Biomedical subjects

Jon B Christianson

Publications and source records attributed to Jon B Christianson.

At least 19 recordsLinked to original sources

PubMed2006

Physician pay-for-performance. Implementation and research issues.

Recent research underscores the gaps that exist between evidence-based medical practices and the care that many patients actually receive. Recognizing this, large purchasers are experimenting with new reimbursement arrangements called pay-for-performance (P4P) that tie a portion of payments for physician services to measures of quality. Agency theory, from the discipline of economics, provides a perspective on the challenges P4P is likely to encounter. The focus of most P4P initiatives on medical group performance raises additional questions about its potential effectiveness as a catalyst for change.

Employee Performance Appraisal↗

PubMed2006

Health plan pay-for-performance strategies.

OBJECTIVE: To examine health plan strategies, planning, development, and implementation of pay-for-performance programs (financial incentives for hospitals and physicians tied to quality and efficiency) at the community level, focusing on differences across markets. STUDY DESIGN: A fifth round of site visits to 12 nationally representative metropolitan areas between January 2005 and June 2005, based on more than 1000 protocol-driven interviews with representatives from health plans, provider organizations, employers, and policy makers. METHODS: In each of 12 communities, we interviewed several executives from 35 health plans, including chief executive officers, marketing executives, and network contracting directors. Additional perspectives were obtained from representatives of employers, large medical groups, and hospital systems. RESULTS: Growing numbers of health plans are developing and implementing pay-for-performance programs for physicians and hospitals. Although in their early stages, plans' customized programs show substantial design variation within and across markets. This design variation reflects local conditions that include information technology capabilities, data availability, relative leverage of health plans and providers, willingness of providers to participate, and employer influence. The concerns of providers include the administrative burden of health plans' customized programs and the potential for conflicting financial incentives. CONCLUSIONS: Most health plans are committed to pay-for-performance programs. Although providers would prefer health plans in their communities to use a single standardized set of measures and methods, this is unlikely given local market environments. A national effort directed at standardization might significantly reduce the extent of customization but also may limit the opportunities for local collaboration with providers.

Administrative Personnel↗

PubMed2005

The QUEST for quality: what are medical groups doing about it?

BACKGROUND: It is important to know whether medical groups have quality improvement (QI) priorities, approaches, activities, and congruence that will allow them to achieve major improvements in quality of care. METHODS: Simultaneous surveys were sent to medical and administrative leaders of 18 medical groups, 84 of their constituent clinics, and their primary care physicians providing the majority of the primary care in the Minneapolis/St. Paul metropolitan area. RESULTS: Of the 18 medical groups, 17 have an overall physician leader for QI and 11 have the same at each of their constituent clinics. Nearly 100% of clinic leaders report their group leaders see QI as important and expect clinics to improve care, while 69%-84% of their physicians report the clinic leaders are committed to QI for diabetes and heart disease. Diabetes and coronary heart disease are the priorities for improvement by 14 and 12 medical groups respectively. Only seven groups report adequate QI resources and only three report that incentives are aligned with quality. Intermediate groups generally appear to be just as active and supportive of QI as large ones. DISCUSSION: These medical groups and their constituent clinics and physicians appear ready to work on the issues raised by the Institute of Medicine (IOM). However, they believe that limited resources and financial incentives that are not aligned with quality constrain their ability to help America cross the quality chasm.

Disease Management↗

PubMed2005

Deploying Six Sigma in a health care system as a work in progress.

BACKGROUND: An integrated health care system deployed Six Sigma in four clinical projects. The selected projects targeted Medicare profitability, emergency department cycle time reduction, clinic patient preparation, and medication safety. CROSS-PROJECT ANALYSIS: The six-month start-up period yielded several lessons. For example, the selection and sequence for implementing strategic performance improvement (PI) projects, and the decision to use Six Sigma methods, should be guided by an overall system of project portfolio management. IMPLEMENTING SIX SIGMA: Fairview Health Services (FHS) had begun with a partial deployment with the intent of using the experience to inform subsequent full deployment. Yet even before completing analyses of project outcomes, FHS decided to proceed with full deployment. Leaders developed strategic and communication plans, allocated resources, and provided for further training. In 2005, three years after the initial implementation period, Six Sigma implementation has continued. A systemwide method for setting priorities for PI projects is in place, supported by a Web-based system for managing, tracking, monitoring, and communicating results. FINAL REFLECTIONS: Cultural change is a challenge in any environment where staff is rooted in a single PI methodology and is skeptical about the credibility of Six Sigma because of its tie to manufacturing. Health care organizations will need to find better ways to engage physicians, especially community physicians whose patients and clinical practices could be affected by Six Sigma projects.

Delivery of Health Care, Integrated↗

PubMed2005

Exporting the Buyers Health Care Action Group purchasing model: lessons from other communities.

When first implemented in Minneapolis and St. Paul, Minnesota, the Buyers Health Care Action Group's (BHCAG) purchasing approach received considerable attention as an employer-managed, consumer-driven health care model embodying many of the principles of managed competition. First BHCAG and, later, a for-profit management company attempted to export this model to other communities. Their efforts were met with resistance from local hospitals and, in many cases, apathy by employers who were expected to be supportive. This experience underscores several difficulties that appear to be inherent in implementing purchasing models based on competing care systems. It also, once again, suggests caution in drawing lessons from community-level experiments in purchasing health care.

Consumer Behavior↗

PubMed2005

Physicians' perceptions of managed care: a review of the literature.

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians' perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

Attitude of Health Personnel↗

PubMed2005

Physician evaluations of care management practices in Medicaid programs.

OBJECTIVE: To assess differences in care management practices for Medicaid beneficiaries in predominantly commercial and predominantly Medicaid health plans. STUDY DESIGN: Physicians in the networks of 8 managed care plans participating in Medicaid programs were surveyed regarding the availability and usefulness of care management practices and the overall quality of care management. The responses of physicians in plans serving predominantly Medicaid enrollees were contrasted with the responses of physicians in predominantly commercial plans who cared for Medicaid enrollees. METHODS: Logistic regression analysis was used to calculate adjusted odds ratios relating to the availability of care management practices. Multiple regression techniques were used to construct comparisons of adjusted means relating to the usefulness of practices and the overall quality of care management. RESULTS: Physicians in predominantly commercial plans reported greater availability of care management practices. No patterns of differences were noted in ratings of the usefulness of practices if available. Physicians in predominantly commercial plans rated the quality of care management higher than physicians in predominantly Medicaid plans. However, there remains room for substantial improvement for commercial and other Medicaid contracting plans. CONCLUSIONS: Commercial plans add value to Medicaid programs, and efforts to discourage their withdrawal from participation are justified. However, physician evaluations support the potential for better care management in all types of contracting plans.

Adult↗

PubMed2004

Employee choice of consumer-driven health insurance in a multiplan, multiproduct setting.

OBJECTIVE: To determine who chooses a Consumer-Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool. STUDY DESIGN: We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans--a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system. PRINCIPAL FINDINGS: Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher-income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out-of-pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price-sensitive. CONCLUSIONS: This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out-of-pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.

Choice Behavior↗

PubMed2004

Consumer experiences in a consumer-driven health plan.

OBJECTIVE: To assess the experience of enrollees in a consumer-driven health plan (CDHP). DATA SOURCES/STUDY SETTING: Survey of University of Minnesota employees regarding their 2002 health benefits. STUDY DESIGN: Comparison of regression-adjusted mean values for CDHP and other plan enrollees: customer service, plan paperwork, overall satisfaction, and plan switching. For CDHP enrollees only, use of plan features, willingness to recommend the plan to others, and reports of particularly negative or positive experiences. PRINCIPAL FINDINGS: There were significant differences in experiences of CDHP enrollees versus enrollees in other plans with customer service and paperwork, but similar levels of satisfaction (on a 10-point scale) with health plans. Eight percent of CDHP enrollees left their plan after one year, compared to 5 percent of enrollees leaving other plans. A minority of CDHP enrollees used online plan features, but enrollees generally were satisfied with the amount and quality of the information provided by the CDHP. Almost half reported a particularly positive experience, compared to a quarter reporting a particularly negative experience. Thirty percent said they would recommend the plan to others, while an additional 57 percent said they would recommend it depending on the situation. CONCLUSIONS: Much more work is needed to determine how consumer experience varies with the number and type of plan options available, the design of the CDHP, and the length of time in the CDHP. Research also is needed on the factors that affect consumer decisions to leave CDHPs.

Adult↗

PubMed2004

Evaluation of the effect of a consumer-driven health plan on medical care expenditures and utilization.

OBJECTIVE: To compare medical care costs and utilization in a consumer-driven health plan (CDHP) to other health insurance plans. STUDY DESIGN: We examine claims and employee demographic data from one large employer that adopted a CDHP in 2001. A quasi-experimental pre-post design is used to assign employees to three cohorts: (1) enrolled in a health maintenance organization (HMO) from 2000 to 2002, (2) enrolled in a preferred provider organization (PPO) from 2000 to 2002, or (3) enrolled in a CDHP in 2001 and 2002, after previously enrolling in either an HMO or PPO in 2000. Using this approach we estimate a difference-in-difference regression model for expenditure and utilization measures to identify the impact of CDHP. PRINCIPAL FINDINGS: By 2002, the CDHP cohort experienced lower total expenditures than the PPO cohort but higher expenditures than the HMO cohort. Physician visits and pharmaceutical use and costs were lower in the CDHP cohort compared to the other groups. Hospital costs and admission rates for CDHP enrollees, as well as total physician expenditures, were significantly higher than for enrollees in the HMO and PPO plans. CONCLUSIONS: An early evaluation of CDHP expenditures and utilization reveals that the new health plan is a viable alternative to existing health plan designs. Enrollees in the CDHP have lower total expenditures than PPO enrollees, but higher utilization of resource-intensive hospital admissions after an initially favorable selection.

Choice Behavior↗

PubMed2004

Penetrating the "black box": financial incentives for enhancing the quality of physician services.

This article addresses the impact of financial incentives on physician behavior, focusing on quality of care. Changing market conditions, evolving social forces, and continuing organizational evolution in health services have raised societal awareness and expectations concerning quality. This article proceeds in four parts. First, the authors place financial incentives in the context of broader forces shaping the quality of physician services. Second, the article reviews the literature on financial incentive effects on physician behavior. Third, a simple net income maximization model of physician choices is presented, from which are derived formal hypotheses regarding the effect of financial incentives on physician choices of quality per unit of physician service and the quantity of services per patient. The model is extended qualitatively to offer further hypotheses and research directions. Finally, gaps and limitations of the model and of the extant empirical research are articulated, and additional researchable questions are posed.

Attitude of Health Personnel↗

PubMed2004

Community responses to national healthcare firms.

Over the last 25 years, national Health Maintenance Organization (HMO) and hospital firms attempted to enter local markets, either by acquiring formerly independent, locally based HMOs and hospitals or by directly entering local markets. While national HMOs have been relatively successful, national hospital firms have had much less success. This paper explores the reasons for this difference. It reviews changes in presence of national HMO and hospital firms in markets, discusses common conceptual lenses through which national entry into local markets typically has been viewed, and shows how social network theory can be used to develop a better understanding of why the entry experience of national HMO and hospital firms varies across markets. The paper concludes with a research agenda that addresses issues raised by social network theory and its application to national firm entry into local markets.

Economics, Hospital↗

PubMed2003

Managing costs, managing benefits: employer decisions in local health care markets.

OBJECTIVES: To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems. DATA SOURCES/STUDY SETTING: Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities. STUDY DESIGN: This is an observational study with data collection over a six-year period. DATA COLLECTION/EXTRACTION METHODS: The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions. PRINCIPAL FINDINGS: The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results. CONCLUSIONS: General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.

Cost Control↗

PubMed2003

Association between interruptions in medicaid coverage and use of inpatient psychiatric services.

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.

Eligibility Determination↗

PubMed2003

Evaluating health plan quality 1: a conceptual model.

OBJECTIVE: To develop a theoretical foundation for measuring health plan quality from a physician's perspective. STUDY DESIGN: Literature review and theory development. METHODS: We defined health plan quality as the degree to which health plan management practices increase the likelihood of high-quality care for individuals and populations and addressed the ways in which health plan quality is similar to, and different from, other commonly used quality measures. Based on an assessment of the literature, we proposed a conceptual model that organizes health plan care management practices into a coherent structure for measuring health plan quality. RESULTS: A conceptual model of health plan operation that organizes managerial practices into a structure for measuring health plan quality from a physician's perspective was developed. CONCLUSION: Health plan quality is distinct from quality of care, and physicians can provide unique, timely, and reliable information about aspects of health plan quality.

Attitude of Health Personnel↗

PubMed2003

Evaluating health plan quality 2: survey design principles for measuring health plan quality.

OBJECTIVE: To develop principles for measuring the quality of specific health plans from a physician's perspective. STUDY DESIGN: Literature review, expert review, cognitive interviews. METHODS: We did a literature review on the use of physician surveys about managed care to determine the contributions and weaknesses of those surveys. Then, an expert review of prior survey efforts to measure health plan quality from the physician's perspective was performed. RESULTS: A survey instrument based on a conceptual model of health plan quality was developed. Its purpose was to measure health plan quality from the physician's perspective. Principles for surveying physicians guided the structure of the survey. CONCLUSION: Survey instruments can be designed to take into account a physician's unique perspective on health plan quality and can include measures that control for potential biases such as anti-managed care bias.

Attitude of Health Personnel↗

PubMed2003

Evaluating health plan quality 3: survey measurement properties.

OBJECTIVE: To assess the measurement and scaling properties of survey items designed to measure health plan quality from a physician's perspective. STUDY DESIGN: Prospective survey design with multivariate regression analysis. METHODS: Data were from 3798 physicians representing 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Scale reliability was assessed by using the Cronbach alpha. Generalist and specialist scales were compared with structural equation modeling. Multivariate analysis was used to examine internal validity by testing theoretically based hypotheses. RESULTS: Scales constructed from the data were reliable, were stable across both generalist and specialist physicians, and demonstrated construct validity. Hypotheses about the relationship between physician experiences with a health plan and physician recommendations of the plan were confirmed, supporting construct validity. CONCLUSION: The items on the survey instrument can be used with confidence to measure health plan quality from a physician perspective.

Attitude of Health Personnel↗

PubMed2003

What do physician recommendations of health plans mean?

OBJECTIVE: To examine what determines physician recommendations of health plans and whether their recommendations reflect experiences with specific plans. STUDY DESIGN: Cross-sectional mail and telephone survey. PARTICIPANTS AND METHODS: A sample of 11453 physicians was surveyed from November 2000 to early 2001, and 3798 (2105 generalists, 1693 specialists) responded. After adjusting for ineligibles and duplicates, the response rate was estimated to be between 41% and 45%. Physician respondents were from 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Plans included those serving commercial, Medicare and Medicaid populations and represented group/staff type HMOs, independent practice associations, and preferred provider organizations. Measurements included self-reported experience with 9 health plan care management strategies and ratings of managed care beliefs and satisfaction with pay. Physicians were asked about their willingness to recommend the health plan to a family member or friend, to people with serious illnesses, or to other physicians. RESULTS: Physician recommendations of a health plan were associated with the health plan's care management activities and with the physician's generalized beliefs about managed care and satisfaction with pay. CONCLUSION: Physician health plan recommendations can reasonably be interpreted as partially reflecting physician experiences with specific plans. Therefore, they can play a role in helping purchasers and consumers compare health plans.

Adult↗