Observers of the American health-care scene have long worried--and produced some studies to prove--that cost-cutting in patient-care delivery would reduce the quality, amount and promptness of medical treatment.
Now, an analysis from the USC School of Public Administration has found evidence confirming some of those concerns. It concludes that patients with cancer are diagnosed and treated later in health maintenance organizations and insurance programs in which patients share the costs of their care (co-payment plans) than people with traditional all-inclusive coverage.
What the implications of this may be in terms of cancer death rates for HMOs and insurance plans with large co-payments are not yet clear, though one of the cancers in question--cervical--is especially amenable to early detection and treatment. But Howard Greenwald, the USC researcher who headed the study, said it is clear that patients in these two program types may needlessly suffer longer anxiety during such a treatment delay than people in fee-for-service practices who are fully covered.
Study of More Than 500 Patients
Greenwald's study included more than 500 Seattle patients covered by traditional insurance, co-payment plans or who were enrolled in the Group Health Cooperative of Puget Sound, an HMO. He found fee-for-service and HMO patients waited about the same amount of time (1.13 and 1.25 months, respectively) between when they first suspected they had cancer and diagnosis. But people with co-payment insurance waited nearly twice as long--2.32 months. Co-payment programs seek to reduce costs by requiring patients to share in paying bills to make them more aware of financial aspects of their care.
Comparing the time between diagnosis and when treatment actually began, co-payment and conventional insurance were virtually identical--.5 and .45 months, respectively. But HMO patients waited far longer--1.42 months. Greenwald's conclusion: Patients forced to assume a significant share of the cost of cancer treatment delay obtaining care, possibly because they fear economic consequences.
HMO patients, on the other hand, wait longer to be treated once they are diagnosed, possibly because HMOs aggressively ration expensive services like surgery, radiation and chemotherapy. Cancers involved were of the lung, pancreas, prostate and cervix, Greenwald reported in the American Journal of Public Health.
"Considering how many new organizations have come along and how much more competitive the environment has become," he said, "I feel this has to raise some important red flags."
But Paul Ellwood, nationally recognized as the father of the HMO movement and head of InterStudy, a Minneapolis consulting firm influential in proliferation of HMOs, said that while he had not seen the USC study, its results might be considered incomplete because ultimate outcomes of the cancer cases involved had not been completely assessed.
As to whether HMOs may generically delay cancer treatment, Ellwood said, "I just don't have any data. I don't know," though he noted that delay in seeking care among people in the co-payment group has the obvious potential to affect outcomes.
Greenwald noted that Group Health enjoys a national reputation as a high-quality program, saying that status led him to question how much the disparity in treatment time may be in more commercially oriented, newer HMOs.
CHOLESTEROL AND LIFE
There's little doubt that levels of cholesterol in the blood have a bearing on a person's prospects of having a serious heart attack or stroke. But while researchers have established the link between cholesterol and health, an unanswered question in what is sometimes called the "cholesterol saga" has been: What is the degree of actual risk to life?
The answer, Boston researchers say in the current issue of Annals of Internal Medicine, is: Not as great as publicity over the cholesterol issue may have implied. In fact, for people with above average cholesterol but who don't smoke and aren't overweight, bringing cholesterol under stricter control may add only between three days and three months to the life spans. Even for high-risk people--those with high cholesterol, tobacco use and weight problems--strictly cholesterol-related life expectancy reduction ranges between 18 days and 12 months.
The research team noted that death is not the only cholesterol-related problem and that controlling cholesterol may delay or reduce the stabbing chest pains of angina pectoris symptoms and prevent some nonfatal heart attacks. In one of two editorials accompanying the new Boston study, though, two Boston experts urge physicians to consider the trade-off between gains in life expectancy of as little as a few days and the cost and other problems implicit in strict cholesterol-control programs.