Biomedical subjects

Bryan Dowd

Publications and source records attributed to Bryan Dowd.

15 recordsLinked to original sources

PubMed2006

The future of health promotion/disease prevention programs: the incentives and barriers faced by stakeholders.

According to Healthy People 2010, 95% of employers with more than 50 employees reported that they offered at least one health promotion activity by 1999. Employment-based health promotion/disease prevention (hp/dp) programs have significantly increased in frequency and scope since 1985. Yet, 20 years later, the reported results for employee health lag behind the literature documenting the impact of lifestyle-related health risks on morbidity, healthcare utilization, and costs. In this article, we consider the key stakeholders involved-employers, health plans, and employees-and explore their legitimate and feasible roles in employment-based hp/dp programs, including the incentives and barriers they face to program participation. We argue for the integration of hp/dp programs into the traditional health protection mission of occupational health and safety professionals.

Disease Management↗

PubMed2004

Does Medicare managed care provide equal treatment for mental illness across races?

BACKGROUND: While disparities in access to care are well documented, little is known about the quality of mental health care received by racial and ethnic minorities. We examined the quality of mental health care received by elderly enrollees in Medicare + Choice plans. METHODS: An observational study was performed using individual-level Health Plan Employer Data and Information Set data. From 4182 to 5,016,028 individuals 65 years or older and enrolled in Medicare + Choice plans in 1999 were involved in different measures. Rates of mental health inpatient discharges, average length of stay, percentage of members receiving mental health services, rates of follow-up after hospitalization for mental illness, optimal practitioner contacts for antidepressant medication management, and effective acute- and continuation-phase treatment were assessed. RESULTS: Compared with whites, minorities received substantially less follow-up after hospitalization for mental illness. The 30-day follow-up rates for whites, African Americans, Asians, and Hispanics were 60.2%, 42.4%, 54.1%, and 52.6%, respectively. Minorities also had lower rates of antidepressant medication management for newly diagnosed episodes of depression. The rates of optimal practitioner contacts for whites, African Americans, Asians, and Hispanics were 12.5%, 12.0%, 11.1%, and 10.6%; the rates of effective acute-phase treatment were 60.1%, 48.5%, 40.7%, and 57.6%; and the rates of effective continuation-phase treatment were 46.7%, 32.7%, 31.9%, and 39.6%, respectively. The statistically significant disparities persisted after adjusting for effects of age, sex, income, plan model, profit status, and region of the country. CONCLUSIONS: The overall quality of mental health care for people enrolled in Medicare + Choice managed care plans is far from optimal. There are large and persistent racial differences that merit further attention to better understand their underlying causes and solutions.

Aged↗

PubMed2004

Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents.

BACKGROUND: There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use. OBJECTIVE: The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged >or=68 years, as determined by the relationship of these criteria to health service use in older community residents. METHODS: Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an in-home interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services. RESULTS: A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P<0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry. CONCLUSIONS: Our data suggest that in representative community residents aged >or=68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria).

Aged↗

PubMed2004

Multiple prior years of health expenditures and Medicare health plan choice.

This study examines the effect of multiple prior years of health expenditures on the probability of enrollment in a Medicare HMO. Beneficiaries may require more than one year of prior expenditure data to form a reliable estimate of future expenditures if health expenditures have a significant transitory component. We used a logit model to estimate the influence of 1991-1993 Part A expenditures and demographic data on the choice of health plans in 1994. The results indicate that beneficiaries use multiple years of expenditures in their choice of health plan and the effect of prior spending declined with time.

Aged↗

PubMed2004

Assessing the influence of incentives on physicians and medical groups.

This article describes issues that should be considered in the development of a theory or theories about incentives from which testable hypotheses could be derived. Economic, psychological, and organizational theories are described, and issues that should be considered in hypothesis generation are presented. Psychological factors influencing incentives include decision framing, regret, heuristics, and reinforcements. Organizational factors influencing incentives include bundling of services or people, matching of incentive structure with work organization, and the incompletely contained hierarchical nesting of incentives. Finally, the dynamics of incentive change are considered, with a focus on describing the conditions under which physicians and physician organizations respond to incentive changes.

Attitude of Health Personnel↗

PubMed2004

The problem of multiple margins.

The papers in this collection extend the work of John Wennberg and colleagues on variations in the use of health care services and the relationships between variations and health outcomes. Below I explore some theoretical issues that shed light on these observations and reconcile them with other findings in the literature that appear to contradict the work presented here. The analysis centers importantly on the distinction between different types of margins. It is important to understand these differences as a preparation to predicting the outcomes of possible health care reforms.

Delivery of Health Care↗

PubMed2004

Managing patient care cost in Minnesota medical group practices.

This study was designed to identify the mechanisms employed by medical group practices in Minnesota to control the costs of care. Several studies have found that health care costs in Minnesota are lower than in many other states, but no one knows why. We explore this issue by analyzing the factors in Minnesota medical group practices considered to be essential to cost control and, to the degree possible, by comparing those data with national data. It appears that Minnesota practices are somewhat less efficient than national averages--as measured by relative value units or procedures per full-time equivalent physicians--but that Minnesota practices have lower per-member, per-month (PMPM) costs. It also appears that the lower PMPM costs result from structural factors such as electronic information systems, physician profiling, and use of clinical guidelines rather than from financial incentive systems. This article also reports physician compensation and revenue trends, most notably that there appears to be a shift away from fixed salaries and toward productivity-based compensation; and there is a shift away from capitation payments and toward modified fee-for-service payments.

Contract Services↗

PubMed2003

Risk selection and benefits in the Medicare+Choice program.

We estimate the relation between enhanced benefits offered by the Medicare+Choice (M+C) plan in 1999 and a measure of risk selection based on inpatient encounter data. Higher risks are attracted to plans that offer outpatient drug coverage. The risk score increases by 2.2 percent for drug coverage with an annual limit less than $800 and by 3.6 percent for coverage with a limit more than $800. However, some benefits such as dental coverage were related to favorable risk selection. If M+C plans competed on the basis of benefits and premiums, as they would if they could give untaxed premium rebates, benefits that attract high risks would be underprovided.

Dental Health Services↗

PubMed2002

The Minnesota Health Partnership and Coordinated Health Care and Disability Prevention: the implementation of an integrated benefits and medical care model.

In the spring of 1996, the Minnesota Health Partnership (MHP) received a demonstration grant from the Robert Wood Johnson Foundation Workers Compensation Health Initiative to pilot a model of health care that was designed to combine the best practices of general health and workers' compensation medical care. This paper outlines the genesis of the MHP, and the relationship of its Coordinated Health Care and Disability Prevention model to traditional managed care and 24-h care models. In order to effectively implement disability prevention principles within a primary care clinical setting, it is essential to increase health care provider awareness that the disability relating to a specific impairment can be positively impacted by specific clinical strategies. The basis and specifics of these strategies are also discussed. Plans for the evaluation of this model will also be described.

Employment, Supported↗

PubMedDate not supplied

How does the culture of medical group practices influence the types of programs used to assure quality of care?

OBJECTIVE: It is widely acknowledged that the culture of medical group practices greatly influences the quality of care, but little is known about how cultures are translated into specific types of programs focused on quality. This study explores this issue by assessing the influence of the organizational culture on these types of programs in medical group practices in the upper Midwest. DESIGN AND METHODS: Data were obtained from two surveys of medical group practices. The first survey was designed to assess the culture of the practice using a nine-dimension instrument developed previously. The second survey was designed to obtain organizational structure data including the programs identified by the literature as important to the quality of care in medical practices. Completed surveys were obtained from eighty-eight medical groups. The relationship of the group practice culture to structural programs focused on quality of care was analyzed using logistic regression equations. RESULTS: Several interesting patterns emerged. As expected, practices with a strong information culture favor electronic data systems and formal programs that provide comparative or evidence-based data to enhance their clinical practices. However, those with a quality-centered culture appear to prefer patient satisfaction surveys to assess the quality of their care, while practices that are more business-oriented rely on bureaucratic strategies such as benchmarking and physician profiling. Cultures that emphasize the autonomy of physician practice were negatively (but not at a statistically significant level) associated with all the programs studied. Practices with a highly collegial culture appear to rely on informal peer review mechanisms to assure quality rather than any of the structural programs included in this analysis. CONCLUSION: This study suggests that the types of quality programs that group practices develop differ according to their cultures. Consequently, it is important for practice administrators and medical directors to develop quality assurance programs that fit their cultures if they are to gain buy-in by their clinicians. Future research should assess the effect of culture-structure fit on quality and safety outcomes.

Cross-Sectional Studies↗

PubMedDate not supplied

Financial and organizational factors affecting the employment of nurse practitioners and physician assistants in medical group practices.

This study examines the financial and organizational factors that are associated with the employment of nurse practitioners (NPs) and physician assistants (PAs) in medical group practices. The source of the data is a survey of 128 medical group practices in Minnesota. The findings suggest that the employment of NPs and PAs and their ratios to primary care physicians (PCPs) in practices that employ them are influenced by the organizational characteristics of the group practice but not by the degree of financial risk sharing for patient care. Although neither the number of years of experience in financial risk sharing nor more revenue from capitation payment contracts were related to employment of these midlevel practitioners (MLPs), large practices, those located in rural locations, not-for-profit practices, and those that scored low on cohesive cultural traits were more likely to employ MLPs. The data provide insights into the market for MLPs and the potential for these clinicians in the future health care system. As medical group practices become larger and have more organizational capacity, they can likely be expected to increase the employment of MLPs and integrate them into their organizations.

Capitation Fee↗

PubMedDate not supplied

Postpartum health of employed mothers 5 weeks after childbirth.

PURPOSE: Most new mothers return to work soon after childbirth. A need exists to reexamine the definition of postpartum health and evaluate employed women's recovery from childbirth in association with such factors as delivery type and breastfeeding. METHODS: Using a prospective cohort design, we recruited Minnesota women into the study while they were hospitalized for childbirth in 2001. Telephone interviews were conducted 5 weeks postpartum. Eligible women were 18 years or older, employed, and spoke English. Multivariate models using 2-stage least squares were used to estimate factors associated with physical and mental health and postpartum symptoms. RESULTS: A total of 817 women were enrolled (71% response) in the study; 716 women completed interviews at 5 weeks postpartum. On average, women reported 6 postpartum symptoms, most frequently fatigue (64%), breast discomfort (60%), and decreased desire for sex (52%). Findings showed that cesarean (vs vaginal) deliveries were associated with significantly worse physical function, role limitations, and vitality. Multivariate findings showed that the effect of delivery type on physical health was moderately large (beta = -5.96; P = or <.01), and breastfeeding was associated with an increased frequency of postpartum symptoms (beta = 4.63; P = .01). CONCLUSIONS: These mothers experienced several childbirth-related symptoms at 5 weeks postpartum, indicating a need for ongoing rest and recovery. Health concerns were greater for women who were breastfeeding and for those whose babies were delivered by cesarean section, suggesting a need for greater support for these women and a reassessment by the medical community of the progressively growing practice of cesarean deliveries.

Adult↗

PubMedDate not supplied

Having it all: national benefit equity and local payment parity in Medicare.

The Medicare Payment Advisory Commission (MedPAC) has identified two important problems with the Medicare+Choice (M+C) program: nationwide geographic inequity in government-financed benefits, and unequal government payments for M+C plans versus fee-for-service (FFS) Medicare in the same market area. MedPAC concludes that both problems cannot be solved simultaneously. We argue that both problems could be solved if Congress discontinued its policy of underwriting the cost of FFS Medicare. Instead, Congress should define a national entitlement benefit package and have all health plans submit bids on the package in each market area. The government's premium contribution should be equal to the lowest bid submitted by a qualified health plan in each market area. The contribution could be adjusted for health risk, the special obligations of FFS Medicare, and welfare enhancements associated with FFS Medicare that are valued by both beneficiaries and taxpayers but unrelated to beneficiaries' health status.

Aged↗

PubMedDate not supplied

Racial variation in quality of care among Medicare+Choice enrollees.

This paper examines racial variation in quality of and access to care experienced by elderly persons enrolled in Medicare+Choice plans. We used eight individual-level Health Plan Employer Data and Information Set (HEDIS) measures to compare whites with blacks, Asians, Hispanics, and Native Americans. Across all measures, black enrollees received lower-quality care. Hispanics and Native Americans were less likely to receive some types of care but were as likely or more likely to receive other types of care. Asians received equal or better care for all measures. It is important that studies of health care quality include all racial subgroups since the black/white patterns may not apply.

Black or African American↗

PubMedDate not supplied

Medical groups' adoption of electronic health records and information systems.

We surveyed a nationally representative sample of medical group practices to assess their current use of information technology (IT). Our results suggest that adoption of electronic health records (EHRs) is progressing slowly, at least in smaller practices, although a number of group practices plan to implement an EHR within the next two years. Moreover, the process of choosing and implementing an EHR appears to be more complex and varied than we expected. This suggests a need for greater support for practices, particularly smaller ones, in this quest if the benefits expected from EHRs are to be realized.

Data Collection↗