Managed Care Penetration and Cancer Care

最近的证据表明，随着管理式医疗市场份额的增加，收费服务部门的支出减少。这一观察结果表明，管理式医疗对整个卫生保健系统产生了广泛的影响，并被称为“溢出”效应。这是未知的；然而，收费服务部门的护理质量是否随管理式护理普及率的变化而变化。如果在普及率较高的市场中，由于所需服务的提供减少而导致支出减少，这些市场的保健质量下降或改善的速度就会比其他市场慢。我们建议研究管理式医疗的普及是否与医疗质量和治疗选择有关，以提供给诊断为乳腺癌、结直肠癌或前列腺癌的医疗保险患者。我们将(1)检验管理式护理渗透与护理质量之间的关系(早期乳腺癌患者初始治疗后的年度乳房x光检查，III期结肠癌患者的辅助化疗，II期或III期直肠癌患者的辅助化疗和放疗；建议对诊断为结直肠癌的患者进行监测活动（例如在诊断一年内进行结肠镜检查）；在确诊为局限性前列腺癌的男性一年内进行PSA检测；(2)研究管理式医疗渗透与乳腺癌（乳房切除术与保乳手术）和前列腺癌（保守治疗与手术或放射治疗）中同样有效但费用不同的治疗方法的使用之间的关系；(3)研究管理式医疗渗透的变化可能导致护理模式变化的机制。也就是说，管理式医疗对市场内提供者专业组成和市场内技术可用性的影响是否会部分解释与管理式医疗渗透变化相关的护理变化。我们将使用SEER-Medicare数据来识别1992年至1996年间诊断的患者。我们将从卫生保健融资管理局和InterStudy获得数据，以构建县、卫生保健资源区和大都市统计区各级管理医疗普及的措施。我们将使用层次回归模型在每个层次中进行分析。减少癌症相关发病率和死亡率的努力取决于所提供的已知有效的服务。在没有确定一种有效治疗方法的情况下，可以通过提供符合患者偏好的服务来改善生活质量。该项目旨在确定市场力量是否会影响癌症治疗模式。如果管理式医疗普及与医疗服务的提供呈负相关，就需要针对决策者、提供者和患者采取干预措施，以抵消市场力量的影响。

Recent evidence suggests that as the market share of managed care increases, expenditures in the fee-for-service sector decrease. This observation demonstrates managed care's extensive effect on the entire health care system and is referred to as a "spillover" effect. It is not known; however, whether quality of care in the fee-for-service sector varies as function of managed care penetration. If lower expenditures in markets with higher penetration result from reductions in the provision of needed services, quality of care in these markets will either decline or improve at a slower rate than in other markets. We propose to examine whether managed care penetration is associated with the quality of care and choice of treatments provided to Medicare patients diagnosed with breast, colorectal, or prostate cancer. We will (1) examine the association between managed care penetration and the quality of care (annual mammography following initial therapy for women diagnosed with early-stage breast cancer; adjuvant chemotherapy for patients diagnosed with stage III colon cancer; adjuvant chemotherapy and radiation therapy for patients diagnosed with stage II or III rectal cancer; recommended surveillance activities (for example, colonoscopy within one year of diagnosis) for patients diagnosed with colorectal cancer; and PSA testing within one year of diagnosis for men diagnosed with localized prostate cancer; (2) examine the association between managed care penetration and the use of treatments that are equally effective but that differ in cost for breast cancer (mastectomy versus breast conserving surgery) and prostate cancer (conservative management versus surgery or radiation therapy); and (3) examine mechanisms by which changes in managed care penetration may lead to changes in patterns of care. That is, whether the influence of managed care on the provider specialty composition within a market and on the availability of technologies within a market will partially explain variations in care associated with changes in managed care penetration. We will use SEER-Medicare data to identify patients diagnosed between 1992 and 1996. We will obtain data from the Health Care Financing Administration and from InterStudy to construct measures of managed care penetration at the county, Health Care Resource Area, and Metropolitan Statistical Area level. We will conduct our analyses within each of these levels using hierarchical regression models. Efforts to reduce cancer- related morbidity and mortality depend upon the provision of services known to be effective. In cases where one effective treatment has not been identified, quality of life can be improved by providing services that are congruent with patients' preferences. This project seeks to determine whether market forces influence the patterns of cancer care. If managed care penetration is negatively associated with the delivery of care, interventions targeted toward policy-makers, providers, and patients will be needed to counteract the effects of market forces.