impact of managed care is that there have been
randomized, controlled trials outlining who benefits and in what
situations for carotid surgery that have been published for years,
and both the American Heart Association and the American Stroke
Association had set guidelines on what is considered appropriate or
inappropriate patients to have carotid surgery," Dr. Halm said.

In addition, it is "widely known" that high-volume surgeons and
hospitals have better outcomes for carotid surgery, and the managed-
care plans would have access to this information, he pointed out.

In the current study, the researchers looked at whether Medicare
patients who were enrolled in Medicare Choice (MC) managed care
plans (the precursor to Medicare's current MC plans) had lower rates
of inappropriate CEA, had their operations performed more frequently
by high-volume surgeons or hospitals, or had better perioperative
outcomes than those enrolled in fee-for-service (FFS) plans.

Clinical data were abstracted from medical records for 8691 FFS
patients and 897 MC patients undergoing CEA to assess
appropriateness and outcomes, including death and stroke within 30
days of surgery. Patients in both groups had similar indications for
surgery, perioperative risk, and comorbidities, they note.

In the end, there were no differences in inappropriateness between
FFS and MC patients, and MC patients were in fact less likely to be
referred to either a high-volume surgeon or a high-volume hospital
than FFS patients (P < .05).

Nor were there differences between groups in risk-adjusted rates of
death or stroke (OR 0.97; 95% CI, 0.69 ¡V 1.37).

Because CEA is always elective and there are good published data
upon which to make informed decisions, the conclusion must be that
these plans did not, for whatever reason, avail themselves of them,
Dr. Halm said. "This is something they were really set up to do,
that they had access to do, and they just failed to do it."


The researchers also carried out a follow-up survey of plan medical
directors to see whether they had missed plans that were actively
trying to use evidence-based criteria to send patients to high-
quality providers or prevent overuse through utilization-review
mechanisms. "None of them had any procedure-specific utilization
review guidelines they were using," he added.

Instead, he noted, "they seemed largely to be focusing on
contracting based on negotiated cost, not really based on either the
quality of the docs or the hospitals that were delivering the care.
Unfortunately, even though they had financial incentives to prevent
overuse of inappropriate care, they weren't using the second
utilization review mechanism actually set up to do that in a
structured or guideline-driven way."

"Managed Care Lite"


"It's worth saying that this time period represents close to the
apex of managed care's intrusiveness and choice restriction, when
the managed-care backlash was happening," Dr. Halm added. "This
wasn't a test of the 'managed care lite' that we have now, so if
they would have been able to do something, they should have been
doing it back then, but they didn't."

They plan to do some further analyses in this area, he said. "One is
to try to come up with an algorithm that will help neurologists,
surgeons, and referring docs to evaluate which patients are the best
candidates for carotid surgery and to help individualize the short-
term risk of complications for a given patient to help inform
decisions about who should go to surgery and who might be too high
risk."

They are also looking at differences by race in outcomes and
appropriateness, he noted.

The study was supported by the Agency for Healthcare Research and
Quality, the Center for Medicare and Medicaid Services, and by the
Robert Wood Johnson Foundation.

Am J Med Qual. 2008;23:448-456. Abstract