Biomedical subjects

Sarah von Schrader

Publications and source records attributed to Sarah von Schrader.

5 recordsLinked to original sources

PubMed2003

Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study.

OBJECTIVES: The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings. RESEARCH DESIGN: Primary care practice-based study of referred and nonreferred office visits. SUBJECTS: The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states. MEASURES: Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities. RESULTS: The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages. CONCLUSION: The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.

Capitation Fee↗

PubMed2002

Managed care, primary care, and the patient-practitioner relationship.

OBJECTIVES: This study examines how specific attributes of managed health plans influence patients' relationships with their primary care practitioners (PCPs) and determines whether these effects are mediated by access to, continuity with, or perceived choice of PCPs. DESIGN, SETTING, PATIENTS: The data source was the nationally representative 1996/97 Community Tracking Study Household Survey (cumulative response rate 65%). The study population (N = 19,415) was composed of 18- to 64-year-old adults whose most recent visit in the past 12 months was made to their primary care delivery site. MAIN OUTCOME MEASURE: Patients' ratings of their interpersonal relationships with their PCPs as measured by a 7-item scale. RESULTS: Gatekeeping arrangements that require patients to select a primary care physician or obtain authorization for specialty referrals were associated with lower ratings of the patient-PCP relationship. Health plan use of a provider network had no effect on the patient-PCP scale score. Although there were no significant differences across any insurance payer categories, uninsured adults rated their relationships with PCPs as significantly poorer than did their insured counterparts. Shorter office waits, having a specific clinician at the primary care site, better perceived choice of PCPs, and a longer duration of relationship with the primary care practitioner were associated with higher ratings of the patient-PCP relationship. Perceived choice of primary care practitioners, but not access to or continuity with PCPs, attenuated some of the negative effects of gatekeeping arrangements on patients' relationships with their primary care practitioners. CONCLUSIONS: Managed health plans that loosen restrictions on provider choice, relax gatekeeping arrangements, or promote access to and continuity with PCPs, are likely to experience higher patient satisfaction with their primary care practitioner relationships. Lack of health insurance impedes the development of patients' relationships with their primary care practitioners.

Adolescent↗

PubMed2002

Family physicians' referral decisions: results from the ASPN referral study.

OBJECTIVE: To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN: Prospective cohort study. POPULATION: All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED: Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS: Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS: Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Decision Making↗

PubMedDate not supplied

Primary care physician specialty referral decision making: patient, physician, and health care system determinants.

PURPOSE: To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making. METHODS: Physicians (n=142) and their practices (n=83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n=34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. RESULTS: Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gate-keeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. CONCLUSIONS: PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

Adult↗

PubMedDate not supplied

Variability in physician referral decisions.

BACKGROUND: Because it is possible that part of the variability in frequency of interventions and even in outcomes results from the variability in referral patterns of primary care physicians, our objectives were to examine primary care physician decision making about referrals for several common adult and childhood conditions. METHODS: One hundred thirty-six family physicians in 80 office-based practices recorded reasons for referral to the most common types of specialists and the expectation of the specialist for conditions with at least seven referrals to each specialist. RESULTS: By far the most referrals were expected to be short-term (< 12 months); for more than 50%, the referrals were for consultation only (rather than direct intervention). For most of the 10 types of conditions, there were no apparent differences in reason for or expectation of the referral that would explain the choice of different types of specialists for referral. Expectations for shared care were generally more common in referrals to nonphysicians than to physicians. CONCLUSIONS: This study revealed unexplained variability among family physicians in the specialists to whom patients are referred for specific conditions. Why some patients with the same condition are referred to surgeons and others to medical specialists is unclear, at least in the context of expectations for referral as being long-term vs short-term or consultative vs referral for definitive management. The impact of this variability on costs and outcome could be considerable and deserves more intensive study.

Decision Making↗