Managed care and measuring medical outcomes: did the rise of HMOs contribute to the fall in the autopsy rate?

The U.S. autopsy rate has fallen precipitously since the 1940s, decreasing from 50 percent of bodies to less than eight percent today. Much of the decrease occurred after 1971 when hospitals were no longer required to do a minimum number of autopsies for accreditation. Since this time, major changes in the health care sector have occurred in the United States, highlighted by the increased importance of managed care. Using data for 46 states from 1987 to 2000, we analyze the degree to which the rise in manage care explains the decrease in the autopsy rate. We find that increases in health maintenance organization market share explain 21 percent of the decrease in the autopsy rate over the years from 1987 to 2000 and reductions in the number of hospital deaths explain another 30 percent. In contrast, we find that increases in the availability of magnetic resonance imaging had no significant effect on autopsy rates when other factors are held constant. Reforming health care financing to restrain the growth in health care costs using incentive mechanisms similar to those employed by managed care organizations has been a recurring policy goal in the United States. Our results imply that these reforms may inadvertently reduce the incentive to monitor medical outcomes using techniques such as autopsies, which is often called the "gold standard" in measuring medical outcomes.