International Journal of Health Care Quality Assurance

Health care utilization by the elderly in HMOs: comparing risk and cost contracts
Kris Siddharthan, W. Michael Reid,
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 Health care utilization by the elderly in HMOs:
comparing risk and cost contracts
Kris Siddharthan
Depar tment of Health Policy and Management, College of Public Health,
University of South Florida, Tampa, Florida, USA
W. Michael Reid
Depar tment of Health Policy and Management, College of Public Health,
University of South Florida, Tampa, Florida, USA

Data are utilized collected However, they pe rtain mostly to commercial,

from the American Associa-
tion of Health Plans, a trade
association representing
HMOs, to study differences in
utilization patterns between
medicare beneficiaries
Downloaded by DIPONEGORO UNIVERSITY At 23:26 15 May 2018 (PT)
Introduction
The feder al government h as encour aged
Medica re beneficia ries to enroll in health
m ainten a nce orga nizations (HMOs) to p ro-
vide seniors greater choice in obtaining
health ser vices. Participating health pla ns
nongovernment patients. Other resea rch h as
studied the deliver y of ca re to unique popula-
tions such as Medica re or Medicaid beneficia-
ries enrolled in specific health pla ns (Gold-
fa r b et al., 1991; Krieger et al., 1992). To our
k nowledge, no com pa r ative studies h ave been

enrolled in Medicare risk and ca n sign r isk or cost cont r acts including so
cost contracts with health called health ca re p repay men t pla ns (HCPPs)
plans. Utilization is measured with the Health Ca re Fin a ncing Administr a-
by the number of ambulatory tion (HCFA) to p rovide health ca re ser vices.
procedures performed, outpa- In r isk cont r acts, the health pla n receives a
tient and emergency room fixed monthly pay ment from Medica re for
visits, and acute and nona- each enrolled mem be r, usu ally 95 pe rcent of
cute discharges. Comparedto the adjusted aver age pe r capita cost, a nd
elders enrolled in risk plans, mu st p rovide all ser vices on a n at-r isk basis.
those in cost arrangements Cost cont r acts p rovide th at the HMO is reim-
appear to exhibit higher bursed by HCFA for the reason able cost of all
inpatient and outpatient use. ser vices actu ally p rovided to Medica re
Members of for-profit plans enrollees. If a beneficia r y chooses to use a
experienced greater outpa- nonpla n p rovide r, Medica re inter media ries
tient visits, accreditation did will pay a ny claim s without regard to a
not appear to influence uti- patient’s HMO status. Usu ally r isk pla ns
lization, and IPA arrange- p rovide a greater r a nge of benefits, exa m ples
ments resulted in a decrease of which m ay include the waiving of Part B
in outpatient utilization.
p remiums a nd vision a nd dental ca re.
Financial and policy issues HCPP is a for m of cost cont r act to p rovide p
are discussed. rofession al ser vices. Ma ny of the HCPPs
cont r acting with HCFA a re in fact labor or
em ployer orga nizations th at a rr a nge for the p
rovision of ser vices exclusively to their
mem be r s. HCFA reported there were 179 r isk
cont r acts (3.96 million enrollees) a nd 87 cost
cont r acts (enrolling 416,000 Medica re benefi-
cia ries) in 1996.
While r isk cont r acts p rovide incentives for
health pla ns to p rovide efficient ca re, cost
cont r acts lack incentives for cost cont rol
through aggressive case m a n agement or
This research was supported utilization m a n agement p rogr a m s a nd possi-
by a grant from the Institute bly result in higher utilization a nd cost th a n
of Aging at the University of fee-for-ser vice Medica re. With increased
South Florida, Tampa, FL. pa rticipation, currently 14 pe r cent of
Medica re beneficia ries (Group Health Associ-
ation of America, 1995), the cost a nd qu ality of ca
re p rovided by health pla ns h as come
unde r scrutiny.
International Journal of
Health Care Quality Va r ious studies h ave com pa red utilization
Assurance patterns a mong enrollees in p repaid pla ns
11 / 2 [1998] 45–49 versus t r adition al fee-for-ser vice (Ma uldon et
© MCB University Press al., 1994; Safron et al., 1994; Sh a ughnessy
[ISSN 0952-6862 ]
a nd Sclen ke r, 1995; Udva rhelyi et al., 1991).
conducted on differences in the qu a ntity a nd qu
ality of ca re p rovided to the elde rly who
a re covered by different pay ment
mech a nism s in cont r acts between HCFA a nd
m a n aged ca re com pa nies. Medica re is
p roposing other va r iations of cost cont r acts
such as a p referred p rovide r option (PPO).
An other option would be a PPO to include
sup ple ment al insur a nce cover age th at is
currently met by Medigap insur a nce. The
im pact of greater choice a mong the elde rly
a nd the associated cost a nd qu ality issues a re im
porta nt policy questions th at should be
studied.
Research questions
This study will exa mine two im porta nt
resea rch questions:
1 Are there differences between the outpa-
tient a nd inpatient ca re received by
Medica re beneficia ries who a re mem be r s of
HMO r isk pla ns a nd the ca re received by
Medica re patients who a re enrolled in cost cont
r acts while cont rolling for other fac-
tors such as enrollment patterns a nd HMO ch a
r acteristics?
2 Ca n a ny such differences be explained by
HMO-specific ch a r acteristics such as
enrollments, ow nership, orga nization a nd
accreditation status?
Data and methods
The data used in this study were collected in a
survey conducted in 1995 by the America n
Association of Health Pla ns (AAHP), a t r ade
association rep resenting the interests of
health pla ns. A total of 354 health pla ns pa r-
ticipated in the survey. HMOs a re required to
report much of the data p rovided to AAHP to
regulator y agencies in states where they a re
licensed to enroll mem be r s. Hence, even
though the data a re self-reported, results of

[ 45 ]
 Kris Siddhar than and
W. Michael Reid
Health care utilization by
the elderly in HMOs:
comparing risk and cost
contracts
International Journal of
Health Care Quality
Assurance
11 / 2 [1998] 45–49
Downloaded by DIPONEGORO UNIVERSITY At 23:26 15 May 2018 (PT)
Table I
Characteristics of health plans enrolling Medicare populations
Variable
Enrollment (in 000s, n = 354)
Medicare enrollment (in 000s,
n = 98)
Mean age of plan in years
Percent staff model
Percent group model
Percent network model
Percent two-tier IPA
Percent three-tier IPA
Percent with NCQA qualification
0 = no; 1= yes
Tax status (percent)
nonprofit, 501 ( c) 3
nonprofit, 501 ( c) 4
nonprofit, other
for profit, privately held
for profit, publicly held
Ownership (percent)
Blue Cross / Blue Shield
Private insurer
HMO company
Hospital and / or physician
Other
[ 46 ]
our study ca n be viewed as h aving si mila r
validity to other resea rch involving health pla
ns.
We excluded from our a n alysis those pla ns
th at h ad obtained government app roval to
sta rt Medica re p rogr a m s but h ad not as yet
enrolled a ny Medica re patients, a nd those
th at were in ope r ation for less th a n a yea r.
Table I outlines ch a r acteristics of the 98 pla ns
used in the fin al a n alysis. The m ajority of the
pla ns (n = 58) enrolled seniors unde r exclu-
sive r isk cont r acts com pa red to cost cont r act-
ing (n = 23). Seventeen pla ns enrolled mem-
be r s unde r both types of a rr a ngements p re-
sum ably in different geogr aphic a reas. We
could not ascertain from the data if choice a
mong cost a nd r isk pla ns was available to
mem be r s in a ny m a rket.
About 42 pe r cent of the pla ns were not-for- p
rofit orga nizations with the rest either p r i- vately
held (20 pe r cent) or publicly t r aded
corpor ations (38 pe r cent). At the ti me of the
survey, the pla ns on aver age h ad been in ope r-
ation for about 16 yea r s. The pe rcentages
show n in Table I for the va r ious models of
HMOs correspond to the p roportion of mem- be r
s ser ved by each type of model in the sa m- ple.
For exa m ple, app roxim ately one in 12
patients received ca re in a staff model setting. This
does not necessa r ily im ply th at one in 12 HMOs
was a staff model as m a ny pla ns h ave different
orga nization al st ructures in differ-
Mean Standard Deviation Minimum Maximum
122.01 185.46 13.2 236.05
19.5 57.0 6.7 83.1
16.14 8.64
8.64
13.93
16.31
41.58
19.51
0.43
25.5
12.2
4.1
20.4
37.8
9.2
12.2
42.9
21.4
14.3
ent m a rkets or h ad different a rr a ngements with
p r im a r y ca re p rovide r s a nd specialists.
Sixty-one pe rcent of ca re-giving was p rovided
unde r a n a rr a ngement wherein physicia ns or
group p r actices cont r act di rectly with a
health pla n (two-tier a rr a ngement) or inde-
pendent p r actice association (IPA) which
then cont r acts with one or more HMOs
(three-tier a rr a ngement). This a rr a ngement is
commonly referred to as a n IPA model
HMO.
Though the aver age pla n h ad been in exis-
tence for 16 yea r s, numerous mergers a nd
acquisitions m ay h ave ch a nged the st ructure a
nd size of the origin al health pla n over the yea r
s. In recent yea r s, HMOs h ave sought
accreditation from the Nation al Committee
for Qu ality Assur a nce (NCQA), a not-for-
p rofit orga nization th at reviews pla n pe rfor-
m a nce in the a reas of qu ality assur a nce,
credentialing, utilization, mem be r r ights a nd
responsibilities, p reventive health ser vices,
a nd medical records in gr a nting accredita-
tion. Although enrolling Medica re mem be r s
is not a feder al requirement, HMOs h ave used
NCQA accreditation to m a rket their pla ns. At the
ti me of the survey 43 of the 98 pla ns h ad
obtained NCQA accreditation.
Table II outlines inpatient a nd outpatient
utilization ch a r acteristics of Medica re
patients in cont r acts purely of a cost (C pla ns) or r
isk (R pla ns) n ature a nd those with both
cost a nd r isk com ponents (C & R pla ns). C & R
pla ns m ay fall into one of two categories.
They m ay offer choice in a r isk or cost con-
t r act in a pa rticula r geogr aphic a rea or they
m ay offer exclusive r isk / cost cont r acts in
different geogr aphic a reas. Mea ns a nd sta n- da rd deviations (within pa
rentheses) denote la rge va r iations in ca re-giving.

Those enrolled exclusively in cost cont r acts appea r to utilize acute ca re Comparison of C plans and R plans
(disch a rges / 1,000 enrollees), non acute ca re (disch a rges / 1,000
enrollees), a nd a m bulator y ca re (outpatient
visits) more th a n those in r isk a rr a ngements. Ma ny health pla ns,
especially staff models,
h ave urgent ca re centers staffed with sala ried p rovide r s to which m a n aged ca
re patients
who need immediate attention a re di rected
instead of emergency depa rt ments in hospi- tals. Therefore, the
utilization of outpatient
a nd emergency room s m ay be confounded by altern ate ca re sites such as
urgent ca re cen-
ters a nd m ay explain some of the va r iations in the reported numbe r of visits.
The data available did not pe r mit b reakdow n of office visits as initiated by
patients or ca re
p rovide r s or the numbe r of repeat visits. The

[ 47 ]
 Kris Siddhar than and
W. Michael Reid
Health care utilization by
the elderly in HMOs:
comparing risk and cost
contracts
International Journal of
Health Care Quality
Assurance
11 / 2 [1998] 45–49
Downloaded by DIPONEGORO UNIVERSITY At 23:26 15 May 2018 (PT)
numbe r of outpatient p rocedures pe rfor med
appea r s to be si mila r across both groups.
The r ate of non acute disch a rges was
slightly higher (about 10 pe r cent) a nd the r ate
of acute disch a rges was substa ntially higher
(about 26 pe r cent) a mong cost
enrollees th a n the r ates of r isk enrollees. The
aver age length of hospital stay was com pa r a-
ble between the two types. HCFA reim burses cost
pla ns for hospital ca re unde r the
Medica re P rospective Pay ment Syste m (based
on diagnosis-related groups or DRGs). Conse-
quently, incentives exist for utilization m a n-
agement in both pla n types.
However, patients enrolled in cost pla ns
stayed longer at non acute ca re facilities with a n
aver age length of stay more th a n 50 pe r-
freesta nding nursing facility in a skilled,
inter mediate or gener al non acute ca re set- ting.
Ma n aged ca re orga nizations gener ally
com pensate p rovide r s of non acute ca re on a
per diem basis (Kongstvedt, 1996) a nd tend to
pay physicia ns a nd hospitals by bundled
units of pay ment such as per diem , capitation, or
sala r y (Goldbe rg et al., 1992). In cost con-
t r acts there is little incentive to cont rol uti-
lization in non acute ca re settings since
Medica re usu ally pays for extended ca re on a
cost basis. However, fin a ncial incentives exist for
ea rly disch a rge in capitation a rr a nge-
ments.
Utilization in C & R plans

cent higher th a n r isk enrollees. We were In pla ns th at enrolled both categories of

un able to dete r mine if the ca re was p rovided in patients, the numbe r of a m bulator y p roce-
a hospital-based skilled nursing unit or a dures pe rfor med per capita a mong enrollees in
cost pla ns was about equ al to those in r isk pla ns
a nd com pa r able to utilization by mem-
Table II
Membership and utilization characteristics of Medicare beneficiaries under be r s in exclusive r isk / cost pla ns. The r ate of
risk and cost contracts emergency room visits was higher a mong
cost enrollees thou gh little difference existed
Risk Cost Risk and cost (75.4) (62
(s.d.) (s.d.) (s.d.)
Variable n = 58 n = 23 n = 17
Mean Medicare enrollment (in 000s) 21.4 5.67 23.1 (R)
(45.4) (5.3) (32.5)
20.5 (C)
(51.3)

Ambulatory procedures/ 1,000 lives 337.36 182.1 263.1 (R)

(560.5) (635.6) (211.9)
314.7 (C)
(283.8)
Emergency visits / 1,000 lives 250.9 182.1 263.1 (R)
(288.3) (159.3) (211.9)
314.7 (C)
(283.8)
Outpatient visits 5611.2 8518.8 7325 (R)
(4442.7) (159.6) (3842)
7280 (C)
(4391)
ALOS (nonacute care) 16.6 27.1 17.4 (R)
(9.7) (10.9) (4.01)
25.08 (C)
(7.88)
ALOS (acute care) 5.63 6.02 5.14 (R)
(1.01) (2.83) (0.67)
5.50 (C)
(1.12)
Nonacute discharges / 1,000 lives 43.3 48.4 69.2 (R)
(58.5) (92.4) (41.2)
62.6 (C)
(34.2)
Acute discharges / 1,000 lives 170.4 214.05 198.5 (R)

[ 48 ]
in the reported r ate of outpatient visits. Aver- age length of stay for acute ca re ad
missions
for cost patients was higher though the differ- ence was not as la rge as th at
between
enrollees in exclusive C pla ns a nd R pla ns.
Non acute a nd acute ca re disch a rges pe r 1,000 covered lives was com pa r able
across the two
groups.

Independent variables Multivariate analysis

We conducted a regression a n alysis to dete r- mine the effect of health pla n
specific ch a r ac- ter istics, such as size in ter m s of enrollment, numbe r of yea r s
in ope r ation, whether for
p rofit or not, accreditation status with the NCQA, type of cont r act the
enrollee is
enrolled in, a nd orga nization of pla n
(whether IPA or not) on five utilization mea- surements. The independent a nd
dependent va r iables, their coded values a nd esti m ated
coefficients a re contained in Table III.
E nrollment figures refer to the aver age enrollment in a pla n in 1995. The va r
iable
denoting yea r s in ope r ation pe rtains to the
ti me of initial incorpor ation of the orga niza- tion a nd does not include the effect
of merg- ers a nd acquisitions due to consolidation in
the ind ustr y. In our a n alysis, we used accredi- tation status, denoted by
the va r iable NCQA, as a p roxy for qu ality of ca re p rovided. NCQA
monitors qu ality in m a n aged ca re orga niza- tions by requiring pla ns to
report pe rfor-
m a nce measures through the Healthpla n E m ployer Data Infor m ation
Set (HEDIS).

[ 49 ]
 Kris Siddhar than and
W. Michael Reid
Health care utilization by
the elderly in HMOs:
comparing risk and cost
contracts
International Journal of
Health Care Quality
Assurance
11 / 2 [1998] 45–49
Table III
Results of utilization measures regressed with explanatory variables (stan-
dardized)
Procedures
Downloaded by DIPONEGORO UNIVERSITY At 23:26 15 May 2018 (PT)
Version 3.0 of HEDIS established
pe rfor m a nce criteria in more th a n 60 cate-
gories of ca re p rovision. For this a n alysis, we
aggregated discrete categories referencing
tax status of the orga nization a nd type of
HMO into va r iables with du al outcomes
(p rofit / non-p rofit a nd IPA / non-IPA). The
va r iable IPA is set to one if the m ajority of
lives covered by the pla n a re by a n a rr a nge-
ment with a n IPA a nd equ als zero other wise.
Emergency Discharges Discharges Outpatient
reim burse ment agreements between health
pla ns a nd p rovide r s, other resea rch suggests
th at recommended elements of routine a nd
p reventive ca re a re more likely to be pe r-
for med in staff/ group pla ns th a n in fee-for-
ser vice settings (Udva rhelyi et al., 1991).
Beca use of a lack of patient data we were
un able to ascertain the effects of socioeco-
nomic va r iables such as age, gende r, income
levels, place of residence, a nd other patient ca re
ch a r acteristics on the utilization mea-
sures though such va r iables h ave been show n
tient visits.
Although we could
not dete r mine

(ambulatory) visits (nonacute) (acute) visits

1,000 1,000 1,000 1,000 1,000
Variable Coefficient Coefficient Coefficient Coefficient Coefficient
Intercept –224.0 515.9 – 90.6 197.3 937.0
Enrollment 0.42 –0.33 –0.88 1.4 ** –36.3
Years in operation 0.68 0.44 –3.3 –2.3 * 38.1
Tax status
1 = profit; 2 = nonprofit 230.3 ** –171.4 28.8 –29.1 1578.0
NCQA 87.1 –49.0 38.6 38.3 * –724.3
1 = accredited
2 = nonaccredited
Risk –207.1 –43.7 * 88.1 –23.6 * 308.1
1 = risk contract
0 = no risk contract
Cost 50.1 –116.4 –23.5 * 18.7 822.2
1 = cost contract
0 = noncost contract
IPA 457.3 ** –113.9 11.6 –24.6 –560.0
1 = IPA model
0 = nonIPA model
Note: * p < 0.01; ** p < 0.05

The regression results were si mila r to the

findings in the univa r iate a n alysis. Beca use of la
rge va r iations in the unde rlying dist ribu- tions,
few of the esti m ated coefficients were
statistically significa nt. Com pa red to r ates in the
C & R pla ns, which were used as the con- t rol va
r iables, fewer p rocedures were pe r-
for med in r isk cont r acts with fewer ad mis-
sions to acute ca re facilities. Exclusive cost
pla ns experienced more outpatient visits a nd
disch a rges related to acute ca re. Me m be r s in
for-p rofit pla ns could be expected to experi-
ence one a nd h alf more outpatient visits th a n
those in si mila r not-for-p rofit pla ns. Accredi-
tation status did not appea r to influence uti-
lization. Beca use we were not awa re of the pay
ment a rr a ngements between the health
pla ns a nd p rovide r s, we could not dete r mine
the effects of reim burse ment st r ategies on
costs a nd qu ality of ca re.
Independent p r actice association a rr a nge-
ments appea r to place less em ph asis on outpa-

[ 50 ]
to influence ca re given to Medica re popula- tions (Burstin et al., 1992;
Goldbe rg et al., 1992). The effect of biased selection a mong cons u mers
whenever choice is available is
k now n – healthier pe r sons will enroll in m a n- aged ca re pla ns while the
less healthy will
elect the fee-for-ser vice option (Brow n et al., 1993; Buch a n a n et al., 1986).
Little is k now n about differences in health status of seniors who enroll in cost
versus r isk cont r acts. Out- of- pocket costs a nd health status play a m ajor role in
the decision of senior citizens to join
health pla ns (Hill a nd Brow n, 1992). The
exclusion of the mentioned factors int roduces bias into our a n alysis.

Conclusions
As currently funded a nd ad ministered, the Medica re p rogr a m will run out of
money, even before the baby boom gener ation
reaches 65 yea r s of age. To cont rol costs while expa nding choice m ay require
significa ntly
increased enrollment of seniors into health pla ns. The feder al government pla ns
to p ro- vide a n a rr ay of choices to Medica re benefi- cia ries as evidenced by the
Medica re P reser- vation Act of 1995. That legislation offers
elde r s a choice of p repaid pla ns (HMOs), point of ser vice (POS) pla ns, p
referred
p rovide r orga nizations (PPOs), a nd fee-for- ser vice pla ns. Those who select
more expen- sive pla ns m ay h ave to pay more for th at
choice.
Our limited resea rch indicates th at
Medica re cost cont r acts with HMOs appea r to exhibit ch a r acteristics of unm
a n aged ca re
a nd overutilization as in fee-for-ser vice. With more reporting of patient data in
the future
through HEDIS, it should be possible to
include the effects of patient-specific ch a r ac- ter istics on health ca re utilization in
com pa r- ative a n alyses. It is im pe r ative th at more
resea rch be conducted on cost a nd qu ality
issues associated with greater choice so th at Medica re refor m ca n achieve the
desi red
policy goals of m aximizing choice a nd qu ality within reason able budgeta r y
constr aints.

[ 51 ]
 Kris Siddhar than and References
W. Michael Reid Brow n, R.S., Clement, D.G., Hill, J.W., Retchinl,
Health care utilization by
S.M. a nd Bergeron, J.W. (1993), “Do health m
the elderly in HMOs:
comparing risk and cost ainten a nce orga nizations work for
Medica re?”, Health Care Financing Review,
contracts
Fall, Vol. 15 No. 1, pp. 7-23.
International Journal of
Health Care Quality Buch a n a n, J.L. a nd Cretin, S. (1986), “Risk selec-
tion of fa milies electing HMO membership”,
Assurance
11 / 2 [1998] 45–49 Medical Care , Janu a r y, Vol. 24 No. 1, pp. 2383-7.
Burstin, H.R., Lipsitz, S.R. a nd Brenn a n, T.A.
(1992), “Socioeconomic status a nd r isk for
substa nda rd medical ca re”, JAMA , Vol. 268, pp.
2383-413.
Goldbe rg, K.C., Ha rtz, A. J. a nd Jacobsen, S. J.
(1992), “Racial a nd community factors influ-
encing coron a r y a rter y bypass gr aft surger y
r ates for all 1986 Medica re patients”, JAMA ,
Downloaded by DIPONEGORO UNIVERSITY At 23:26 15 May 2018 (PT)
Vol. 267, pp. 1473-7.
Goldfa r b, N., Hillm a n, A.L., Eisenbe rg, J.M., Kelly,
M.A., Cohen, A.V. a nd Dellheim, M. (1991),
“Im pact of a m a ndator y Medicaid case m a n-
agement p rogr a m on p ren atal ca re a nd bi rth
outcomes”, Medical Care , Janu a r y, Vol. 29
No. 1, pp. 64-71.
Group Health Association of America (1995),
HMO Industry Profile, Group Health Associa- tion
of America, Washington, DC.
Hill, J.W. a nd Brow n, R.S, (1992), Health Status,
Financial Barriers and the Decision to Enroll in
Medicare Risk Plans, Mathem atica Policy Resea
rch Inc., P r inceton, N J.
[ 52 ]
Kongstvedt, P.R. (1996), The Managed Health Care
Handbook , Aspen P ublishers, Gaithersburg, MD.
Krieger, J.W., Connel, F.A. a nd Logerfo, J.P. (1992),
“Medicaid p ren atal ca re: a com pa r ison of use a
nd outcomes in fee-for-ser vice a nd m a n aged ca
re”, A merican Journal of Public Health,
Febru a r y, Vol. 82 No. 2, pp. 185-90.
Ma uldon, J., Leibowitz, A., Buch a n a n, J.L., Da
m be rg, C. a nd McGuiga n, K.A. (1994),
“Rationing or r ation alizing child ren’s
medical ca re: com pa r ison of a Medicaid
HMO with fee-for-ser vice ca re”, A merican
Journal of Public Health , June, Vol. 84 No. 6, pp.
899-904.
Safr a n, D.G., Tarlov, A.R. a nd Rogers, W.H. (1994), “
P r im a r y ca re pe rfor m a nce in fee-for-ser vice a
nd p repaid health ca re syste m s. Results from
t he Medical Outcomes Study”, JAMA, 25 May, Vol.
271 No. 20, pp. 1579-86.
Sh a ughnessy, P.W. a nd Sclen ker, R.E. (1995), “Case
mix of home health patients unde r capitated
a nd fee-for-ser vice pay ment”, Health
Services Research , Ap r il, Vol. 30 No. 1,
pp. 79-113.
Udva rhelyi, I.S., Jennison, K., P hillips, R.S. a nd
Epstein, A.M. (1991), “Com pa r ison of t he
qu ality of a m bulator y ca re for fee-for-ser vice a
nd p repaid patients”, A nnals of Internal
Medicine, 1 Septe m be r, Vol. 115 No. 5,
pp. 394-400.