Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Louis F. Rossiter


The purpose of this prospective study is to examine the effects of differences in utilization controls on HMO enrollees' health, satisfaction with quality of care and access, and disenrollment. Previous studies of alternative care systems have shown that they are able to decrease costs (Luft, 1981; Anderson, Herald, Butler, Kohrman, & Morrison, 1985), but have not examined the organizational structure within the organization that oversees utilization. No prior studies have examined the effects of different types and degrees of utilization controls on the health, satisfaction, and access of enrollees.

For this investigation, Williamson's (1975) theory of organizations, transaction costs economics, is used as the analytic framework. It is applicable to a study of utilization controls because it explains the organizational design or "governance structure" adopted to promote economic efficiency.

Data for this study comes from the National Medicare Competition Evaluation's (NMCE) initial and follow-up beneficiary surveys and was merged with data about the plans. Data on the utilization controls to which the enrollees were exposed comes from the NMCE case studies prepared about six months after the plans started enrolling Medicare patients. Data on health, satisfaction, and access measures comes from the beneficiary surveys. The surveys were conducted about a year apart; the first one occurring upon enrollment in the HMOs.

Separate analyses using ordinary least squares and logit regression techniques were performed for 1,175 continuous enrollees and 376 disenrollees using the merged data. The disenrollees were treated as a distinct group because their leaving the HMO may have been motivated by dissatisfaction with utilization control.

The analysis found that exposure to different types and stringency of utilization controls was not associated with changes in enrollees' health. They did affect satisfaction with quality of care and appointment convenience.

Disenrollment was significant; 18% of the enrollees left the plans during the study. Utilization controls accounted for 49.2% of the variance in disenrollment from the plans.


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