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Do Patient Ratings of Care Suffer in VA's with High rates of Managed Care Practice Adoption?

Yano EM, Mittman BS, Simon BF, Wang M, Rubenstein LV. Do Patient Ratings of Care Suffer in VA's with High rates of Managed Care Practice Adoption? Paper presented at: VA HSR&D National Meeting; 2002 Feb 1; Washington, DC.


Objectives: While a managed care 'backlash' has received significant public attention in the media and has spurred legislative and political action surrounding the protection of patients' health care rights, little is known about whether patient ratings of care suffer in VA medical centers with above average rates of managed care practice adoption. Methods: We combined (1) facility-level risk-adjusted patient ratings of care (e.g., continuity, coordination, accessibility) from the VA National Ambulatory Care Survey, and (2) characteristics of VA practice organizations (including managed care arrangements) from the VHA Survey of Primary Care Practices. This survey was fielded to the primary care directors at all VA's in October 1999 (93% response rate). Managed care scales were derived for gatekeeping, pre-authorization, profiling, guidelines, and educational programs from previously validated scales developed for California managed care practices; median cutpoints were used to identify VA's with high and low adoption levels. Bivariate and multivariate analyses were conducted to assess the factors associated with patient ratings of care. Results: Adoption of managed care practices was not associated with patients' ratings of either access or coordination. Better continuity scores occurred at sites with higher-than-average gatekeeping (p < .05), pre-authorization (p < .001), profiling (p < .001) and managed care education (e.g., orientations, retreats) (p < .01), but not those with more guideline implementation. However, after multivariate adjustment for medical center features associated with continuity problems (complexity, academic affiliation, urban location), only adoption of pre-authorization practices was independently associated with patient ratings of care, and, contrasting bivariate results, indicated significanlty lower patient-reported continuity (OR = 3.68, p < .005). Conclusions: Adoption of managed care practices has had little effect on patient ratings of care, with the exception of use of pre-authorization. While relatively infrequently adopted in VHA, pre-authorization was a strong predictor of lower patient ratings of continuity. Impact statement: VA leaders, like their private-sector counterparts, continue to struggle with adopting care strategies that help them deliver high quality care at lower cost. While VHA has avoided the managed care 'backlash' seen in other settings, veterans' ratings of their care is clearly affected by how such care is organized and react negatively to stringent utilization management.

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