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Independent physician groups contracting with HMOs may be doing a better job of managing care than doctors employed by HMOs, a new study suggests.

Physician groups that are paid a capitated fee by HMOs and administer their own managed care techniques generated fewer hospital days and outpatient visits than doctors who are governed by HMO supervisors, the study found.

The study, recently reported in the New England Journal of Medicine, found that hospitalization rates were about 40% lower for six large California medical groups, which have their own governing boards and review committees, than doctor groups that are directly employed by an HMO.

James C. Robinson and Dr. Lawrence P. Casalino of the University of California School of Public Health in Berkeley, found hospital days per 1,000 HMO enrollees in the six medical groups studied ranged from 120 to 149 for non-Medicare patients between 1990 and 1994. In contrast, the mean number of hospital days for HMOs was 232 in California and 297 for the United States in 1993.

Outpatient visits also were lower for the six self-managed doctor groups, though much less dramatically. For HMO patients in 1994, the groups' average number of non-Medicare office visits ranged from 3.1 to 3.9 per patient annually. For California, the average number of visits per year for HMOs was 3.8 per patient; for the United States as a whole, HMOs had 3.6 visits on average.

Although the study does not evaluate the quality of care provided by physician groups, the numbers appear to show that doctor-run medical groups manage care more effectively to reduce costs and boost efficiency, said Mr. Robinson, a specialist in health economics.

"They don't rely on the HMOs for utilization review," Mr. Robinson said in an interview. "They manage themselves rather than being managed externally. In the East, managed care is something that is done to physicians. In the West, managed care is something done by physicians."

The study was accompanied in the New England Journal of Medicine by an essay written by two physicians sharply criticizing capitation. They cited the California study's finding of lower inpatient and outpatient treatment levels as proof that doctors in such settings steer away from sick patients because they are less profitable.

But Mr. Robinson said the findings instead highlight doctors' response to calls for waste reduction in health care.

Requests for reprints of the study should be sent to James C. Robinson, School of Public Health, 418 Warren Hall, University of California, Berkeley, Calif. 94720.