Quality of life and patient satisfaction: ESRD managed care demonstration

Health Care Financing Review, Summer, 2003 by Trinh B. Pifer, Jennifer L. Bragg-Gresham, Dawn M. Dykstra, Jennifer R. Shapiro, Caitlin Carroll Oppenheimer, Daniel S. Gaylin, Nancy Beronja, Robert J. Rubin, Philip J. Held

INTRODUCTION

It has been postulated that an MCP can provide better and more comprehensive health care at a lower cost (Starr, 2000). However, it has also been stated that the main disadvantage of MCPs is the restrictive nature of their health care management approaches (Reschovsky, Kemper, and Tu, 2001). For instance, patients are confined to a specific group of health care providers. This has often caused great dissatisfaction among patients who desire or need greater flexibility in their health care plan. Improving and maintaining patient satisfaction and quality of life have become important treatment goals in end stage renal disease (ESRD) (Kutner, Brogan and Kutuer, 1986). Patient quality of life, as measured by the SF-36[R] (Medical Outcomes Trust, Inc., 2003), has been shown to predict morbidity, hospitalization, and mortality in dialysis patients (Hays et al., 1994). This investigation evaluates patient satisfaction and quality of life in the ESRD managed care demonstration.

The demonstration was conducted from 1996 to 2001 at three different sites: Health Options, Inc. (HOI), a subsidiary of Blue Cross[R]/Blue Shield[R] of Florida; Kaiser Permanente Southern California Region (Kaiser); and Xantus Health Care Corporation in Tennessee. Only the Florida and California sites remained operational for the duration of the demonstration. Enrollment was strictly voluntary. Recruitment materials were mailed by CMS to adult, Medicare primary, ESRD patients residing in the demonstration service area counties. The demonstration sites were also given opportunities to directly recruit ESRD patients and staff at local dialysis facilities. Patients were allowed to disenroll at any time.

The two active demonstration sites were based on different models of care. Kaiser was a large closed-system plan for specialists and inpatient care. In contrast to Kaiser's group-model structure, HOI relied on contracts with an independent network of providers to provide patient care. Both plans were based on a multidisciplinary team approach to patient-centered care management. Each enrollee was assigned to a team including a nephrologist, a case manager, a renal social worker, a dietitian, and a pharmacist; other relevant providers and specialists were included as needed. In most cases, the nephrologist also served as the patient's primary care provider in the MCP. Case managers were expected to be in daily contact with the nephrologist and coordinate the multidisciplinary team. Responsibilities of the case managers included monitoring patient care and promoting quality improvement, coordinating and managing patient needs, providing early intervention, and educating patients. The Kaiser case management team also included transplant coordinators, who provided case management for all transplant patients and worked to obtain transplants for qualified patients as quickly as possible. The coordinator also provided patient education and long-term post-transplant followup. Additional benefits provided by both plans included coverage for prescription drugs, other copayments, and nutritional supplements. Oppenheimer et al. (2003) fully describes marketing, enrollment practices, and benefit offerings in the demonstration.

Patient satisfaction was assessed from questions designed to measure satisfaction with services provided by dialysis facility and staff, and primary care physician. The questions also examined patient satisfaction with the benefits provided by the demonstration plans and the reasons why patients chose to enroll or not enroll. Patient quality of fife was assessed using the SF-36[R] instrument, which has been validated to capture physical and mental health scores for the ESRD patient population. Both patient satisfaction and quality of life data were collected on a questionnaire that was administered to demonstration patients and comparison groups.

METHODS

Sampling and Data Collection

Baseline data were collected on 1,479 demonstration patients, and followup data were collected on 750 one year after enrollment. The smaller sample size at followup was due to data collection and budgetary limitations, not patient attrition or disenrollment. This smaller sample was randomly selected from the larger baseline sample and a power analysis determined that this was the smallest sample size needed to detect a 5-point difference in quality of life scores.

For the evaluation of patient satisfaction, data on two different comparison groups were collected in a similar fashion and from the same dialysis facilities as the demonstration. The first comparison group consisted of 190 FFS patients and the second group was a sample of 190 managed care patients not enrolled in the demonstration--non-demonstration managed care (NDMC). Both of these samples were matched to the demonstration patients on age, race, and time since onset of ESRD.

In addition to the comparison groups, the quality of life analysis also compared demonstration patients to those from the Dialysis Outcomes and Practice Patterns Study (DOPPS), a nationally representative sample of hemodialysis patients in the U.S. (Young et al., 2000). The sample of DOPPS patients was restricted to California and Florida (n=377 and n=539, respectively).