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Biomedical subjects

T D Wingert

Publications and source records attributed to T D Wingert.

17 recordsLinked to original sources
PubMed1996

The effects of capitation payment on the organizational structure of medical group practices.

This study explores the effects of capitation payment on the structural elements used by medical group practices to control physician-directed use of resources and the quality of patient care. Forty-five medical groups located in the highly competitive Minneapolis/St. Paul metropolitan area were studied. The range of capitation payment in these medical group practices is from 2% to 87%. Although the practices vary considerably in the extent to which they have developed these control mechanisms, it does not appear that capitation payment is a major factor influencing that pattern. It appears that many of these medical group practices either use less formal mechanisms than those included in this study to control resource use and the quality of care or use none at all. In either event, the data suggest that the effects of capitation payment on the structure of medical practices may be overestimated.

Capitation Fee↗
PubMed1996

Assessing the culture of medical group practices.

This study was designed to identify the relevant components of the organizational culture of medical group practices and to develop an instrument to measure those cultures. Building on the work of industrial psychologists and organizational sociologists, a 35-item instrument was developed through an iterative process with more than 100 medical groups. The final instrument was tested using responses from physicians practicing in two very different medical groups: one a prepaid group practice with salaried physicians and the other, until recently, a fee-for-service practice. Using stepwise discriminant analysis of the responses to this instrument, more than 90% of the physicians were able to be placed in the appropriate practice setting.

Decision Making, Organizational↗
PubMed1994

Measuring the dimensions of physician work.

Medicare has adopted a physician fee schedule that places emphasis on measuring physicians' work. We assessed the construct validity of self-reported work scores for 11 selected medical services performed by 44 internists in two large group practices. These physicians' work scores correlated highly with their ratings of time, physical and mental effort, and stress required to produce the services. Eighty-five percent of the variance in total work scores could be explained by the dimensions of work. Time was the most important input, but mental effort also was important for internists. We also found that physicians may reduce the total work required to produce two services for a patient if they provided those services in one visit, rather than in separate visits. Savings occurred for service pairs in which the physician could reduce his or her own time. Our findings imply that the Medicare fee schedule pays internists mainly for the time and mental effort required to produce medical services. They also underscore the importance to physicians of saving time by providing two services during the same patient visit.

Cost Savings↗
PubMed1992

Economies of scope and payment for physician services.

Physician payment reform will base payment largely upon physician work. Current reforms assume that services are provided independently, yet physicians may often perform two or more services at one time. There is evidence from other industries that services provided jointly may not require the same total resources as identical services provided independently. This study evaluated whether physician-reported work and time were the same for some common services when provided jointly and when provided separately. Six case vignettes were constructed consisting of two services each. Forty-four general internists rated the total work and time required for each vignette performed as a whole, and for the two services performed separately. Total work was estimated using a magnitude estimation technique similar to that used in developing the resource-based relative value scale. For five of the six vignettes, the work rating for performing the services together was significantly less than the sum of the ratings for the separate services. The work savings associated with providing services together ranged from 4% to 30% of the total work of the separate services. A similar reduction was observed for the estimated time to perform services jointly in four of the six vignettes. In no case was work or time lower when services were provided separately. Physicians report lower work and time for at least some pairs of services, compared with providing the same services separately. Reimbursement mechanisms that fail to account for these reductions may provide incentives to combine or add services.

Data Collection↗
PubMed1992

Factors related to the provision of hospital discounts for HMO inpatients.

Using 1986 AHA hospital survey data, we analyzed hospital-HMO contract provisions, hospital operating characteristics, and market conditions for a national sample of 801 hospitals with HMO contracts to determine the factors related to provision of a discount and the magnitude of the discount if present. Seventy-eight percent of the hospitals reported that at least one of their HMO contracts provided a discount for inpatient services. Risk-sharing provisions, the number of hospitals within a five-mile radius, the proportion of the population enrolled in HMOs, and the number of HMOs operating in the metropolitan statistical area (MSA) were directly related to provision of discounts. Public hospitals were less likely than other facilities to provide discounts. For the magnitude of the discounts, risk-sharing provisions and the number of hospitals within a five-mile radius were again related, as was the number of HMOs operating in the MSA--but this time the number-of-HMOs variable had an inverse relationship. The results suggest that increased HMO market activity does result in price competition for hospital services but that hospital discounting strategies are extremely complex and may not follow conventional market theories. Hospitals appear to be using contracts both to stabilize their relationships with HMOs and increase market share, and they are increasingly giving discounts to achieve those ends.

American Hospital Association↗
PubMed1991

Quality assurance issues raised by proposed limited-service rural hospitals.

This article explores quality assurance issues that are likely to arise related to limited-service rural hospitals, an institutional alternative to existing rural hospitals. In exploring these issues, we use as an example, the Montana Medical Assistance Facility, a limited-service rural hospital model about to be implemented by the Health Care Financing Administration as a demonstration. While such medical assistance facilities will need to meet licensure and certification requirements, it is not reasonable to expect them to meet regulations that are designed for large hospitals. Also, because of their limited resources, medical assistance facilities will likely need outside help from a larger institution to perform quality assurance activities, particularly peer review activities. A key challenge for the medical assistance facility will be to define the nature of this relationship, while retaining ultimate responsibility for quality of patient care. Assuring quality of care is a particularly important issue for medical assistance facilities since community acceptance and financial viability will depend critically on establishing a record for quality of care that is at least comparable to existing small, rural hospitals.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1990

Institutional alternatives to the rural hospital.

An important aspect of the ongoing debate on rural health policy is how to deliver inpatient care in sparsely populated rural areas. One alternative is to create a new classification of rural inpatient facility that would deliver more limited services than available in a rural hospital, have more flexibility in staffing requirements, and possibly be reimbursed differently. The support of the Health Care Financing Administration for the concept of a limited service rural hospital is critical, since such a facility would not be financially viable without Medicare payment. Several organizational and public policy issues that merit consideration in the design and implementation of institutional alternatives to rural hospitals are discussed, including licensure and certification, scope of services, personnel, quality assurance, and payment.

Hospital Administration↗
PubMed1985

Parathyroid hormone enhances glucagon secretion from the isolated perfused rat pancreas preparation.

We examined whether PTH could increase glucagon secretion in an in vitro system, the isolated perfused rat pancreas. Since the response of the A cell has been shown to be modulated by antecedent exposure to elevated concentrations of glucose, bovine PTH (Beckman 1-34) was superimposed upon 15-min infusions of glucose followed by arginine or upon infusions of arginine alone. In the presence of PTH (44 ng/ml) and when the ambient calcium concentration was 9.0 mg/dl, arginine (168 mg/dl)-induced glucagon secretion was augmented. This occurred regardless of whether arginine was preceded by glucose (150 mg/dl). The glucagonotropic effect of PTH was absent in the presence of a low ambient calcium concentration (3.0 mg/dl). PTH failed to affect glucose-induced glucagon suppression.

Animals↗
PubMed1980

Augmentation of insulin secretion by a non-nutrient drink.

Because it is known that nutrients can enhance insulin release, we studied the effect of a drink which was devoid of nutrients upon the immunoreactive insulin response to i.v. glucose in 13 normal subjects. The summated immunoreactive insulin secretory response during an i.v. glucose infusion (500 ml 10% glucose over 30 min) was 178 +/- 32 (SEM) microU/ml. However, when subjects ingested 500 ml 3% mannitol in a physiologic electrolyte solution given 30 min before the i.v. glucose, 56% augmentation of insulin release was noted (277 +/- 38 microU/ml, P less than 0.005). Post-infusion serum glucose was lower when the drink preceded i.v. glucose. The 3% mannitol-electrolyte drink itself did not significantly alter insulin, gastrin, gastric inhibitory polypeptide, or glucagonlike immunoreactivity. Two percent mannitol-electrolyte solution did not produce the insulin enhancing effects of the more hypertonic solution. In contrast with the effects of glucose, when arginine was used as the i.v. insulin secretagogue, antecedent 3% mannitol-electrolyte ingestion produced no enhancement of insulin release. This study demonstrates that ingestion of a non-nutrient drink with an osmolality of at least 456 mosmol/kg augments insulin secretion in response to a subsequent i.v. glucose load.

Adult↗
PubMed1979

Sinemet and thyroid function in Parkinson disease.

Patients on chronic carbidopa-levodopa (Sinemet) therapy underwent thyroid function testing that included measurement of serum thyroxine (T4), triiodothyronine (t3), thyrotropin (TSH), T3 uptake (T3U), free T4 index (FT4I), and free T3 index (FT3I). The subjects were studied both in a random sampling and in a controlled manner, fasting and 2 hours after receiving the drug. All subjects were euthyroid by testing, and there was no significant difference in thyroid hormone levels of patients and controls or in fasting values and values 2 hours after the drug. However, there was a small but significant reduction in serum TSH levels after Sinemet. Therapeutic doses of Sinemet have no significant effect on thyroid function in euthyroid patients with Parkinson disease.

Carbidopa↗
PubMedDate not supplied

The effects of medical group practice organizational factors on physicians' use of resources.

Few studies have systematically examined the influence of physician, patient, and practice characteristics on physician-directed use of resources within the overall environment of medical group practices and none have included the practice culture in the analysis. This study analyzes the effects of the structure and culture of medical group practices on the amount of resources used to manage uncomplicated hypertension episodes of care for enrollees in a Minneapolis/St. Paul HMO during 1990. Three findings emerged from this study: (1) resource use for a well-defined episode of care varies much more than one would expect in this highly competitive managed care environment; (2) the culture of the group practice appears to be more important than organizational structure in determining resource use for the treatment of hypertension; and (3) together the culture and structural variables only explain 8 percent of the variance in resource use. The study indicated that medical group practice organizations have less influence on physicians' practice styles than expected. The group practices studied are all located in a highly competitive managed care environment and these conditions should be causing them to create more standardized practice styles among their physicians. However, wide variations in individual physician practice styles account for most of the differences observed. Either much of the unexplained variance in resource use for this episode of care results from unobserved patient and illness characteristics, or managed healthcare is not yet causing medical group practices in Minnesota to challenge physicians' individualistic practice styles.

Cost-Benefit Analysis↗
PubMedDate not supplied

Constructing episodes of care from encounter and claims data: some methodological issues.

There is growing agreement that episodes of care methodology provides the most effective means of analyzing health care delivery because it organizes health care services around the condition or illness for which they were prescribed. This paper presents a computerized approach for developing episodes of care from encounter and claims data and discusses some methodological issues. We found that we could group into five generic types of episodes of care the 31 illnesses that incur the majority of expenses for a health maintenance organization. This article describes the process for developing these types and summarizes the specific criteria defining the episodes of care for the 31 illnesses.

Algorithms↗