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Can decision-trees and economic incentives help reduce utilization and cost of health care services?

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Can decision-trees and economic incentives help reduce utilization and cost of health care services?
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Jones, Pamela J
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English
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xi, 169 leaves : ; 29 cm

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Subjects / Keywords:
Health maintenance organizations -- Cost control ( lcsh )
Decision trees ( lcsh )
Clinical medicine -- Decision making ( lcsh )
Medical care -- Cost control ( lcsh )
Clinical medicine -- Decision making ( fast )
Decision trees ( fast )
Health maintenance organizations -- Cost control ( fast )
Medical care -- Cost control ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 153-169).
General Note:
School of Public Affairs
Statement of Responsibility:
by Pamela J. Jones.

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University of Colorado Denver
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Auraria Library
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ocm40273803
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LD1190.P86 1998d .J66 ( lcc )

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Full Text
CAN DECISION-TREES AND ECONOMIC INCENTIVES
HELP REDUCE UTILIZATION AND COST OF HEALTH CARE SERVICES?
by
Pamela J. Jones
B.S., Colorado State University, 1975
M.S.S., University of Denver, 1988
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Public Administration
1998


1998 Pamela J. Jones
All rights reserved.


This thesis for the Doctor of Philosophy-
degree by
Pamela J. Jones
has been approved
by
Sheri Eisert
Bernard W. Nelson
Date


Jones, Pamela Jean (Ph.D., Public Administration)
Can Decision-Trees and Economic Incentives Help Reduce
Utilization and Cost of Health Care Services?
Thesis directed by Professor Robert Gage
ABSTRACT
In response to rising health care costs, private and
public participants in health care delivery have
implemented a number of initiatives to control
utilization and cost of health care services. One of
those initiatives is the application of clinical
decision-trees as a management tool in the delivery of
health services to control utilization. Decision-trees,
also called algorithms or pathways, have been most
commonly used in health maintenance organizations.
Another initiative is change in payment methods to
physicians with the inclusion of economic incentives.
Cost control may be linked to incentive payments made to
the physician when they share in savings that accrue to
the health maintenance organization.
The major issues examined in this dissertation are
whether or not the use of clinical decision-trees along
with physician economic incentives reduce health care
utilization and cost compared to indemnity insurance.
The basic theory here is that utilization and cost are
iv


reduced when an algorithm is applied to the delivery of
services and physician economic incentives are also
present to reward adherence to that algorithm.
This research found clinical decision-trees reduce
utilization. The study also found that discounted
physician payments negotiated by HMO contribute to
reduction of cost of health services compared to the
traditional indemnity insurance environment. Impact on
cost reduction through physician economic incentives,
while present in some cases, could not be explicitly
quantified in this study.
This abstract accurately represents the content of
the candidate's thesis. I recommend its publication.
V


DEDICATION
This dissertation is dedicated to my sons, Ben and Chris.


ACKNOWLEDGMENT
My sincere thanks to Dr. Robert Gage for serving as the
Chairman of my Dissertation Committee and for sharing his
wisdom and patience with me.
I also thank Dr. Sheri Eisert, Dr. Bernard Nelson and Dr.
John Sbarbaro for sharing their knowledge and kind
guidance.
And, I thank my dear husband Ken for his generous support
during this project.


CONTENTS
CHAPTER
1 INTRODUCTION............................1
The Problem........................3
Hypotheses.........................4
2 LITERATURE REVIEW.......................7
The HMO Industry...................8
Staff Model HMO..............12
Group Model HMO..............12
Network Model HMO............14
IPA Contracted HMO...........15
Market Forces and the HMO.........17
Physician Payment Methods.........19
The Role of the Physician and
Economic Impact..............21
Balancing Economics and Ethics....23
Payment Method and Economic
Incentives...................25
viii


Staff and Group Model HMOs.,.25
Network and IPA Model HMOs.,.26
Clinical Decision-Trees...........31
Gauging Appropriate Use
of Services.............33
Standard Processes of Care...36
Otitis Media.................40
3 EMPIRICAL ANALYSIS.....................50
Methods...........................50
Hypotheses...................51
Data Description.............53
Patients, Providers and
Payers.......................56
Model........................57
Model A.................58
Model B.................58
Clinical Decision-Trees......59
Referral Processes...........65
Physician Payment Methods .... 69
IX


Results
72
Analysis Limitations...............80
4 CONCLUSIONS.............................84
Utilization.......................8 6
Cost...............................92
Implications for Public Policy....97
Economic Incentives..........9 9
Training the Doctor..........102
Clinical Efficacy............103
APPENDIX
A. Questionnaire..........................106
B. Data Description.......................109
C. Clinical Decision-Trees................Ill
D. Referral Guidelines...................12 9
E. Physician Payment Methods..............141
GLOSSARY....................................144
BIBLIOGRAPHY................................14 9
x


TABLES
Table
2.1 Physician Payment Methods in HMOs
3.1 Colorado Residents and HMO Enrollment
3.2 Providers Involved in the Treatment of Acute Otitis Media
3.3 HMO Application of Clinical Decision-Trees
3.4 Referral and Precertification for Surgery-
3.5 Physician Payment Methods
3.6 Cost of Tympanostomy Tubes Surgery
3.7 Acute Otitis Media Infection Rates
3.8 Average Surgeries Per 1,000 Infections
3.9 Summary Results of Chi Square Test of Independence for Hypothesis One
3.10 Summary of Cost Differences
xi


CHAPTER 1
INTRODUCTION
Many initiatives have been implemented or proposed
to address use and cost of health care services. One
approach to managing health care and health care costs
is the structured use of decision-trees and associated
information. Along with requiring physicians to adhere
to clinical decision-trees when requesting approval to
provide services to a member of an HMO, the physician
may also be required to provide services within a
payment model that provides economic incentives to
control utilization and cost.
Does application of an algorithm to health care
delivery impact utilization and cost reduction compared
to none? Do physician payment incentives assist in
achieving the same goals reduction of utilization and
cost as compared to an environment where financial
incentives are not in use? Decision-frameworks or
algorithms are becoming more widely used by health
1


maintenance organizations (HMOs) to control the
utilization and cost of health services. Clinical
decision-trees and algorithms are also referred to as
pathways, protocols or care plans. They are written
descriptions of process of care in terms of sequence and
timing in order to manage health care for patients.
Some HMOs provide economic incentives to encourage
physicians to adhere to decision-frameworks.
To provide a basis for understanding the HMO
environment, the role of the physician is examined in
this study as it relates to the physician's required use
of decision-trees in directing patient care. Emphasis
is placed on examining the impact of provider decision-
making on utilization and cost of health services
through structured use of a decision-tree. Treating
Otitis Media with the surgical placement of Tympanostomy
Tubes is used as the vehicle to answer the research
questions. The research hypotheses that follow support
the view that application of a treatment algorithm
reduces insertion of Tympanostomy Tubes (25-35%) with a
2


corresponding reduction in cost.(Kleinman, et al., 1994,
p. 1250-1255)
The Problem
Otitis Media, ear infection, affects two-thirds of
American children by the age of two.(Kleinman, et al.,
1994, p. 1250-1255) It is considered the most common
diagnosis of children and the second most common
diagnosis in medicine.(Kleinman, et al., 1994, p. 1250-
1255) One approach to treating Otitis Media has been
Myringotomy with insertion of Tympanostomy Tubes. This
procedure involves the insertion of small cubes through
the tympanic membrane to reduce the frequency of
recurrent Acute Otitis Media (AOM).(Kleinman, et al.,
1994, p. 1250-1255)
It is estimated that approximately 670,000
surgeries to insert Tympanostomy Tubes were conducted in
1988 in the U.S., making this procedure the most common
surgery for children.(Kleinman, et al., 1994, p. 1250-
1255) The use of these tubes has become a common
3


treatment for ear infections because of the immediate
impact on symptoms. Parents also place significant
pressure on providers to insert the tubes because of
inconveniences and illness symptoms associated with ear
infections in children.
In response to concerns about overuse and
unnecessary costs, algorithms limiting physician
flexibility in using this surgery have merged and are
frequently found in managed care organizations.
Additional concerns with this surgery have been focused
on otoeh sequelae that resulted in long-term tympanic
membrane damage. The procedure is a simple, low-risk
surgery for which the surgeons and facilities are
reimbursed approximately $1,800 to $2,600 in a fee-for-
service environment. Tympanostomy tubes are more
expensive than other approaches to treating AOM.
Hypotheses
To evaluate whether decision-trees and
corresponding payment incentives impact utilization and
4


cost in the HMO environment compared to the non-HMO
environment, two hypotheses were tested:
Hypothesis One: The application of decision-frameworks
to the use of Tympanostomy Tubes reduces utilization of
the surgery in HMOs as compared to a non-HMO
organization where physicians have broader discretion in
treating AOM.
Hypothesis Two: Despite variations in payments to
physicians in different HMOs, economic incentives
provided to physicians in an HMO assist in reducing
costs associated with the placement of Tympanostomy
Tubes as compared to a non-HMO organization.
This study is unique because it compares two
approaches of controlling access and cost in the HMO
environment to the absence of such controls in the non-
HMO environment.
I
5


The chapters that follow seek to answer the
research questions. A review of literature related to
health care decision-trees and the effects of various
financial incentives on physician behavior in HMOs is
offered to establish a basis for understanding the
research questions. Next, the impact of decision-
frameworks and financial incentives is discussed. The
surgical procedure that inserts Tympanostomy Tubes in
eardrums is used to address the research questions,
followed by an empirical analysis that tests the
hypotheses. The study concludes with a summary of the
results of the analysis and their relevance to public
affairs, health care policy and recommendations for
further study.


CHAPTER 2
LITERATURE REVIEW
This study examines control of utilization and cost
through application of decision-trees and physician
economic incentives. These processes are management
tools found in the HMO environment. Decision-trees are
applied by HMOs to determine if a health service
proposed to treat a certain condition is appropriate.
Economic incentives paid to physicians in the HMO
typically require the physician to adhere to decision-
trees and other health plan rules. The challenge is to
determine if there is theoretical foundation for broader
application of these tools in the health care industry.
The following discussion reviews literature on the HMO
industry, physician payment methods and clinical
decision-trees to provide background and foundation for
the study.
Societal demand for change in the cost of health
care has resulted in many initiatives. One has been the
7


establishment of HMDs. Use of clinical decision-trees
and physician economic incentives are commonly found in
HMOs. To understand the impact on utilization and cost,
it is important to understand how decision-trees and
economic incentives are implemented in HMOs.
The HMO Industry
HMOs are prepaid, organized health plans that place
emphasis on physician management and enhanced management
of utilization. HMOs have demonstrated cost reduction a
number of ways, including but not limited to less
hospitalization and the ability to negotiate lower
payment rates to providers. They emerged in the United
States in the late 1960s. And, we find their origins
closely related to Henry Kaiser's answer to the health
needs of his labor force involved in a large
construction project in Southern California in the early
1930s. Because the project was in a remote area with no
health services available, injured workers had to be
transported long distances for treatment by a physician.
8


Henry Kaiser solicited the assistance of a surgeon
to open a health clinic at the construction site for
workers and their families. He established a program
whereby the employer would pay a monthly fee to support
the physician and the cost of the clinic. This was the
beginning of Kaiser Permanente, one of the largest HMOs
in America. The Kaiser approach is one that takes
prepayment for services, the health insurance premium,
and finances a closed system of health care services.
In doing so, Kaiser has been able to control use of
services and costs within a defined provider group under
one financial model; becoming one of the most successful
HMOs in the United States.
HMOs received indirect marketing support from the
federal government through the HMQ Act of 1973. HMOs who
meet federal criteria for designation as a federally-
qualified HMO, receive Congressional support through
grants and guaranteed loans. The original focus of the
Act was to provide funding for HMOs to reduce cost. One
of the first examinations of HMO impact on U.S. health
9


care was a 1984 RAND Corporation study that determined
that hospitalization in the HMO environment was 40%
lower than the rest of the industry.
The HMO orientation to health delivery places
importance on the role of the physician. HMO policies
are based upon projected needs of enrolled populations.
The policies and management tools employed by HMOs are
examined later in this study. Along with primary care
physician-directed care, a few HMOs rely on non-
physician providers for first-contact care. In the HMO,
the specialist physician is viewed as a provider who
might overestimate the value of a service. Careful
attention is paid to utilization of services and
maintaining ratios of primary care providers and
specialists providers required per 1,000 enrolled lives.
HMOs document the entire spectrum of care and are able
to do so because they provide services to a defined
population. They have made significant strides in the
development of quality indicators, cost savings and
managed access because they have a defined group that is
10


served by a defined set of providers that can be
studied.
A typical HMO plan includes a well-defined benefit
program, an administration completely focused on the
management of the plan, guidelines or rules that must be
adhered to by patients, a finite provider panel, co-
payment requirements, one-year required enrollment and
explicit service standards. One of the major arguments
in favor of HMOs is their focus on reducing the cost of
care.
There are basically four different types of HMOs -
staff model, group model, independent provider
association (IPA), and the network model. Each are
structured in a way that provides medical services under
different management and financial scenarios. While the
actual application of clinical decision-trees might vary
by type of HMO, clinical decision-trees are prevalent in
most of these organizations. The following describes
these models, their differences, use of decision-trees
and physician economic incentives.
11


Staff Model HMO
The staff model HMO employs its providers and
typically owns all facilities used in provision of
health care to its members. Criteria for employment of
a physician in the staff model HMO tend to be more
stringent, such as board certification in ones field of
expertise.(Gold, Hurley, Lake, Ensor, and Berenson,
December 21, 1995) Physicians employed in the staff
model earn a salary and may have the opportunity to
participate in an incentive program based on the overall
financial success of the HMO.(Hurley, et al., December
21, 1995) As with all types of HMOs, the staff model
HMO primary care physician plays a pivotal role in
directing care and use of services. Typically, the
primary care provider is requested to use decision-
trees An example of this type of HMO is the Group
Health Cooperative of Puget Sound.
Group Model HMO
A group model HMO is comprised of two distinct
12


operations. One is referred to as the "health plan." It
is responsible for management of facilities and services
that support medical care hospitals, pharmacies,
marketing, clinics, etc. The other operation is the
"medical group practice," comprised of physicians who
provide services, usually exclusively, to the HMO through
a contractual relationship.
An example of a group model HMO is Kaiser
Permanente. This HMO is divided nationally into regional
plans licensed by individual states. Each regional plan
is comprised of two distinct legal entities. The medical
group performs services for the health plan through a
contract.(Zacker, p. 171-175, April, 19S6) Physicians in
a group model HMO may have the opportunity to participate
in economic incentives. However, incentives are
typically based upon the overall financial success of the
medical group and the health plan.(Hillman, A.L., Pauly,
M.V. Kerstein, J.J., July 13, 1989) Specifics of the
incentive program are documented in the agreement between
the medical group and the health plan. It is not uncommon
13


for medical group economic incentives to be given up for
a reduction in health plan premiums to maintain a
competitive status in their employer market.
Network Model HMO
Some HMOs rely on a contracted independent network
organization for providers and support services. This
structure is referred to as a network HMO. Under the
network model, an independent organization develops a
network for the HMO. Networks are typically independent
corporations that serve only to manage and contract a
provider network. They develop a panel of providers
secured through participating provider contracts and
then make the plan available to the HMO and the employer
through what is referred to as an access
arrangement.(Gold, M.R., et al., December 21, 1995)
Network providers are typically physicians in
private practice who provide health care services
dictated by the network provider contract.(Gold, M.R.,
14


et al., December 21, 1995) Network HMOs, through
contracts, legally obligate physicians to adhere to
their plan rules, support for the application of
clinical decision-trees and reimbursement. These
contracts may or may not offer a financial incentive,
but they do legally require adherence to the plan rules.
Network HMO can reimburse physicians in a number of ways
- full capitation, partial capitation, or discounted
fee-for-service.
IPA Contracted HMO
One of the more loosely structured HMOs is the IPA
model. (Gold, M.R., et al. December 21, 1995) An IPA is
an organization that contracts with HMOs on behalf of
independent physician practices to be available for HMO-
insured patients.(Corrigan & Thompson, 1991, p. 656-661)
The physician contracts with the IPA, and the IPA
contracts with the HMO on behalf of the physician.
Financial risk to primary care physicians is becoming
more prevalent in the IPA HMO than in others.(Gold, M.R.,
15


et al., December 21, 1995) The financial risk is being
moved to the primary care physicians as they direct the
care of enrolled patients with a gatekeeper orientation.
In doing so, they are making resource allocation
decisions and are held financially responsible at the
same time.
As with network HMOs, IPAs contract with the HMO to
provide health services. The contract dictates plan
rules, expected physician behavior and reimbursement
method. In a 1994 survey of 138 managed care plans, 56%
of IPA HMOs used capitation as the dominant method of
payment to primary care providers.(Hurley, R., et al.,
December 21, 1995) Clinical decision-trees can be
applied by the HMO or by the IPA depending on the nature
of the IPAs' contractual relationship with a particular
HMO. Physicians within IPAs can have agreements with
many HMOs or they may have an exclusive agreement with
one HMO. It is important to note the tremendous
variation within these four basic categories of HMOs.
This variation is demonstrated in the clinical decision-
16


trees, referral guidelines and payment methods discussed
later in this study.
Market Forces and the HMO
HMO penetration has grown significantly over the
past 27 years. In 1970, there were 30 HMOs in the United
States; that number increased to 240 in 1982. (Hoft &
Glaser, 1982, p. 1681-1689) Today, over 700 KMOs operate
in the United States. Central to most HMOs are three
critical factors to their operation managed access to
services, productivity and patient satisfaction.(Moore,
1990, p. 427-432) As they have become a dominant feature
of health care in many U.S. markets, they have strived to
maintain a strategic advantage over other types of
delivery systems through lower premiums, reliance on the
primary care physician to ensure efficient and effective
medical practice, reducing cost and maintaining a
reputation of high-quality. (Moore, 1990, 427-432)
The basic difference between HMOs and indemnity
insurance resides in the economic exchange for services.
17


Traditional indemnity insurance is structured to provide
financial support for possible damage, loss or hurt.
Individuals who are insured for health care under an
indemnity plan pay a premium and participate in payment
for actual health services through an annual contribution
called a deductible. HMOs also require out-of-pocket
contributions for care but not at the level that might be
present in an indemnity program. Indemnity plans may
apply a fee schedule from which physicians are
reimbursed. In some plans, physicians are able to
collect balances due on their charges from the patient.
Hospitalizations and surgeries are typically reviewed for
medical necessity before precertifying payment of the
services.
In a traditional indemnity program, there have been
some efforts to constrain unnecessary use of services,
but not the extent of that found in the HMO. A hybrid of
indemnity insurance is referred to as a preferred
provider organization or PPO. This type of plan has
implemented a contracted network to reduce its
18


reimbursement levels. Clinical decision-trees are used
on a limited basis in PPOs and there are no financial
incentives to manage utilization outside of non-payment
for services that have not been precertified for medical
necessity.
To better understand the difference between HMOs
and indemnity insurance plans, it is important to
understand how providers are paid for their services.
An overview of the various reimbursement models found in
HMOs follows.
Physician Payment Methods
Health insurance plans can be grouped in two basic
categories HMO and indemnity. At a very basic level,
the manner in which providers are paid for their
services can be categorized into three methods: fee-
for-service, salary, and capitation. The prevalent
method of payment in an indemnity program is fee-for-
service. However, methods of payment in an HMO can be
fee-for-service, capitation, salary, incentive or a
19


combination of these methods.(Caslino, L.P., January,
1992)
The impact of physician economic incentives on
utilization and cost in the HMO is tested in this study.
It is important to understand the theoretical
foundations of economics as they relate to the research
questions.
While the foundations of pragmatism, policy science
and decision theory can be found in the development and
use of decision-trees, the desired outcome associated
with a policy or guideline can be traced to economic
theory. In Economics of Social Issues. Sharp, Register
and Leftwich (1990) provide an overview of the growth in
personal health care expenditures that has occurred in
recent years in the United States. They attribute the
growth to population, inflation in the economy, increase
in medical care prices in excess of price inflation,
changes in consumer tastes and preferences, changes in
the demographic features of the population and changes in
technology and supply.
20


The authors identify special characteristics of the
health care industry important to consider when
evaluating it from an economic perspective: spillover
benefits, consumer ignorance, perceived rights to good
health, unpredictability of illness and the role of the
physician. In most industries, data are available to
assist in predicting price and quantity. Because illness
is difficult to predict, efficient allocation of scarce
resources is a problem. From an economic perspective,
the rising cost of health care can be traced to
restriction to entry into the health care markets, slow
response of supply to demand changes, the impact of
government subsidy and the demand for health care
services. They conclude that the central economic
problem is the inability to efficiently allocate
resources in the health care industry.
The Role of the Physician and the Economic Impact
The role of the physician is one that operates on
both sides of the market. Physicians are suppliers of
21


health services and they demand health services.(Sharp,
Register, Leftwich, 1990) They provide medical services
to patients and a physician also direct demand for goods
and services required for the patient's health care
needs. For example, a child with an ear infection is
evaluated by a physician to confirm a diagnosis and
determine a treatment plan for the diagnosis. The
treatment plan may involve prescribing medicine, referral
for testing hearing, or referring the patient for
surgical intervention.
The uniqueness here has to do with the dominant role
of the physician in health care. The physician is at the
center of the majority of health care decisions and
directs the consumption of goods and services required by
a patient. This role is confirmed in state licensing
requirements, hospital admitting rules and drug
enforcement guidelines. The American physician is
trained through a mentoring system; one that requires the
medical student to learn by providing the same services
as their teachers. At the same time they are learning
22


how to practice medicine the way their teachers practice
medicine, they are also trained to make autonomous
decisions about the treatment needs of their
patients. (Moore, G.T., July, 1990)
The independence and control held by this profession has
been identified as one of the primary reasons health care
costs have escalated so dramatically in the U.S. In an
attempt to reduce expenditures, the federal government
has legislated reimbursement reductions along with
benefit changes for those insured through government
payers. The HMO has incorporated some of the changes
implemented by the Health Care Finance Administration and
added the required adherence to clinical decision-trees
and the implementation of economic incentive awards to
physicians for the control of utilization and cost. The
basic assumption here is that because the physician has
such a pivotal role in health care, the imposition of
decision-trees and economic incentives to control
utilization and cost can have a powerful impact.(Lomas,
J., November 9, 1989)
23


Balancing Economics and Ethics
In The Moral Dimension Toward a New Economics.
Etzioni (1988) studies choice and identifies the
importance of evaluating the means we use to realize a
choice. He suggests that our policy designs or choice
processes are often made on normative-affective grounds
and not just on the basis of logical and empirical
considerations. This perspective would be consistent
with the many social and emotional variables present in
the delivery of health care. At the completion of their
education, American physicians take the Hypocratic Oath.
This oath requires the physician to always, among other
things, advocate for the needs of their patients.
Etzioni provides an equation that he feels should be
interrelated with the pragmatics of supply and demand:
pleasure + morality = value. These codeterminates
combine economics with elements of other social sciences
to develop socio-economics. At a very basic level, the
challenge here is to determine needs vs. wants; this
challenge is complicated by the structure and unique
24


characteristics of the industry. The use of clinical
decision-trees and economic incentives combine some of
Etzioni's ideas on recognizing culture, evolution or
experience that may impact supply and demand.
Payment Methods and Economic Incentives
Fee-for-services reimbursement is the most basic
economic exchange found in health care delivery and finds
its origins in traditional indemnity plans.(Casalino,
L.P., January, 1992) HMOs reimburse physicians and other
providers within their system a number of ways.
Staff and Group Model HMOs
Staff model HMOs employ their providers and pay
them a salary. The possibility exists that staff model
HMO physicians may have the opportunity to realize a
financial incentive in addition to their salary. That
incentive is typically tied to the overall performance
of the HMO and is not considered to be an effective tool
in controlling utilization and cost.(Hillman, A.L.,
December 31, 1987)
25


Within the group model HMO, the group contracted
with the HMO typically employs its providers and they
are also paid a salary. Physicians may have the
opportunity to realize a financial incentive in addition
to their salary. The incentive is tied to the overall
performance of the HMO. Physicians are not directly
held accountable for financial risk in the group or
staff model HMO. (Hillman,A.L., et al. July 13, 1989)
Network and IPA Model HMOs
IPA and Network physicians provide services under a
contract with an HMO that dictates how the physician is
remunerated for medical care. The most basic mechanism
is reimbursement of charges or discounted charges. Some
HMOs reimburse providers using a common fee schedule
that is discounted within the provider's contract.
Discounts can be negotiated using McGraw-Hill Relative
Value Units or the Medicare Resource-Based Relative
Value Units.(Casalino, L.P., January, 1992)
In more aggressive markets, providers are paid
26


capitated amounts for their services the most risky
mechanism for reimbursement. Under capitation, a
provider is paid a specific sum of money for provision of
care to a person or group for a specified amount of time.
The amount paid is set prior to the delivery of services.
In some cases, a provider assumes all financial risk for
care documented in an agreement. In others, the provider
may assume financial risk for provision of an explicit
set of services.(Berwick, D.M., October 17, 1996)
Berwick suggests that the majority of HMOs use a
combination of tools to control cost and utilization
along with capitation utilization review,
precertification, etc. Further, he suggests that
capitation should not be the only tool used to control
patterns of care. The impact of capitation is dependent
upon other variables such as the delivery system or
physician behavior. Consequently, it is important to
test other variables such as economic incentives and
clinical decision-trees to determine if there is an
impact on utilization and cost. The following table
27


illustrates physician payment methods commonly found in
each type of HMO.
Table 2.1 Physician Payment Methods in HMOs
PHYSICIAN PAYMENT METHODS
HMO TYPE FFS DISC FFS CAP PART CAP SALARY INCENT
STAFF X X
GROUP X X
NETWORK X X X X X
I PA X X X X X
*FFS = fee-for- service
DISC FFS = discounted fee-for-service
CAP = capitation
PART CAP = partial capitation
SALARY = salary
INCENT = incentive payment
In addition to dictating payment method, clauses
within a physician's contract with an HMO may require
adherence to the health plan's rules, define the
physician's level of participation in the plan and
require cooperation with medical management guidelines.
28


HMOs dictate billing and collection requirements for
providers in their contracts and they require provider
credentialing to ensure all physicians and non-phvsician
providers are practicing in good standing with generally
accepted institutional standards, e.g. Joint Commission
on Accreditation of Health Care Organizations (JCAHO) or
National Committee on Quality Assurance (NCQA)
guidelines. Provider contracts with HMOs may also
dictate a limitation of services. Possible legal
actions relating to malpractice or defaulting on
obligations are always outlined in these contracts.
Physicians participating in an HMO through a contracted
relationship are not always well-informed about criteria
or decision-trees applied by the HMO when there is a
request for services that require review and approval by
the HMO.
A key feature in the success of an HMO is the role
of the primary care provider. The HMO primary care
provider can be a family practitioner, general
internist, a primary care pediatrician or a non-
29


physician primary care provider. They direct the care
of all enrolled patients. And, in doing so, are
responsible for use of services and resulting costs to
the HMO.(Emanuel, E., January 25, 1995)
Because of the focus on primary care management,
criteria for referrals to specialists are an important
feature of HMO management.(Starfieid, 1993, p. 103-109)
One of the approaches has taken the form of clinical
decision-trees. Decision-trees provide a framework to
guide the care of the patient and assist the primary care
provider in controlling costs. Typically, depending on
the type of HMO, the primary care provider can be awarded
economic incentives for adherence to clinical decision-
trees .
Medical management in HMOs involves the use of
protocols that have been organized through medical
schools, research and collaboration with panels of
experts. Clinical decision-trees are a step-by-step
process used to direct treatment for specific
conditions. HMOs have come to employ a number of
30


mechanisms like decision-trees to direct care in an
attempt to control utilization and cost.
Clinical Decision-Trees
Berwick and others suggest that there are a number
of variables that impact use and cost of services along
with payment methods. The one actually tested in this
study, clinical decision-trees, seems to have a direct
link to utilization and ultimately cost because of its
link to physician behavior. Along with economic theory
it is important to understand the theoretical basis for
decision-trees and their potential impact on utilization
and cost.
Clinical decision-trees and algorithms are also
referred to as pathways, protocols or care plans. They
are written descriptions of process of care in terms of
sequence and timing in order to manage health care for
patients. The common theme in the literature is the
need for appropriate and adequate information. Without
guidelines, the ability to account for variability in
31


the outcome or final product is difficult. This is true
for health care and other industries. Our ability to
determine if a procedure or course of therapy is
appropriate is limited without decision-trees.
Hadorn suggests that the "rule of rescue" for
reducing inappropriate utilization and cost is through
carefully defining treatment indications for symptoms
and complaints. His decision process is based upon a
cost-effective analysis:
1. Patient experiences net-benefit from
treatment.
2. Determination of the length of the
benefit.
3. Understanding the direct-costs of
providing the treatment.
Necessary Care Guidelines specify clinical
indications for which services have been reasonably
well-demonstrated to providing significant net health
benefits versus no alternative treatment.(Hadorn, 1991,
p. 2218-2225)
Early efforts to review a physician's approach to
32


treating patients, include establishment of utilization
review functions in insurance companies. A ratio of
savings to cost was set at 8 to 1; by requiring a review
of the physician's approach to treating a particular
condition, insurance companies realize an 89% reduction
in cost as compared to unchecked treatment.
Professional Standards Review Organizations (PSROs) were
established for peer review by physicians. Preadmission
certifications, on-site review of patient care and
concurrent review were also used to monitor the care
provided to patients.(Feldstein, Wickizer, Wheeler,
1988, p. 1310-1314) The difficulty with these
mechanisms is studying their effectiveness because of
the small numbers of conditions routinely treated along
with inadequate data.
Gauging Appropriate Use of Services
Brober suggests that methods for judging
inappropriate use of services have always been applied to
people who have received a procedure as opposed to people
33


who have a complaint or symptom; retrospective vs.
prospective. The scientific basis for clinical decisions
will always be incomplete, so we need to find a way to
validate the combination of biomedical literature with
expert judgment to arrive at a judgment of
appropriateness. The inability to clearly evaluate
whether clinical decisions are made in the best interest
of the patient is evolving into a major concern in health
care delivery. In reviewing policy changes over the past
30 years, the focus on health policy has been to reduce
remuneration to the system; creating an economic
incentive to reduce unnecessary or inappropriate
services. What has not been studied closely, from a
policy perspective, is the decision process used by
physicians in the direction of care for patients. An-
important characteristic of American health care is the
independent role of physicians; they still command most
decisions about health care services. Wennberg(November
13, 1987) suggests the major issue in health care and
clinical decision-making is the diversity of accepted
34


opinion on the need and the value of determined
treatments.
The 1988 Rand Health Insurance Experiment analyzed
rates of inappropriate use of health services. They
found that ratings of the appropriateness of medical
interventions have been used to support practice
guidelines and have been suggested for use in
preoperative screenings. The value and credibility of
methods to assess the appropriateness of medical
interventions cannot be determined until studies can
estimate the many variables impacting the outcome of the
treatment process.(Phelps, 1993, p. 1241-1245) Rand
Corporation and Phelps assert there is a critical need
to invest in a scientific basis for understanding when
various treatments work, and for whom, and to provide
the best possible information for decision-making.
Brook and Vaiana believe a significant portion of
current medical care is inappropriate and the main force
behind cost increases. They suggest the amount of
inappropriate care is explained by the practice style of
35


individual physicians. In a study that was conducted to
evaluate Medicare patients who had undergone a coronary
angiography, a carotid endarterectomy or an upper
gastrointestinal endoscopy, it was determined that 37%
of the services provided to the sample population of
4,500 were inappropriate and a direct result of
physician behavior.
Standard Processes of Care
Katherine L. Kahn (Rand Corporation, Winter, 1993-
94, p. 2) has followed these initiatives recommending
the development and implementation of standard processes
of care and process measures. Lomas (November 9, 1989)
agrees, but suggests that successful practice guidelines
or decision-trees will only work if they move the
medical practice closer to behavior recommended by the
decision-trees. Guidelines or decision-trees alone will
not be sufficient; there needs to be an economic
incentive present. Lomas studied the use of practice
guidelines and evaluated their use by looking at
36


applying a consensus process that included prospective
assessment of attitude, practice as reported by
physicians and the actual practice before the release of
the guidelines. The study actually found that a medical
practice is influenced by many things research
evidence, threat of malpractice claims, inadequate
skills, economic and socioeconomic pressures. He
concluded that decision-trees should not be developed in
isolation from other initiatives that seek to modify
inappropriate practice.
Brober looked at what might happen if decision-
trees or clinical decision criteria were made available
on a routine basis. He suggests that:
1. Policies would be altered so resources are better
directed to need.
2. Information could be used as a stimulus to self-
improvement in providers.
3. Consumer reports would offer this information.
4 New textbooks of medicine organized around
guidelines might be developed and medical education
could be altered with greater emphasis on information
sciences in the medical school environment.
37


5. Development of performance-based review systems
that are required for education degrees and professional
re-certification.
6. The requirement of licensing bodies to rely on
physician's compliance with care guidelines.
7. Third party payers would develop their provider
panels using only those who adhere to guidelines.
8 Third party payers could deny payment for lack of
compliance.
9. Patients and physicians could use guideline
information together toward better decision-making.
10. Litigation may decrease because malpractice claims
would be based upon the agreed protocols.
While specific studies have focused on the
potential for cost savings, quality and access, the
historical autonomy of the physician and her/his
relationship with the patient could be negatively
impacted unless use of guidelines is balanced. Some
considerations include preserving choice, competence,
communication, compassion, continuity and no conflict of
interest.(Emanuel, 1995, p. 323-329)
The patient-doctor relationship is the corner-stone
for achieving, maintaining and improving health
38


care(Emanuel, 1995, p. 323-329) The American Medical
Association's Council on Ethical and Judicial Affairs
identified guidelines that assist the physician in
balancing the use of decision-trees and economic
incentives in the care of their patients:
1. Physicians continue to plan for the interest
of their patients first.
2. Physicians should be able to challenge HMOs
and other types of managed care plans that
place restrictions on their ability to serve
the needs of their patients.
3. If physicians are employed or remunerated by
managed care firms and are offered economic
incentives, those incentives are permissible
only if they promote cost-effective delivery
of health care at the same time avoiding
withholding of necessary medical care. And,
physicians must make their economic incentives
known to their patients.
One procedure that has received attention with respect
to the use of decision-trees is Myringotomy with
insertion of Tympanostomy Tubes to treat acute Otitis
Media (AOM). AOM is a common diagnosis in children.
The treatment options for AOM have grown with expansion
of technology and the demand to treat a painful
39


condition. Because of the high number of diagnoses and
the growth in costs for treatment, insertion of
Tympanostomy Tubes is used as a vehicle in this study to
examine the impact of decision-trees and economic
incentives in the HMO environment.
Otitis Media
Otitis Media affects two-thirds of American
children by two years.(Kleinman, et al., 1994, p. 1250-
1255) It is the most common diagnosis among children
and the second most common diagnosis in
medicine. (Kleinman, et al. 1994, p. 1250-1255)
Morbidity associated with ear infections is hearing loss
and/or delayed development. Recurrent Otitis Media
and/or a persistent middle ear effusion may stimulate
evaluation to consider the placement of Tympanostomy
Tubes. (Kleinman, et al. 1994, 1250-1255) This
procedure involves the placement of tiny ventilation
tubes that are inserted through the eardrum to reduce
the frequency of acute Otitis Media and reduce the
extent of hearing loss. The ventilation tubes are
40


placed through the eardrum after it has been excised,
using a procedure called Myringotomy(making an incision
in the eardrum to allow drainage), which allows drainage
of fluids built-up behind the eardrum. There are
complications associated with Tympanostomy Tubes -
prolonged drainage(otohrea) persistent perforation of
the eardrum and scarring of the eardrum which may be
associated with long-term hearing loss. Because the
condition and treatment are so common and account for
approximately $3-4 billion in health care costs each
year, use of decision-trees to guide treatment of Otitis
Media in an effort to reduce utilization and cost is the
vehicle for examining the research question in this
study.
Myringotomy with insertion of Tympanostomy Tubes
has received a fair amount of attention in recent years
as surgical intervention is being challenged as the best
approach to care. The University Hospital Consortium
convened a panel of experts to develop explicit criteria
to assess the appropriateness of the procedure. Along
41


with a national utilization management firm, they
identified a two-step process to assess medical
appropriateness of Tympanostomy Tube insertions: First,
a nurse reviewer conducts a telephone interview with a
physician's office staff. They interview both the
primary care physician and the Otolaryngologist. The
interview is guided by an interactive computer program
that uses a smart-logic branching algorithm. The nurse
reviewer enters each answer into the computer and is
prompted to ask each question in the program. All
questions are based upon the decision-tree or algorithm
for the surgery. If the nurse reviewer finds there is an
indication of equivocal or inappropriate referral for
the surgery, the interview is completed.
Second, cases found to be inappropriate are subject
to the next step. This step entails a discussion
between the physician, reviewer and the surgeon for the
purpose of verifying data to identify any extenuating
clinical concerns that might override the decision-tree
criteria.
42


Kleinman (1994, p. 1250-1255) offers a review of
another study conducted that approaches the establishment
of appropriateness criteria for placement of Tympanostomy
Tubes to treat Otitis Media. A panel of physicians and
otolaryngologists applied the use of a Two-Round Delphi
method from UCLA and Rand Corporation to evaluate options
and establish criteria. Their overall goal was to find
criteria that guide the appropriate use of placement of
Tympanostomy Tubes for which the expected health benefits
of the tubes exceed the expected negative health
consequences by a sufficiently wide margin. If a wide
margin was present, then the procedure was worth doing.
The panel compared expected medical risks and benefits
while excluding explicit considerations of cost. The
appropriate ratings were based upon a 9-point scale: 1-3
= highly inappropriate, 4-6 = equivocal, and 7-9 = highly
appropriate. The panel also relied on the direction of
literature dedicated to the treatment of Otitis Media.
After reviewing the results of applying the rating system
and literature review in a retrospective study, they
43


found insertion of Tympanostomy Tubes had no demonstrated
advantage over other medical management therapy options.
Other studies disagree with this perspective and suggest
a number of alternatives, including surgery, are
available for successful treatment of AOM.
In "Theoretical Cost Effectiveness of Management
Options for Children With Persisting Middle Ear
Effusions," Berman (1994, p. 353-363) reports that by age
2, American children have a total of 9.3 million episodes
of Acute Otitis Media with an annual cost of medical and
surgical treatment of approximately $3-4 billion dollars.
Berman's approach is the development of a decision-tree
that provides steps for the diagnosis and management of
acute Otitis Media:
44


Visit 3
(12 waaks post ACM)
visit 1 vNit ?
(g was la post ACM) (9 waaks post ACM)
Cura
MEE
Cura
MEE
Cura
MEE
Cura
MEE
MEE
Cura
MEE
Cura
MEE
Cura
MEE
Cura
MEE
Cura
MEE
Cura
MEE
Cura
MEE
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Surgary
Printed with permission from Stephen Berman, M.D.,
Professor of Pediatrics, University of Colorado School of
Medicine
Berman
for medical
s decision-tree provides steps to consider
and surgical treatment. What is essential in
45


his research and relevant to this study is the decision-
process. Berman's decision-tree guides the therapy
approach through the number of patient visits and the
number of weeks after acute Otitis Media is diagnosed.
The guidelines focus on what to do if a certain condition
exits, what therapy modality can be partnered with a
condition and a recommended step for treatment. The last
resort therapy modality for all steps in the decision-
tree is surgery medical management is identified as a
first option(s) to rule out before insertion of
Tympanostomy Tubes. The cost of each level of care
within the decision-tree is outlined comparing costs
associated with medical management versus costs
associated with surgical intervention. The study
concludes that the most cost-effective option for
treatment is the combination of two types of medicine
(corticosteroid and antibiotic) followed by a sequence of
steps that identify a different medical therapy after
which, if cure is still not achieved, referral for
surgery. The study identifies that even when the need
46


for surgery is present, the use of the combination
treatment method during the initial visit results in
cost -reduction. Travel costs and lost wages as they
relate to the illness are included in the analysis.
Savings associated with the study are $372.81/patient
when use of the combination therapy is applied versus
sequential use of antibiotics followed by surgery.
Savings associated with the application of the
combination therapy followed by surgery for non-
responding patients are approximately $225.55 per case in
a private-practice environment. Berman goes on to
identify that no data are available to support the
insertion of Tympanostomy Tubes that helps language
development. "Otitis Media in Children" places
importance on the parent's preference for treatment
regardless of the decision-tree or the cost.
Another approach to the treatment of acute Otitis
Media comes from Bluestone(1994, p. 1051-1053) in
"Appropriateness of Tympanostomy Tubes." This response
to the need for treatment decision-trees focused on
47


Otitis Media offers a surgical perspective. The
decision-tree proposed here suggests that surgical
insertion of Tympanostomy Tubes through Myringotomy
incision is indicated when long-term ventilation or
drainage, or both are necessary:
1. Chronic middle ear infection, asymptomatic and
unresponsive to medical management (and not
improving) and has persisted for at least three
months when an infection is in both ears or six
months when in one ear. Insertion may be done
earlier when there is a significant hearing loss,
disequilibrium or vertigo, or when Tinnitus is
present, etc., or when there is a cumulative
duration of 6-12 months when the infection is
present.
2. Recurrent acute Otitis Media, especially when
antimicrobial prophylaxis fails to reduce the
frequency, severity, and duration of the disease -
three or more episodes during the previous six
months, or four or more attacks during the previous
year with one recent attack.
3. When a supportive complication is suspected or
present.
4. Eustachian tube dysfunction, even in the absence of
middle-ear effusion, when the patient has persistent
symptoms that are not relieved by medical treatment
options.
5 When a Tympanoplasty is performed if Eustachian tube
function is thought to be poor.
48


The structure of these decision processes reflects
the views of those who support the physicians and/or
surgeons. To better understand the structure and use of
decision-trees, it is important to review perspectives,
discussions, and theories that are the basis for how we
have made decisions and how we might make decisions in
the future. The empirical analysis that follows tests
the impact of clinical decision-trees and economic
incentives on use and cost of Myringotomy with
Tympanostomy Tubes.
49


CHAPTER 3
EMPIRICAL ANALYSIS
This chapter provides a summary and discussion of
information collected to address the research questions -
do clinical decision-trees reduce utilization of health
services in an HMO? And, do economic incentives paid by
HMOs to providers reduce cost of services? The research
questions were addressed analyzing treatment of Acute
Otitis Media with the surgical placement of Tympanostomy
Tubes. The analysis that fellows offers descriptive
information about the population effected by AOM and the
cost of treating AOM with Tympanostomy Tubes. An overview
of the HMOs' decision-trees, referral guidelines, and
physician economic incentives assists in studying the
research questions.
Methods
A comparative analysis was conducted to determine if
use of decision-trees resulted in different utilization of
50


Myringotomy(the process of incising the infected eardrum)
with insertion of Tympanostomy Tubes. The analysis
compared decision-trees, referral guidelines and payment
incentives used by ten Colorado HMOs during 1994 and 1995.
The study involved comparison of the surgery utilization
rate/1,000 AOM infections for Colorado HMOs to that found
in a sample Colorado indemnity plan to test the first
hypothesis. And, the study compared cost of Tympanostomy
Tubes surgery to HMOs to the cost of Tympanostomy Tubes to
an indemnity insurance plan. A discussion of each
hypothesis follows:
Hypotheses
To evaluate whether decision-trees and
corresponding payment incentives impact utilization and
cost in the HMO environment compared to the non-HMO
environment, two hypotheses were tested:
51


Hypothesis One: The application of decision-frameworks
to the use of Tympanostomy Tubes reduces utilization of
the surgery in HMOs as compared to a non-HMO organization
where physicians have broader discretion in treating AOM.
Hypothesis Two: Despite variations in payments to
physicians in different HMOs, economic incentives
provided to physicians in an HMO assist in reducing costs
associated with the placement of Tympanostomy Tubes as
compared to a non-HMO organization.
The tests reflect the uniqueness of the study
because it compares two approaches of controlling access
and cost in the HMO environment to the absence of such
controls in the non-HMO environment. The comparative
analysis relies on a number of sets of data for
observation years 1994 and 1995. Descriptions of the
data and definitions of variables tested in the
hypotheses follow:
52


Data Description:
Observation Years: 1994 and 1995
Total # Colorado Residents
Number of Children under 6 years old in Colorado
Total # of Pediatricians Licensed in Colorado
Total # of Family Practitioners Licensed in Colorado
Total # of Otolaryngologists Licensed in Colorado
Total # of HMOs in Colorado (Universe)
Total # of Colorado Residents enrolled in Colorado HMOs
Est. # of Children < 6 years indemnity sample
Est. # of Children < 6 years enrolled in Colorado HMOs
Sample Size for Analysis
Frequency of use of Decision-Trees for Referral or
approval of Tympanostomy Tubes in HMO
Regional AOM Incident Rate in Children < 6 years
Colo. HMO AOM Incident Rate per 1,000
Avg. # Indemnity Tympanostomy Surgeries/1,000 AOM Infect.
Avg. # HMO Tympanostomy Surgeries/1,000 AOM Infect.
% Difference Between Surgery Rates in HMOs and Indemnity
Cost of Tympanostomy Tubes in Indemnity (Surgery Only)
53


Cost of Tympanostomy Tubes in an HMO (Surgery Only)
% Difference Between Cost in HMOs and Indemnity
Sources: Colorado Division of Local Government, Colorado
Medical Society, Baumgarten, Allen (1994/1995)Colorado
Managed Care Review, and Study Questionnaire-Appendix A.
Variables To Be Tested:
Variable
Description
Level
Hypothesis One
Dependent
Variable:
Utilization of Total Number Performed HMO and
Tympanostomy Tubes Indemnity
Surgery/1,000
Infections
Independent
Variable:
Clinical Decision-
Trees and Referral
Guidelines
Decision and referral
criteria required for
payment of surgery
HMO and
Indemnity
54


Hypothesis Two
Dependent
Variable:
Cost of Payment to physician HMO and
Tympanostomy Tubes by the payer Indemnity
Surgery to the
Payer
Independent
Variable:
Physician payment Actual method of HMO and
methods and/or paying physicians Indemnity
economic incentives used by payers
In 1994, 15 HMOs were licensed in the State of
Colorado and 16 in 1995. The study group includes Antero
Health Plans, CIGNA HMO of Colorado, FHP, HMO Colorado,
Kaiser Permanente, Prudential, QualMed, Inc., Rocky
Mountain HMO, Colorado Child Health Plan and United
Healthcare. Cost of surgery for the HMO environment and
the indemnity environment was derived from published
sources. Proprietary information and data for each HMO
obtained through a questionnaire(Appendix A)are identified
by alpha code.
55


Patients, Providers, and Payers Children under the
age of six years represented approximately 4.5-6% of
Colorado's population during the observation years. The
approximate number of children enrolled in Colorado HMOs
in 1994 was 40,577 and 45,158 in 1995.(Appendix B)
Enrollment in the HMO plans increased 10% between 1994 and
1995.
Table 3.1 Colorado Residents and HMO Enrollment
12M___________________12.35
Colorado Residents 3,631,606 3,684,748
Children < 6 Years 217,896 221,085
Total HMO Enrollment 901,700 1,003,519
HMO Children < 6 Years 40,577 45,158
Source: Appendix B
Physicians associated with the treatment of AOM are
primary care pediatricians, family practitioners and
otolaryngologists. During 1995, approximately 349 primary
care pediatricians, 1,354 family practitioners and 115
56


otolaryngologists maintained a license to practice
medicine in the State of Colorado. (Colorado Medical
Society, 1997) These data are not available for 1994,
although the Colorado Medical Society indicates any change
between 1994 and 1995 was minimal.
Table 3.2 Providers Involved in the Treatment
of Acute Otitis Media
___________1994___________L125.
Colorado Providers:
Pediatricians n/a 349
Family Practitioners n/a 1,354
Otolaryngologists n/a 115
Source: Appendix B
Model
The data organized for this study was used to gain an
understanding of the differences between management of
health care in HMOs and indemnity insurance plans and to
provide information necessary to test the two study
hypotheses.
i


Model A Hypothesis One.
A basic comparison of the
actual difference in the mean surgery utilization per
1,000 AOM infections is provided to begin testing
hypothesis one. A binomial chi square test of
independence was then performed to the relationship
between payer-type and surgery utilization per 1,000 AOM
infections for hypothesis one.
Model B Hypothesis Two. A cost comparison is
provided for hypothesis two to determine if the difference
in the average cost of surgery in an indemnity insurance
plan was larger than that found in the HMO populations.
Before testing the hypotheses and the potential for
a relationship between insurance type and surgery
utilization and differences in cost, it is important to
understand the criteria that differentiate HMOs from
indemnity insurance plans. They can be grouped into three
basic categories application of clinical decision-trees,
referral processes and payment methods. Each HMO was
studied to determine the extent to which the criteria were
applied in the management of the plan. While the criteria
58


varied somewhat, the application was uniform in each HMO.
Descriptions of these criteria follow.
Clinical Decision-Trees With the exception of one,
all HMOs reporting in this study rely on clinical-
decision tree(s)to some degree. Each HMO's decision-tree
is derived from a recognized expert(s) or organization.
Two are derived from proprietary firms and one is derived
from a consortium of nationally recognized medical
academies. The firms or agencies identified with the
clinical-decision trees reported in this study are:
American Academy of Pediatrics in Consortium with
the American Academy of Otolaryngology-Head and Neck
Surgery, and the American Academy of Family Medicine
(AAOPC)
Millman and Roberts (M/R) Actuarial Firm
Experts and Expert Panels
Value Health Systems (VHS)
ISP Guidelines (ISP)
Two of the study HMOs exclusively rely on the AAOPC
guidelines. One uses AAOPC,M/R and ISP. Another uses
59


AAOPC, M/R, a panel of experts and actively takes into
consideration geographic differences in the practice of
medicine when making decisions about approving payment
for surgery. HMO F relies exclusively on M/R's decision-
tree. Two HMOs make referral and surgical approval
decisions using internally-developed criteria for
decision-making both quite different. One relies upon a
combination of the AAOPC and VHS decision-trees.(Table
3.7)
HMO E views decision-trees as a source of
prospective utilization management that only serve to
aggravate its providers. This HMO performs retrospective
provider profiling. If, through provider profiling, it
is found that they are demonstrating practice patterns
outside an identified norm, the provider is offered the
profile information to assist them in changing their
practice patterns. If they do not, they may face required
adherence to a clinical decision-tree in the
future.(Table 3.3)
60


Table 3.3
HMO Application of Clinical Decision-Trees
HMO
AAQPC
M/R
EXPERT
.VHS
ISP
A
B
C*
D
E**
F
G
H
I
,T
X
X
X
X
X
X
Source: Interviews/questionnaires Appendices A & B
*HMO C did not provide decision-tree information.
**HMO does not require adherence to decision-trees for
approval of surgery.
The structure of each decision-tree identified in
this study varies by origin. The AAOPC defines the
target population for the decision-tree or guidelines
and then offers three criteria that can be used to
appropriately identify candidates for tympanostomy
tubes:(Appendix C)
1. observation, antibiotics, and environmental
factors;
61


length of infection within 3 months, hearing
loss, antibiotic therapy, environmental factors
and surgery
2 .
3. length of infection within 6 months, hearing
loss, environmental factors and surgery.
M/R guidelines are organized in three categories of
management Treat by PCP/Do Not Refer, Failed
Conservative Treatment/Refer, and Automatic Referrals.
The clinical decision-tree within each referral category
is focused on courses of treatment within specific
periods of time. Under the conservative category, time
periods associated with 10 days, 3 months and 6 months
are identified with antibiotic therapy. The second and
third categories are associated with a series of
diagnostic evaluations that eventually bring the
physician and the HMO to a final decision regarding
surgery, e.g. x-rays, speech evaluation, tympanograms,
audiograms.(Appendix C)
HMO G's decision-tree is internally-designed
providing guidance under four criteria that are absolute
indications for tympanostomy tubes:(Appendix C)
62


1. Bilateral middle ear effusion longer than four
months, with speech difficulty.
2. Five or more discreet episodes of AOM within one year;
antibiotics given may be considered for three
infections within a 6-month period.
3. Cranial facial abnormalities or documented immune
deficiency.
4. Patients with retraction pockets, adhesive otitis
media, cholesteatoma or other irreversible ear
pathology.
HMO H follows a decision-tree developed internally
and practices generally accepted adherence to three
criteria. Referral for surgery occurs when a child has
more than four episodes within 6 months or have more than
6 episodes of AOM without effusion, or have more 3
episodes of AOM within six months of otitis media with
effusion.(Appendix C-H)
HMO I employs the VHS decision-tree that requires
answering 50 questions that are part of a computer
program that gives direction to the physician in how care
63


should be provided to the patient. (Appendix C-E)
While HMO J is considering dropping required use of
a clinical decision-tree to control the cost and
utilization of tympanostomy tubes, currently, it has
applied seven criteria when making a determination on
funding surgery:(Appendix C-J)
1. Four episodes of AOM within 6 months with antibiotic
treatment.
2. Middle ear effusion greater than 4 months not resolved
with antibiotics.
3. Middle ear effusion greater than 4 months with hearing
loss.
4. Chronic, recurrent otitis media or otitis media with
effusion along with cleft lip and/cr palate.
5. Replacement of a tube that has extruded and the
patient continues to have recurrent otitis media.
6. Refractory AOM.
7. Serious complications of otitis media.
64


While similarities were found in some of the
clinical decision-trees, the variation among them was
remarkable.
Referral Processes HMOs typically require that
visits to a specialist provider, outpatient procedures
and inpatient procedures be approved prior to the
services taking place. The referral approval process for
surgery occurs after the clinical decision-tree has been
applied to a request for surgery.(Appendix D) All ten
HMOs studied in this project require physicians to secure
a documented referral prior to specialist or procedural
services are rendered. The flow charts that follow
illustrate the differences in surgery approval processes
found in HMOs and non-managed or indemnity insurance
plans:
65


Table 3.4 Referral and Precertification for Surgery
Indemnity
A Patient is seen by surgeon to determine need for
surgery.
B If surgery is required, surgeon requests pre-
certification of the surgery from the insurance
company to ensure payment for services.
C If the surgery meets the insurance company's
medically necessary criteria, it is approved for
payment and the surgery is pre-certified.
D The insurance company communicates decision to pay
for services to the surgeon.
E The surgeon communicates the insurance company's
decision to the patient.
66


HMO
8 5
A Patient is seen by their primary care physician.
B If the primary care physician feel the condition may
require surgery, the patient is referred to a
surgeon.
C If the surgeon feels surgery is necessary, the
surgeon recommends surgery to the patient's primary
care physician.
D If the primary care physician agrees, the surgeon
requests review by the HMO Medical Director and the
clinical decision-tree is applied to the request for
surgery.
E Depending on whether or not the request for surgery
meets the clinical decision-tree criteria, the
Medical Director will either approve or decline
payment for the surgery.
F If the surgery is approved, then the surgery is pre-
certified by the HMO for payment.
G The Medical Director/utilization staff communicate
decision-to the surgeon.
I


H The surgeon communicates the HMO's decision to the
primary care physician for final concurrence.
I The primary care physician sometimes communicate the
HMO's decision to the patient.
J The surgeon will communicate the HMO's decision to
the patient.
In this study, each HMO's referral process is
different from the others, either in process or criteria.
In some cases, the referral process is handled through
telephone consultation, in others it is documented using
special forms that assign a "referral number" that is
identified on claims for payment. HMO E relies on the
referral process to document utilization for
retrospective provider profiling. All other HMOs
administer the referral process to control access prior
to delivery of services.
The most common aspect of the HMO's referral rules
is the economic penalty assessed when a referral is not
acquired prior to delivery of services. All ten HMOs
will deny payment of claims for services provided without
an approved referral. The physician providing services
68


under contract with the HMO agrees to this type of
penalty when negotiating a participation agreement. The
patient is held harmless from a physician billing the
patient if their claims are denied by the HMO.
Physician Payment Methods Five types of
remuneration methods are common to the nine HMOs
reporting data in this study. Eight pay physicians under
discounted fee-for-service contracts to provide medical
care to their patients.(Appendix E) Seven reimburse
physicians using the McGraw-Hill Relative Value Scale
which assigns values to procedures and then multiplies
those values by a monetary conversion factor.(Appendix E)
One HMO reimburses physicians using the Resource Based
Relative Values (RBRV) system developed by Hsiao for
Medicare Physician Payment Reform.(Hsiao, 1988) Only one
HMO holds all participating physicians to a totally
capitated remuneration where they are financially at risk
for managing all aspects to the patient's care. In this
instance, however, the physicians are salaried employees
69


and are not directly at financial risk for the operation
of the HMO. In two HMOs, primary care physicians are
capitated for the direct care they provide patients. In
these health plans, specialists and other non-primary
care providers are reimbursed discounted fee-for-service.
Four HMOs offer a health plan-wide potential for bonus or
incentive payments if the HMO's annual goals are realized
and there is a surplus at the end of the fiscal year. It
is important to note that no direct link between payment
method and decision-trees could be found in information
provided by the study-HMOs.
Table 3.5 Physician Payment Methods
Payment Methods__________# of HMOs
Discounted FFS 3
McGraw-Hill RVU 7
Medicare RBRVS 1
Full Capitation-Salary 1
Primary Care Capitation 2
Bonus Potential 4
Source: Interviews/Questionnaires Appendix E
70


The average payment for Tympanostomy Tubes in the
study-HMOs was approximately 37-42% less than the
average charge and payment for the same surgery in an
indemnity insurance environment. The surgeries in this
study are, for the most part, performed by the same
surgeons regardless of payer-type:(Appendix B)
Table 3.6 Cost of Tympanostomy Tubes Surgery
1994___________1995
Indemnity $2,000.00 $1,800.00
HMO $1,162.80 $1,139.54
% Difference 42% 37%
Source: Appendix B
During interviews, all medical directors indicated
that there is not a strong enough link between the
overall health plan performance and distribution of
incentives to physicians. They suggested that full-risk
capitation is the only way to modify utilization behavior
and control cost. Total capitation requires the
71


physician to be financially responsible for all aspects
of a patient's care hospitalizations, drugs, nursing
home, etc. This responsibility sometimes involves the
physician actually paying the bill associated with a
patient's care. Until the marketplace shifts to demand
for total capitation, reliance on decision-trees,
referral requirements and discounted reimbursement will
serve as the primary control of utilization and cost in
the HMO environment.
Results
Hypothesis One: This study found surgery
utilization in the HMO environment is reduced through the
application of clinical decision-trees and the required
adherence to referral rules. The regional incidence rate
of AOM in children under the age of six is approximately
477 infections per 1,000 children each year.(Fiegin, R.D.
& Cherry, J.D., 1987) Based upon actual incident rate
data derived from HMOs participating in this study, HMO-
insured children under the age of six experienced AOM
72


incidence rates that range from 566 to 2,037
infections/1,000 children in 1994 and 568 to 2,051
infections/1,000 children in 1995.(Appendix B) The
variability in reported HMO and regional incident rates
might be due to how the diagnosis is managed in the HMO's
information system. Kleinman indicates that AOM is an
over-diagnosed condition.
Table 3.7 Acute Otitis Media Infection Rates
__________1994____________1995_______
Regional AOM
Infection Rate 477/1,000 477/1,000
Colorado HMO AOM
Infection Rate 566-2,037/1,000 568-2,051/1,000
Source: Appendix B
During the late 1980s, the approximate total number
of AOM in young cbiildnsn in. this Unitsd Ststss/ 3.ppnov0d
for Myringotomy with insertion of Tympanostomy Tubes, was
3% of infections or 670,000 surgeries.(Kleinman, et al.,
1994, p. 1250-1255) 1995. The average number of
Tympanostomy Tubes surgeries/1,000 infections in Colorado
73


HMOs representing 70% of HMO insured lives in 1994 was 43.
The average number of surgeries/1,000 infections in
Colorado representing 67% of HMO insured lives in 1995 was
49. The average number of surgeries/1,000 infections in a
sample Colorado indemnity-insured population was 64 in
1994 and 60 in 1995. Based upon data provided by the
study HMOs, there is a 28-33% difference in surgery
utilization rates between the HMOs and the indemnity
sample. This difference is consistent with the Kleinman
study which found that the application of decision-trees
to the use of Tympanostomy Tubes as a treatment option
could potentially reduce use of surgery approximately 25-
35%.
Table 3.8
Average Surgeries Per 1,000 Infections
1994
-1995
Indemnity
64/1,000
60/1,000
HMO
43/1,000
49/1,000
2.
*5
Difference
33%
28%
Source: Appendix B
74


i
i
i
A chi square test of independence was performed to
further explore hypothesis one focused on differences in
surgery utilization. The test was performed using one
degree of freedom and an alpha value of .05. The numeric
value to be exceeded in order to reject the null
hypothesis was 3.844146 (Ott, Larson, Mendenhall, 1987).
The chi square test was applied to three of the ten
study HMOs. Those HMOs not tested were unable to provide
infection rates and total surgeries for the observation
years 1994 and 1995. The results are summarized in the
following table. Each HMO was compared to a sample
Colorado indemnity plan that insured 210,000 patients
during 1994 and during 1995. The results of the
statistical test are based upon study-HMOs that represent
70% of the total Colorado HMO membership in 1994 and 67%
in 1995.
I
75


Table 3.9 Summary Results of Chi Test of Independence
for Hypothesis One
1994 Actual Observations:
No Surgery
HMO F Surgery (infections) Total
Decision-
Tree 90 2.359 2.449
No Decision- Tree 290 4.508 4.798
Total 380 6,867 7,247
HMO H Surgery No Surgery (infections) Total
Decision- Tree 344 7.655 7,999
No Decision- Tree 290 4.508 4.798
Total 634 12,163 12,797
HMO J Surgery No Surgery (infections) Total
Decision- Tree 1.223 27.290 28.513
No Decision- Tree 290 4.508 4.798
Total 1,513 31,798 33,311
76


I
No Surgery
All HMOs Surgery (infections) Total
Decision-
Tree________1.657_________37,2Q4____38.961
No
Decision-
Tree__________23S_________4.508 4.798
Total 1,947 41,812 43,759
1995 Actual Observations:
No Surgery
HMO F Surgery (infections) Total
Decision-
Tree____________115________3.138 3.253
No
Decision-
Tree____________271________4.508______4.779
Total 386 7,646 8,032
No Surgery
HMO H Surgery (infections) Total
Decision-
Tree______________________7,974 8.314
No
Decision-
Tree___________221________4.508 4.779
Total 611 12,482 13,093
77


No Surgery
HMO J Surgery (infections) Total
Decision-
Tree_________LU7J_________28.515 29.688
No
Decision
Tree____ ______221_________4.508 4.779
Total 1,444 33,023 34,467
All HMOs Decision- Tree Surgery ( 1.628 No Surgery infections; 39.627 ) Total 41.255
No Decision- Tree 271 4.508 4.779
Total 1,899 44,135 46,034
Summary of Chi Square Statistics:
1994 1995
X X
HMO H 18.31749 19 .292999
HMO F 19.36384 17 .05335
HMO J 29.17182 30 .3251
ALL 32.23932 3 2_ .20234
Parameters: Degrees of Freedom = 1 a = .05 Rejection of Null Hypothesis > 3.84146
78


All chi square test results for both observation
years were greater than 3.84146 allowing rejection of the
null hypothesis. The probability that the surgery rate
per 1, 000 AOM infections will be lower in an indemnity
insurance plan than that observed in the HMOs is less than
.0005. The results indicate a significant relationship
between the insurance type(HMO or indemnity) and the use of
surgery.
Hypothesis Two: The impact on cost of services paid
by the HMO through the employment of economic incentives
paid to physicians could not be explicitly demonstrated in
this study. The actual application of an incentive
program could not be traced to a documented change in
physician behavior. The potential for an incentive was
identified in data collected from the study-HMOs. While
literature suggests that economic incentives can impact
behavior, this analysis, focused on 1994 and 1995, could
not specifically demonstrate that perspective. The lack
of data to demonstrate the potential for behavior changes
79


as a result of incentives may be the result of an HMO
market that had not evolved to the point of moving
financial risk to the provider. However, the ability of
the HMO to reduce its cost of surgery through contracted
discounts is demonstrated well in data provided by the
study-HMOs.
The total average cost per surgery in the study
group, including physician and facility costs was
approximately $1,162.80 in 1994 and $1,139.54 in
1995.(Appendix B) These costs do not include pre-surgery
medical management or medical management costs incurred
for AOM that do not require surgery.
Tympanostomy Tubes surgery conducted in the Colorado
HMO environment cost approximately 37-42% less than in an
indemnity environment.(Appendix B) The cost differences
are primarily based upon discounts negotiated with
providers in their participation agreements with the
HMOs. In all HMOs studied, if the referral was not
secured or surgery not precertified, payment was denied.
None of the study HMOs employed full-risk capitation
80


payment in the administration of their plan. Indicating
that the financial risk for the operation of their plan
remained with the HMC and had not moved to the provider
at the time of this study.
Table 3.10 Summary of Surgery Cost Differences
2500---------------------------
The statistical test results were significant for
Hypothesis 1. And, while Hypothesis 2 could not be
confirmed because of the unavailability of information to
track behavior chances to economic incentives, HMOs were
able to reduce their costs through negotiated discounts
with providers. The physician payment methods illustrated
in this study are examples of a management tool used by
81


the risk-bearing entity. In this study that entity was
the HMO. Information necessary to demonstrate that
economic incentives impact cost might include the number
of surgeries performed per 1,000 AOM infections that are
insured through a fully capitated plan and the health
services for which the physician is at financial risk
under that plan.
It is important to recognize that there are
additional factors to be considered when evaluating the
use of decision-trees and payment methods to control cost
and use of services. The overview of variations in
clinical decision-trees, referral guidelines and economic
incentives provides an indication that other variables may
impact use and cost of services in the HMO or in the
indemnity environment. It is important to consider
limitations to this study and the potential for future
study of other variables that might impact cost and use of
services.
82


Analysis Limitations
First, this analysis provides indication that the
criteria that distinguish an HMO from traditional
indemnity insurance impact on use and cost of health
services. Using Acute Otitis Media and Myringotomy with
Tympanostomy Tubes for treatment as a vehicle to study
the research questions also illustrated certain
limitations for this type of analysis. It was very
difficult to establish a consistent incident rate for
Acute Otitis Media in published texts or in the rates
reported by the HMOs in this study. As fCleinman
indicates in his 1994 study, Acute Otitis Media is one of
the most over-diagnosed conditions. Calculation of a
surgery utilization rate per 1,000 infections can be
impacted by how infections are documented. Inconsistent
documentation of infections could also be a result of a
lack of sophistication in health care information
systems.
Second, this analysis suggests a strong relationship
exists between the HMO and a reduction in utilization and
83


cost. While the analysis is based upon data reported by
only three of the ten study HMOs, the results are
significant because the analysis is based upon
information from 67-70% of the entire HMO-insured
population in Colorado. Each HMO was able to provide
information about their management tools. Most were
unable to provide actual data necessary for feedback on
the effectiveness of those tools. In a climate of demand
for cost-effective accountable health care delivery, the
ability to account for the effectiveness of the HMO tools
would seem to be critical. The inability to do so is
clearly a limitation to this type of study.
A third limitation in the study is the scope and
providing for a review of the efficacy of the clinical
decision-trees. This study only focused on one
procedure. In order to realize benefits from a broader
application of clinical decision-trees, it would be
important to study such an application with other
procedures and therapies. And, while the focus of the
study is on control of utilization and cost reduction, an
84


equally important variable to consider when analyzing
clinical decision-trees is whether or not they guide
appropriate care for a patient's condition. Decision-
trees applied in the HMO environment may control
utilization and cost. Equally important is the use of
decision-trees to move treatment closer to a better
health care practice. Further, application of the
clinical decision-tree at the time of the request is
tested in this study. What is not known is the ultimate
outcome of the treatment option driven by the decision-
tree surgery or no surgery. Did the surgery work? We
don't know from this study.
The results of the empirical analysis suggest the
application of clinical decision-trees coupled with
modified physician payments impact utilization and cost
of health services. While it is important to consider
limitations identified with the study, the analysis
confirms that a relationship exists between the study
variables. This relationship provokes discussion in a
number of policy arenas and the potential for significant
85


changes in how we provide services and how we evaluate
them.
86


CHAPTER 4
CONCLUSIONS
A number of conclusions can be drawn from this study
as they relate to the research questions, delivery of
health services, and formulation of public policy for
health care. Results from tests performed on the study
hypotheses provide a basis from which we can continue to
challenge how the health care industry delivers services.
Two management tools found in HMOs, clinical decision-
trees and economic incentives, were analyzed to determine
if they impact utilization and cost of surgery as a
treatment option for ear infections. A significant
relationship between the use of clinical decision-trees
and surgery utilization was demonstrated in testing
Hypothesis 1. Hypothesis 2 could not be explicitly
quantified because of the lack of information necessary
to demonstrate physician behavior changes as a result of
economic incentives. In studying the variables
associated with hypothesis two, it was found that cost
87


reduction to HMOs was realized through negotiated
discounts with providers. Along with the unique
characteristics of HMOs clinical decision-trees,
referral process, and payment methods, results from the
test hypotheses provide some direction for how we might
deliver care and how we determine health care needs
versus wants.
This chapter provides a review of the results from
the empirical analysis and relationships examined in the
two research hypotheses. In addition, the roles of
decision-trees, referral processes and physician payment
methods are examined to understand how they impact
utilization and cost. The analysis results open the door
for us to challenge delivery mechanisms from a use and
cost perspective. A discussion on the broader
implications of the analysis closes this chapter and
focuses on the potential use of these research findings
in the policy arena.
88


Utilization
The comparative analysis performed to test the
relationship between surgery utilization and payer type
indicate a strong relationship between the two variables.
Data collected from this study indicate the surgery
utilization rate found in the indemnity insurance
environment is 28-33% higher than that observed in
HMOs.(Appendix B) In 1994, the HMO surgery utilization
rate was 33% lower than that found in the indemnity
sample and 28% lower in 1995. A chi square test of
independence further demonstrated there is a strong
relationship between HMOs and a reduction in use of
surgery. This results suggest a significant potential
for realizing savings throughout the entire system
through the use of clinical decision-trees. It will be
important to continue to analyze the use of decision-
trees for other types of procedures before a broader
policy mandate is initiated.
The test results for hypothesis one are consistent
with prior research focused on decision-trees. When
89


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