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Study Faults Managed Care

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Most elderly heart attack patients are not getting a recommended and potentially lifesaving test — especially those in managed care, a study suggests.

The test, called an angiogram, is often performed to check blood flow through clogged heart arteries after heart attacks. The study found that patients in managed care were 12 percentage points less likely than those with traditional insurance to get the exam, even when their conditions clearly suggested they should.

``The differences between the managed care and fee-for-service were modest and were really dwarfed by the overall underutilization,'' said Dr. Nathan Every, a Veterans Administration cardiologist in Seattle who has done similar research.

Some patients and researchers suspect that managed care, which pays fixed amounts for treating patients, causes doctors and hospitals to skimp on care.

Studies have given mixed answers, but some research on heart patients has found they get more care under traditional fee-for-service insurance. Even so, it has been largely unclear if the broader care was needed or not. The new study found that it is.

The mammoth analysis of records from about 50,000 Medicare patients was published in Thursday's New England Journal of Medicine. It was carried out by researchers at a group of Boston hospitals and the U.S. General Accounting Office.

They collected records on patients admitted to hospitals in seven states for eight months in 1994-95. They counted how many underwent the angiograms.

In the procedure, dye is pumped into the heart muscle through a skinny tube, and an X-ray image is taken to reveal the heart's condition. The test, which costs about $2,500, can help doctors make critical decisions about treatment.

The researchers set out to compare treatment under the two types of insurance. They were surprised to discover that striking numbers of patients in both groups fail to undergo the test when it is medically warranted.

Among fee-for-service patients, 46 percent were given angiograms when they were clearly warranted under accepted professional guidelines. Among managed care patients, just 34 percent underwent the procedure when justified. Only about 10 percent had clearly unnecessary angiograms under either payment plan.

The lead researcher, Edward Guadagnoli, at Harvard Medical School, cautioned: ``Is this an indictment of managed care? No, we're only talking about one procedure for one condition. I think we need to look at other conditions.''

Representatives of the American Association of Health Plans, which includes HMOs and other managed care insurers, argued that their plans provide doctors with a financial incentive to give the best care.

``If someone is sick and they get sicker, that typically costs more, and your incentive is to not let that happen,'' said Susan Pisano, an association spokeswoman.

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On the Net:

American Heart Association: http://americanheart.org

National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/index.htm
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