| The enrollment of large numbers of Medicare patients into newer, for-profit models of managed care highlights the tension between quality and cost of medical care, particularly for the chronically ill. Diabetes is a common, costly disease with high morbidity and mortality that disproportionately affects older, low-income persons and racial and ethnic minorities. There is evidence of inadequate use of evidence-based therapies and clinical practices for older persons with diabetes, but it is not known if this differs in managed care and fee-for-service settings.; This cross-sectional observational study is a direct comparison of the quality of diabetes care provided to older persons in fee-for-service and for-profit, network model managed Medicare; the patterns of service use in these settings; and the patient sociodemographic characteristics associated with better quality of care. Telephone interviews and standardized clinical examinations were performed on a stratified random sample of Medicare fee for-service and managed care subjects with diabetes in Los Angeles County. Managed care participants were from provider groups that contract with a large health plan. We enrolled 497 managed care and 233 fee-for-service subjects between June 1998 and February 2000. The quality indicators evaluated were self-reported glycosylated hemoglobin (HbA1c) measurement, cholesterol measurement, dilated eye exam, and foot exam in the past year and HbA 1c level and pulse pressure measured during the examination. Multivariate regression models, adjusted for visits to an endocrinologist or diabetes educator and clinical and sociodemographic characteristics, were used to evaluate the influence of system of care on each of the six quality indicators.; For most indicators, we found comparable quality of care for older persons with diabetes in fee-for-service and managed Medicare, despite higher resource utilization in fee-for-service. The exceptions were fewer foot examinations in managed care and, among older persons, fewer dilated eye examinations in fee-for-service. There was better adherence to several quality indicators among persons seen by diabetes providers, particularly endocrinologists. There were few substantial sociodemographic differences overall; however, the oldest old, persons with low education, and Medicaid beneficiaries were at risk for receiving poorer quality of care. Further research is needed to evaluate the influence of organizational and financial arrangements, specialty providers, and patient characteristics on quality of care in both systems of care. |
