Self-selection of enrollers at the creation of a managed care organization

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Abstract
Factors affecting choice between a managed care organization (MCO) and a fee-for-service insurance plan were examined when the University of Geneva health insurance plan was transformed into an MCO, in October 1992. A case-control study using a mailed questionnaire (response rate 84%) was conducted to compare former members who joined the MCO (joiners, n=421) to former members who opted out in order to keep fee-for-service coverage (non-joiners, n=222). Non-joiners were more likely to be women (odds ratio (OR) from multivariate model was 1.15, p=0.50), to be born in Switzerland (OR=2.04, p75,000 Swiss francs (OR=2.00, p<0.01), to have a personal physician (OR=1.96, p<0.01) and to have consulted a specialist (OR=1.69, p=0.02) or used unconventional medicine (OR=4.59, p<0.01) in the past year. During the previous year, non-joiners had more health care visits than joiners (14.6 versus 9.1, p=0.01). Non-joiners reported better mental health and fewer complained of persistent fatigue (OR=2.18, p=0.03). The choice of health plan was strongly influenced by socio-demographic characteristics, past patterns of health services utilization and health status. The self-selection process was paradoxical: MCO joiners had used fewer health care visits than non-joiners, but their self-reported health status was worse. The differences we have observed between self-selected populations have important implications for the financial performance of competing health care delivery systems.

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