 |
|
A Response to Missed Appointments and Medicaid Managed Care
The article by Majeroni et al1 examined appointments made and missed by patients of an urban clinic according to their insurance status. The authors' conclusions focus on patients with Medicaid managed care insurance. I have several concerns about the analyses and conclusions.
First, the dependent variable for the analyses was a proportion, the percentage of missed visits. While a nonparametric analysis of variance was used for all but the final regression analysis, this still does not properly account for small proportions being quite unstable. For example, the difference between 0 and 1 missed visits for a person with 10 missed visits is only 10%, but the same difference for a person with only 2 missed visits is 50%. For a large sample, this will average out, but for a small sample (such as groups of 30 persons), it can lead to unreliable estimates.
Second, I am concerned that the focus of the discussion and conclusions is so heavily based on patients with Medicaid managed care insurance, as the data suggest similar no show rates for patients with private managed care insurance. (I assume that there is a misprint in Table 3, which indicates identical rates of missed appointments and identical attributable risks for the 2 managed care groups, both significant at P<.05, because the text states that the variables for the group with private managed care insurance were not significant.) Although concrete conclusions should not be drawn from small numbers, it would seem that the issue of missed visits may have much more to do with patients who have managed care insurance per se in this practice than with patients who have Medicaid managed care insurance.
Third, as the authors discuss, the patients with Medicaid managed care insurance were clearly a different population from the patients with Medicaid non–managed care insurance. My experience with a similar, voluntary enrollment, primary care case management program was that patients who enrolled generally were less likely to have an established relationship with a provider and frequently did not understand what they were signing up for. Why, otherwise, would they choose to restrict their choice of providers in return for no tangible (and probably no intangible) benefit? This selection bias seems far more likely to explain the differences between patients with capitated and those with fee-for-service Medicaid insurance than any aspects of managed care and patients' reactions to it.
Barry G. Saver, MD, MPH
University of Washington
Seattle
1. Majeroni BA, Cowan T, Osborne J, Graham RP. Missed appointments and Medicaid managed care. Arch Fam Med. 1996;5:507-511.
FREE FULL TEXT
|
In reply
We appreciate Dr Saver's thoughtful comments about our article.1 He is correct in that there was a difference in the rate of missed appointments between patients with private managed care insurance and those with Medicaid managed care insurance. In an earlier analysis, we used the miss rate as a dichotomous variable, with patients missing more than 20% of scheduled appointments labeled "high miss." That multivariate analysis found the significant difference noted in the text. The statement's placement after the reference to Table 3 may have been misleading, and we apologize for any confusion this may have caused.
The numbers in Table 3, which used miss rate as a continuous variable, show identical percentages of attributable risk for patients with private manged care insurance and those with Medicaid managed care insurance; however, as noted by Dr Saver, it is difficult to rely on figures derived from a group as small as the private managed care group. We, too, noted the disparity between patients with any managed care insurance and those with fee-for-service insurance and wondered why there was such a difference.
Our Medicaid managed care program differs from the one described by Dr Saver in that there were incentives for patients to enroll. They were promised a "personal physician," exempted from the state's 13 visits per year cap on Medicaid visits, and provided with bus tokens or other transportation as indicated for physician visits. I do not think that we can assume that they did not know what they were signing up for. In retrospect, the exemption from the cap on the number of covered visits may be 1 reason why managed care was chosen by people who tended to schedule more frequent visits.
Barbara A. Majeroni, MD;
Timothy Cowan, MSPH;
Jason Osborne, MA;
Robin P. Graham, PhD, MPH
State University of New York at Buffalo
1. Majeroni BA, Cowan T, Osborne J, Graham RP. Missed appointments and Medicaid managed care. Arch Fam Med. 1996;5:507-511.
Arch Fam Med. 1998;7:117.
|
