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Management of multiple sclerosis across managed care and fee-for-service systems

From the Department of Neurology (Drs. Vickrey, Ellison, and Myers, M. Beckstrand and Z.V. Edmonds) and Division of General Internal Medicine and Health Services Research (Dr. Shapiro), Department of Medicine, School of Medicine, Department of Biostatistics (Dr. Belin), School of Public Health, and the Neuropsychiatric Institute (S. Delrahim), University of California at Los Angeles; Department of Neurology (S.M. Wolf), Southern California Kaiser Permanente, Los Angeles; and Division of Neurology (Dr. Hanson), Children’s Hospital–Los Angeles/University of Southern California; and Center for Health Care Policy and Evaluation (Dr. Shatin), UnitedHealth Group, Minneapolis, MN.

Address correspondence and reprint requests to Dr. B.G. Vickrey, UCLA Department of Neurology, C-128 RNRC, Box 951769, Los Angeles, CA 90095-1769; e-mail: bvickrey{at}ucla.edu

OBJECTIVE: To measure and compare care for adults with MS across managed care and fee-for-service (FFS) health systems.

METHODS: The authors sampled adults with MS having physician visits over a 2-year period from a group model health maintenance organization (HMO) in southern California, from a midwestern independent practice association (IPA) model managed care plan, and from the FFS portion of the practices of a random sample of southern California neurologists. The authors mailed surveys to subjects in mid-1996; 930 of 1,164 (80%) of those eligible responded. The authors measured sociodemographic and clinical characteristics, management of recent changes in mobility, bladder control, and fatigue, use of a disease-modifying agent, assessment of general health symptoms and issues, and unmet information needs. The authors adjusted comparisons between systems for comorbidity, disease severity, and disease type.

RESULTS: The groups differed on most sociodemographic and clinical characteristics. There were few differences in symptom management; differences that did exist tended toward more referrals or treatment for the FFS group. Access to the disease-modifying agent available at the time of the survey did not differ across systems, although patients’ perceptions of the rationale for not using the drug did vary. General health issues and symptoms were more often assessed in the FFS and IPA systems than in the HMO, but improvement was needed across all three systems of care. There were substantial unmet information needs in all groups and especially high ones in the FFS and HMO samples.

CONCLUSIONS: Strategies to improve care for people with MS should be developed and evaluated, particularly in areas like symptom assessment and meeting patient information needs. Where variations in service delivery exist, longitudinal studies are also needed to evaluate the potential impact on outcomes and to evaluate reasons for variation.

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