PubMed Health⌕ Search

Biomedical subjects

J H Sunshine

Publications and source records attributed to J H Sunshine.

17 recordsLinked to original sources
PubMed1992

Consequences of physicians' ownership of health care facilities--joint ventures in radiation therapy.

BACKGROUND: Physicians are increasingly the owners of health care facilities to which they refer patients for services but at which they do not practice. We studied such ownership arrangements, known as "joint ventures," in the field of radiation therapy, examining their effects on access, use of services, costs, and quality. METHODS: Because 44 percent of free-standing facilities providing radiation therapy in Florida in 1989 were joint ventures, as compared with 7 percent elsewhere (95 percent confidence interval, 3 to 10 percent), we compared data for Florida with comparable data for the remainder of the United States. We also compared radiation-therapy facilities in Florida that were established as joint ventures with those that were not. Since most data were derived from entire populations rather than from samples, any differences found were of necessity statistically significant. RESULTS: No joint-venture facilities providing radiation therapy were located in inner-city neighborhoods or rural areas, but 11 percent of other free-standing facilities and hospital-based facilities were located in such areas. Among free-standing facilities, joint ventures received 39 percent of their revenues from patients with well-paying insurance coverage, as compared with 31 percent for facilities that were not joint ventures (P < 0.01). The frequency and costs of radiation-therapy treatments at free-standing centers were 40 to 60 percent higher in Florida than in the rest of the United States; there was no below-average use of radiation therapy at hospitals or higher cancer rates that explained the higher rates of use or higher costs in Florida. Radiation physicists at joint-venture facilities (the principal personnel involved in quality control other than physicians) spent 18 percent less time with each patient over the course of treatment than did their counterparts at free-standing facilities that were not joint ventures (P < 0.05). Mortality among patients with cancer in Florida was not lower than the U.S. average, even though joint ventures are much more common in that state. CONCLUSIONS: Joint ventures in radiation therapy appear to have adverse effects on patients' access to care. They also appear to increase the use of services and costs substantially. Some indicators show that joint ventures cause either no improvement in quality or a decline. Our results add to the evidence indicating that physicians' self-referral generally has negative consequences. We recommend legislation to ban ownership of joint ventures by referring physicians. Such legislation needs to be carefully designed in order to achieve its objectives and forestall new, financially abusive arrangements.

Ambulatory Care Facilities↗
PubMed1992

Physicians' utilization and charges for outpatient diagnostic imaging in a Medicare population.

OBJECTIVES AND RATIONALE: For 10 common clinical presentations, we assessed differences in physicians' utilization of and charges for diagnostic imaging, depending on whether they performed imaging examinations in their offices (self-referral) or referred their patients to radiologists (radiologist-referral). METHODS: Using previously developed methodologies, we generated episodes of medical care from an insurance claims database. Within each episode, we determined whether diagnostic imaging had been performed, and if so, whether by a self-referring physician or a radiologist. For each of the 10 clinical presentations, we compared the mean imaging frequency, mean imaging charges per episode of care, and mean imaging charges for diagnostic imaging attributable to self- and radiologist-referral. RESULTS: Depending on the clinical presentation, self-referral resulted in 1.7 to 7.7 times more frequent performance of imaging examinations than radiologist-referral (P < .01, all presentations). Within all physician specialties, self-referral uniformly led to significantly greater utilization of diagnostic imaging than radiologist-referral. Mean imaging charges per episode of medical care (calculated as the product of the frequency of utilization and mean imaging charges) were 1.6 to 6.2 times greater for self-referral than for radiologist-referral (P < .01, all presentations). When imaging examinations were performed--including those performed in both physicians' offices and hospital outpatient departments--mean imaging charges were significantly greater for radiologists than for self-referring physicians in seven of the clinical presentations (P < .01). This result is related to the high technical charges of hospital outpatient departments; in office practice, radiologists' mean charges for imaging examinations were significantly less than those of self-referring physicians for seven clinical presentations (P < .01). CONCLUSIONS: Nonradiologist physicians who operate diagnostic imaging equipment in their offices perform imaging examinations more frequently, resulting in higher imaging charges per episode of medical care. These results extend our previous research on this subject by their focus on a broader range of clinical presentations; a mostly elderly, retired population; and the inclusion of higher-technology imaging examinations.

Aged↗
PubMed1992

Partial care in mental health organizations: United States and each state, 1988.

Partial care is a relatively new and rapidly-growing form of mental health care consisting of a planned program of mental health treatment services generally provided in visits of 3 or more hours to groups of patients/clients. In 1970, only one-fourth of U.S. mental health organizations provided partial care services, and patient additions to partial care programs were 56 per 100,000 civilian population. By 1988, close to half of all mental health organizations provided partial care services, and the rate of additions was more than 5 times as high. However, large increases in the number or organizations providing partial care between 1984 and 1988 are due in part to changes in definitions that are elaborated on later in the report. In 1988, multiservice mental health organizations were the most numerous providers of partial care with 1,230 of 1,310 (94 percent) providing this program. This was followed by general hospital mental health services with 332 of 1,489 (22 percent) providing partial care and private psychiatric hospitals with 236 of 447 (53 percent) providing this program. Mental health organizations providing partial care were most numerous in populous States, particularly in California (with 187 mental health organizations providing partial care), New York (174 organizations), and Pennsylvania (131 organizations). There were 212,196 patients on the rolls of partial care programs of mental health organizations in the United States (including Territories) at the beginning of 1988, and 286,715 patients were added to these programs during the year. Multiservice mental health organizations were responsible for a majority of both patients on the rolls and patient additions during the year.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

How accurate was GMENAC?--A retrospective review of supply projections for diagnostic radiologists.

In 1982, the Graduate Medical Education National Advisory Committee (GMENAC), a prominent national panel, predicted there would be 25,650 full-time equivalent (FTE) diagnostic radiologists, a 34% oversupply, by 1990. The radiologists involved in GMENAC, however, using models developed by the American College of Radiology, projected 19,800 FTE diagnostic radiologists in 1990, which was similar to the GMENAC estimate of need. The disagreement arose principally from different assumptions about residents entering the specialty. Recent data show there actually were approximately 21,900 FTE diagnostic radiologists in 1990. The radiologists' projection was 10% below this figure; the GMENAC projection was 17% above it. GMENAC erred principally in assuming diagnostic radiology residencies would not replace general radiology residencies, but rather be an addition to them. The radiologists erred principally in their assumption about the effects of the financial problems of hospitals on the number of residency positions. Accurate long-term projection of physician supply in individual specialties may well not be feasible.

Forecasting↗
PubMed1992

Operational, professional, and business characteristics of radiology groups in the United States.

To learn the main operational, professional, and business characteristics of U.S. radiology group practices, researchers at the American College of Radiology surveyed these groups. Major findings included the following: Approximately 30% of groups provide only diagnostic radiologic services, a similar percentage provides only radiation therapy for oncologic patients, and the remainder provides both types of services. Forty-one percent of groups practice only in hospitals, 11% practice only in an office, and 48% practice in both settings. Diagnostic-only practices average 10,000-12,000 procedures per full-time equivalent radiologist per year. Groups typically require new members to be part of the group for almost 3 years before they become full partners. Formal call schedules are nearly universal among radiology groups. Groups are becoming increasingly involved with health maintenance organizations and other "alternative delivery systems," but fee-for-service remains by far the dominant source of groups' revenue. Most studied characteristics of groups are changing relatively slowly, and trends are generally toward increasing formalization of arrangements.

Age Factors↗
PubMed1992

Hospital and office practices of radiology groups.

To obtain information on the characteristics and practices of radiology groups in the United States, the American College of Radiology conducted a group practice survey in 1989; this report presents the main survey findings about the office and hospital practices of such groups. A questionnaire and one follow-up were mailed to all 2,591 radiology groups in the United States. Responses were weighted to reflect all groups. Hospital practices averaged 0.7 diagnostic radiologic procedures (including outpatient procedures) per patient day, with little variation by hospital type. Magnetic resonance (MR) imaging and angioplasty procedures were concentrated in teaching hospitals, but this was not true of other sophisticated procedures such as computed tomography and nuclear medicine. Offices averaged 15,000 diagnostic examinations annually, with less variation than expected according to group size. In both hospitals and offices, more than 90% of technologists were registered. Outsiders (most often, referring physicians and hospitals) had a financial interest in half of all offices. MR imaging and mammography grew faster than any other examinations, but only 44% of hospital practices accepted nonreferred patients for mammography.

Ambulatory Care↗
PubMed1992

Recruiting radiologists: the 1991 hiring survey.

Recent studies present widely varying views on the radiologist staffing situation, ranging from a projected surplus of over 6,000 radiologists to an estimated shortage of 5,000. To help clarify the situation, the American College of Radiology undertook a stratified random sample survey of radiology groups' recruitment efforts and hiring results in 1991. This survey of 192 groups achieved a 78% response rate. It found that half of all groups recruited, seeking to fill a nationwide total of 1,900 positions. Larger groups were more likely to recruit than smaller ones. Groups filled 1,348 (71%) of these positions, while 552 positions remained unfilled, which was 2.8% of groups' total staff. Remaining vacancies ranged from 5% of total staff in the Northeast and 3% in the Midwest to 2% in the South and 1% in the West. The percentage of positions filled was higher (76%) in nonmetropolitan areas than elsewhere. The authors conclude that the supply of radiologists is very close to balancing the number of positions available; the disparity is about 1/10 of some numbers mentioned previously and is probably shrinking. Also, recruiting is not less successful in nonmetropolitan areas and small cities than elsewhere.

Humans↗
PubMed1991

Psychiatric outpatient care services in mental health organizations, United States, 1986.

In 1986, 2,967 mental health organizations, or 62 percent of all mental health organizations in the United States (including territories), offered psychiatric outpatient care services. A total of 5.6 million patient care episodes were provided by these organized outpatient services. These episodes involved a total of 47 million visits and 2.8 million additions, and represented 69 percent of all psychiatric patient care episodes in organized settings that year. Both the number of organizations with psychiatric outpatient care services and the number of outpatient additions to these organizations increased by approximately 4 percent between 1983-84 and 1986. Multiservice mental health organizations were the most prominent type of mental health organization in the provision of psychiatric outpatient care. They comprised 42 percent of the 2,967 organizations offering this type of care and were responsible for 54 percent of the outpatient additions, 53 percent of the episodes, and 54 percent of the visits. Next in importance were freestanding psychiatric outpatient clinics and separate psychiatric services in non-Federal general hospitals. They accounted for 26 percent and 17 percent, respectively, of organizations providing psychiatric outpatient care. Each provided 12 to 18 percent of outpatient additions, episodes, and visits. Over 90 percent of multiservice mental health organizations and Veterans Administration psychiatric organizations offered outpatient psychiatric care. In contrast, this form of care was offered by only 29 percent of State and county mental hospitals, 36 percent of private psychiatric hospitals, 37 percent of nonFederal general hospitals with psychiatric services, and 23 percent of residential treatment centers for emotionally disturbed children.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Expenditures and sources of funds for mental health organizations: United States and each state, 1988.

Expenditures. Expenditures by the 8 types of mental health organizations covered in this report totaled $23.1 billion in 1988 in the United States and territories. Three States (California, New York, and Pennsylvania) accounted for 30 percent of this total. Nationally, State and county mental hospitals (hereafter called State mental hospitals) accounted for the largest proportion of all expenditures (30 percent, down from 34 percent in 1986). Private psychiatric hospitals and multiservice mental health organizations had the next largest expenditures, each accounting for 20 percent of the total, followed by the separate psychiatric services of non-Federal general hospitals at 16 percent. Department of Veterans Affairs (VA) mental health services, residential treatment centers (RTCs) for emotionally disturbed children, freestanding psychiatric outpatient clinics, and freestanding psychiatric partial care organizations accounted for 6 percent, 6 percent, 3 percent, and less than one-half percent of total expenditures, respectively. State mental hospitals represented the largest expenditures of any single type of mental health organization in 23 States; expenditures of private psychiatric hospitals were largest in 12 States; and expenditures of multiservice mental health organizations were the largest in 10 States. The $23.1 billion total for 1988 represented a 25 percent increase over the 1986 figure but, when adjusted for inflation, the estimated increase (expressed in constant dollars) was only 10 percent overall and 8 percent on a per capita basis. Constant dollar expenditures of most types of mental health organizations increased between 1986 and 1988, with the largest increase occurring among private psychiatric hospitals (54 percent). In contrast, constant dollar expenditures decreased for State mental hospitals and VA mental health services. Sources of Funds In 1988, the funds received by mental health organizations totaled $23.4 billion. Of this total, $8.8 billion (38 percent) was provided directly by State governments, predominantly by State mental health agencies. Direct Federal funds, plus Medicare and Medicaid (including the State and local share of Medicaid), provided $6.5 billion (28 percent) of total funding. Fees from clients (including private insurance) provided $5.2 billion (22 percent); direct local government funds provided 7 percent; and all other sources, 5 percent. State governments provided 77 percent of the funds received by State mental hospitals and were also the largest single source of funds for multiservice mental health organizations (51 percent) and freestanding psychiatric partial care organizations (44 percent). VA mental health services were funded by the Federal government, while 62 percent of funding for private psychiatric hospitals came from client fees (including private insurance).(ABSTRACT TRUNCATED AT 400 WORDS)

Community Mental Health Services↗
PubMed1991

Mental health services of the Veterans Administration, United States, 1986.

The mental health services of the Veterans Administration (VA) form an important component of the organized mental health care delivery system in the United States. The 140 VA organizations delivering mental health care represented 3 percent of all mental health organizations in the U.S. in 1986, but accounted for approximately 11 percent of the average daily inpatient mental health census and 8 percent of outpatient mental health visits in organized settings. Their 33,000 full-time equivalent (FTE) staff and $1.4 billion in expenditures devoted to mental health care were approximately 7 percent of the respective totals for all mental health organizations. Between 1983 and 1986, the number of VA organizations offering mental health care increased by only 1, but inpatient mental health additions increased by 22 percent. Average length-of-stay for these inpatients declined by almost as much. Outpatient mental health additions increased by 30 percent, and FTE staff in VA mental health services grew by 10 percent. Mental health services were provided by VA organizations in all States except Alaska, Hawaii, Montana, and North Dakota in 1986. (Veterans are free to make use of programs outside their State of residence.) The largest numbers of mental health services, additions, and episodes were found in States with very large populations, such as California, New York, and Texas. However, the highest rates of additions and episodes per 100,000 civilian population were generally in States with small populations, and often in rural States. For example, Maine, South Dakota, Wyoming, and West Virginia were among the States with the highest rates of additions and episodes. Reflecting the composition of the total population in VA facilities, of 315,630 in VA mental health services, over 95 percent were male, a relatively large percentage (17 percent) were 65 or over, and very few were under 18 years old. About two-thirds were white, non-Hispanic; one-fourth were black, non-Hispanic; and 8 percent were Hispanic. About one-sixth were suffering primarily from drug or alcohol abuse; almost all the rest suffered primarily from mental illness. In November 1986, approximately 36,000 staff persons worked in VA mental health services. About 84 percent of these worked full-time; 9 percent, part-time; and 7 percent, as trainees. The staff included approximately 2,800 psychiatrists, 700 other physicians, 1,600 psychologists, 1,800 social workers, and 7,200 nurses. Three-fourths of the expenditures for VA mental health services went for staff, with other operating expenses consuming most of the remainder.

Adolescent↗
PubMed1991

Residential treatment centers and other organized mental health care for children and youth: United States, 1988.

Residential treatment centers (RTCs) for emotionally disturbed children are an important component of the mental health services delivery system in the United States. The 440 RTCs operating in 1988 represented 9 percent of all mental health organizations in the U.S. in that year. They served approximately 10 percent of the patients who received inpatient and residential treatment care and approximately 2 percent of outpatient psychiatric visits in organized settings. Their 39,000 full-time equivalent (FTE) staff and $1.3 billion expenditures were, respectively, 7 percent and 6 percent of the total for all mental health organizations. Between 1986 and 1988, the number of RTCs increased slightly, while the volume of residential treatment care changed little. However, partial care and outpatient care expanded in RTCs, with the number of visits in these categories increasing by 75 percent and 42 percent, respectively. FTE staff grew by 13 percent, and expenditures increased by 33 percent between 1986 and 1988. In 1988, RTCs were located in all States except North Dakota. The largest number were found in California (48), Massachusetts (38), and New York (28). By definition, all RTCs provided residential treatment care. About one-third of them also provided partial care and one-third provided outpatient care. The highest rates of additions to residential treatment care in RTCs per 100,000 civilian population were found in Minnesota and Colorado. Reflecting the role of RTCs as providers of care to children and youth, 94 percent of residential treatment patients in RTCs were under age 18. Seventy percent of residential treatment patients were male; 28 percent, black; and 10 percent, Hispanic. Approximately 94 percent had mental illness as their principal disability. In December 1988, 43,000 staff worked in RTCs; 14 percent were employed part-time, and 3 percent were trainees. Among others, the staff included approximately 900 psychiatrists, 300 other physicians, 1,700 psychologists, 4,800 social workers, and 1,000 nurses. Nationally, expenditures by RTCs averaged $5 per capita, but the highest per capita spending was $20 in Massachusetts and $14 in Arizona. The principal sources of funds for RTCs were local governments (the source of 33 percent of total funds available to RTCs), State mental health agencies (15 percent of funds), and other State government sources (21 percent of funds). RTCs focus their care on children and youth more than do any other type of mental health organization. At year-end in 1988, 64 percent of all the patients on the rolls of all types of programs in RTCs were under age 18.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1991

The volume and cost of radiologic services in the United States in 1990.

Knowing the total number of radiologic services provided in the United States and their cost is important. This information can, for example, indicate the opportunities available to a radiology practice considering opening a new office or show whether high-technology radiology is, as is widely assumed, an important factor in United States health costs. However, neither the total number of procedures nor their cost is known. We developed two largely independent estimates of each total (one based principally on surveys of radiologists, the other on Medicare data) to cross-validate the estimates and provide an indication of their uncertainty. We estimate that 260-330 million radiologic procedures were performed in the United States in 1990 (including both diagnostic and therapeutic procedures and radiologic procedures performed by nonradiologists) and that payments for these services totaled $19 to $22 billion (including payments for technical components in the hospital setting). This total was approximately 3.5% of national spending on personal health care; high-technology radiology totaled less than half of this amount. The procedures numbered 1.0-1.3 per capita annually, an increase of some 10-40% since 1980. Of the spending total, $10 to $12 billion was paid to physician practices, with a substantial portion of this amount going ultimately to practice expenses, particularly in the office setting. Our results suggest that spending on high-technology radiology is too small to be a major explanation for the current level of health costs in the United States.

Costs and Cost Analysis↗
PubMed1991

Physician payment reform: issues for Canadian radiologists.

Policy decisions taken by the US Congress in the 1980s to restrain health care costs included the designation of diagnostic-related groups, the creation of scales of relative value and legislation to introduce free-for-service payment to physicians in 1992; discrepancies in the system are to be corrected by 1996. Under federal contract a system of resource-based relative-value scales was created for all medical disciplines except radiology, which by special legislation prepared its own experience-based relative-value scale. The scales are based on magnitude estimation of the work of physicians and analyses of actual costs. Codes for medical services have been published, which include a weighting for each service in relation to all others. Multiplication by a conversion factor establishes the fee to be paid by the carriers acting for the Health Care Financing Administration. The relative values will be updated every 5 years. Publication of this information for US Medicare patients (the disabled, the elderly and those with end-stage renal disease) will likely have a profound effect on the physician payment system in Canada. Under the reformed system the lifetime earnings of all physicians will become more similar. Four problem areas are discussed in the paper: self-referral, administrative complexity, malpractice and the plight of those without medical coverage. Resolution of these problems is being actively sought.

Canada↗
PubMed1990

Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians.

BACKGROUND: To assess possible differences in physicians' practices with respect to diagnostic imaging, we compared the frequency and costs of imaging examinations as performed by primary physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring). METHODS: Using a large, private insurance-claims data base, we analyzed 65,517 episodes of outpatient care by 6419 physicians for acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty urinating. The respective imaging procedures studied were chest radiography, obstetrical ultrasonography, radiography of the lumbar spine, and excretory urography, cystography, or ultrasonography. RESULTS: For all four clinical presentations, the self-referring physicians obtained imaging examinations 4.0 to 4.5 times more often than the radiologist-referring physicians (P less than 0.0001 for all four). For chest radiography, obstetrical ultrasonography, and lumbar spine radiography, the self-referring physicians charged significantly more than the radiologists for imaging examinations of similar complexity (P less than 0.0001 for all three). The combination of more frequent imaging and higher charges resulted in mean imaging charges per episode of care that were 4.4 to 7.5 times higher for the self-referring physicians (P less than 0.0001). These results were confirmed in a separate analysis that controlled for the specialty of the physician. CONCLUSIONS: Physicians who do not refer their patients to radiologists for medical imaging use imaging examinations more frequently than do physicians who refer their patients to radiologists, and the charges are usually higher when the imaging is done by the self-referring physician. From our results it is not possible to determine which group of physicians uses imaging more appropriately.

Ambulatory Care↗
PubMed1990

Expenditures and sources of funds for mental health organizations: United States and each state, 1986.

EXPENDITURES: Expenditures by the 8 types of mental health organizations covered in this report totaled $18.5 billion in 1986, for the United States and the Territories. Three States (California, New York, and Pennsylvania) accounted for one-third of this total. Nationally, the largest proportion of total expenditures were the expenses of State and county mental hospitals (34 percent, down from 38 percent in 1983) and those of multiservice mental health organizations (20 percent). In all but 19 States, State and county mental hospitals (hereafter called State mental hospitals) had the largest expenditures of any type of mental health organization; in 10 of the remaining 19 states, expenditures of multiservice mental health organizations were largest. Nationally, separate psychiatric services of non-Federal general hospitals, private psychiatric hospitals, and VA psychiatric organizations ranked next, with 16, 14, and 7 percent of total mental health expenditures, respectively. At the other extreme, residential treatment centers (RTCs) for emotionally disturbed children, freestanding psychiatric outpatient clinics, and freestanding psychiatric partial care organizations accounted for 5 percent, 3 percent, and less than 1 percent of national total expenditures, respectively. The $18.5 billion expenditure in 1986 was a 28 percent increase over the 1983 figure, but when adjusted for inflation, the estimated increase was only 5 percent overall and 3 percent on a per capita basis. Constant dollar expenditures (1983 = 100) of most types of mental health organizations increased between 1983 and 1986, but those of freestanding psychiatric outpatient clinics were virtually unchanged, and those of State mental hospitals and VA psychiatric organizations actually decreased. SOURCES OF FUNDS: In 1986, the funds received by mental health organizations totaled $19.0 billion. Of this total, $7.9 billion (41 percent) was provided directly by State governments, predominantly by the State mental health agencies. Direct Federal funds plus Medicare and Medicaid (including the State and local share of Medicaid) provided $4.8 billion, or one-fourth, of total funding. Fees from clients (including private insurance) provided $4 billion, or 21 percent, of total funding; direct local government funds provided 8 percent and all other sources 5 percent. State governments provided 78 percent of the funds received by State mental hospitals and were also the largest single source of funds, although not so dominant, for multiservice mental health organizations, freestanding psychiatric partial care organizations, and freestanding psychiatric outpatient clinics. VA medical centers were funded by the Federal Government, while two-thirds of funding for private psychiatric hospitals came from client fees...

Costs and Cost Analysis↗