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

Surprisingly, neither the HOI nor Kaiser patients reported higher satisfaction with preventive care and wellness under the demonstration plan. This is one of the most frequently cited benefits of an MCP, but this does not appear to have been an important factor for the two demonstration sites. A variety of explanations are possible. Patients may not have perceived a greater emphasis on preventive care. Alternatively, patients may have valued this benefit less than the significant financial incentives of participating in the demonstration. Another possibility is that patients considered coverage of preventive services to be a financial benefit (i.e., they received preventive services prior to the demonstration, but had to pay out-of-pocket for them).

Health Care Providers and Services

Patient satisfaction with dialysis staff and facility, and medical team appeared to be very high among both demonstration and comparison groups. The demonstration patients reported few differences in satisfaction with their health care providers and their dialysis facility after 1 year of enrollment. This is not surprising, as many of the demonstration patients did not change dialysis facilities after enrolling in the demonstration. Therefore, we did not expect any significant differences in satisfaction toward the health care team or dialysis facility from the demonstration patients at the 1 year followup.

In contrast, there were some very large and statistically significant differences in patient satisfaction with health care providers and services between the demonstration and comparison groups, especially the FFS group. The matched FFS and NDMC patients reported significantly higher satisfaction with their dialysis staff compared with the demonstration patients. It is uncertain why these comparison groups would report higher satisfaction with their dialysis staff since they were recruited from mostly the same facilities as the demonstration patients. It is unlikely that the dialysis staff would have treated demonstration patients differently from FFS or NDMC patients within the same facility.

Another significant difference was that, compared with demonstration patients, FFS patients reported higher satisfaction with the ease in obtaining appointments with their primary care doctor and obtaining referrals to a specialist. This supports the commonly reported disadvantage of an MCR namely, difficulty in gaining access to a primary care doctor or specialist (Reschovsky et al., 2000). In addition to higher satisfaction with access to their physicians, FFS patients also reported higher satisfaction with the availability of social workers and dietitians. A possible explanation for this observation is that under an MCR there may be the perception of restricted access (through referral requirements). FFS patients also reported greater satisfaction with the ability to get to and from their dialysis facilities.

Although FFS patients reported higher satisfaction with their health care providers, they appeared to be less satisfied with their medical care when hospitalized compared with demonstration patients. It is unclear why these differences would be observed, but it may be a reflection of the more comprehensive hospitalization coverage provided under MCPs. Additionally, the demonstration plans provided a comprehensive case management approach, which may have resulted in better coordination of care among physicians, dietitians, social workers, and other specialists when patients were hospitalized. This coordinated care would seemingly provide greater comfort to the demonstration patients during a time when they are not in good health and receiving treatment in a large unfamiliar health care system.