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PubMed2006

Ethnicity data and primary care in New Zealand: lessons from the Health Utilisation Research Alliance (HURA) study.

AIMS: To explore issues in the collection and analysis of ethnicity data in primary care, and discuss the implications of this for health services research. METHODS: Data routinely collected by 25 Wellington Independent Practice Association (WIPA) general practices in 2001. RESULTS: Practices varied in the level of ethnicity data coverage achieved, ranging from less than 10% to greater than 90% of patients. Combining practice data with National Health Index (NHI) ethnicity data increased coverage to at least 70% for registered patients at 23 of 25 practices. There were differences between the data collected in general practices and ethnicity recorded on NHI. However, with the exception of the 'Other' category, this disagreement was not systematic. Practices had lower proportions of patients with ethnicity recorded as 'Other' (not further specified) than NHI ethnicity records. CONCLUSIONS: The study demonstrated that it is possible to collect quality ethnicity data in general practices, although there are challenges. Merging practice-collected ethnicity data with NHI ethnicity data increases coverage. However, there is some mismatch between data sources. The findings support the need for standardised, consistent approaches to ethnicity data collection and analysis, as well as systems and policies that facilitate the collection of high quality data.

Data Collection↗
PubMedDate not supplied

Return on investment in pay for performance: a diabetes case study.

With purchasers' increasing frustration with healthcare costs, more innovative approaches to performance-based reimbursement are in demand. Establishing pay-for-performance programs has become a popular strategy for reorienting payments from rewarding volume to rewarding adherence to performance measures. However, while performance on quality measures has improved, no reports exist about the return on investment (ROI) of pay-for-performance programs. This article compares the overall costs of implementing and maintaining a pay-for-performance program with the resulting cost trend savings for diabetes care for a health maintenance organization's (HMO's) population. The program was a five-year partnership (2000-2004) between a health plan and an independent practice association (IPA) for the HMO product. It reported performance scores on quality, patient satisfaction, and practitioner efficiency at the individual physician level. Physician performance reporting began in 1999, and payment for that performance began in 2002. The cost of the program was 1,150,000 dollars yearly. Savings for diabetes alone in 2003, the first post-intervention year, were 1,894,471dollars. Second-year (2004) savings against the two-year rolling trend were 2,923,761 dollars. For 2003, the resulting ROI was 1.6:1, and for 2004, it was 2.5:1. To our knowledge, this article is the first report of a positive ROI for an HMO-based pay-for-performance program, and it begins to answer the question of whether the investment in such programs is worth the effort.

Cost-Benefit Analysis↗
PubMed1991

Managed-care plans. Their future under national health insurance.

The nation's health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation's physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.

Health Maintenance Organizations↗
PubMedDate not supplied

Health promotion and disease prevention in HMOs: a survey of newly established IPAs in New York City.

Independent Practice Associations (IPAs) are the fastest growing segment of the Health Maintenance Organization (HMO) industry, but little is known about their provision of health promotion and disease prevention to subscribers. To examine the extent to which IPA policies encourage health promotion and disease prevention, we interviewed medical directors and other senior administrators of six newly developing IPA-HMOs in New York City. We also reviewed promotional literature to assess how extensively health promotion and disease prevention were marketed to the potential subscriber. Although medical protocols for preventive screening exist in most IPAs, compliance with guidelines is left largely to the individual physician's judgment for implementation. IPA respondents suggested that their physician panels are oriented toward prevention, but there is uncertain evidence in this regard, and incentive payments could discourage referrals for screening. Health education programs are sporadic. Health promotion and disease prevention do not appear to be a high priority among six newly established IPAs in New York City. We recommend several steps that would encourage IPA-HMOs to increase their health promotion activities.

Adult↗
PubMed1989

The role of health practices in HMO selection bias: a confirmatory study.

This research examines the relation between employees' health practices and health plan selection. A previous study, limited to one firm, showed that employees choosing a health maintenance organization (HMO) and a fee-for-service (FFS) plan had similar health practices. We extend this inquiry to 17 Minneapolis employees, all of whom offer at least one FFS plan and one or more of the 6 Twin Cities HMOs. Health practices were measured by cigarette smoking, heavy drinking (or abstinence from drinking), use of seat belts, and exercise. We estimated health plan choice equations that show that employees with poor health practices do not systematically prefer FFS plans compared with independent practice associations (IPAs). Nor do they select FFS or IPA plans compared with HMOs on the basis of health habits. We suggest that HMOs do not gain long-term cost advantages by enrolling employees with favorable health practices.

Choice Behavior↗
PubMed1987

Pharmacy: a profession in transition or a transitory profession?

Areas in pharmacy that are in transition are described, and ways to prevent the perception of pharmacy as a transitory profession are detailed. Pharmacy has adapted itself over the past 75 years to changes in the health-care system and in societal demands of the profession. The evolution of pharmacy functions has included drug product preparation, establishment of standards, drug distribution, and clinical pharmacy. The profession is continuing to change in reaction to economic and social forces. Hospital pharmacy flourished when it shifted from a profit to a cost center because pharmacy practice researchers documented the contribution of clinical pharmacy to patient care and because hospital pharmacy administrators developed sound management procedures to maintain efficient inventories. Current controversies in pharmacy practice are discussed, including pharmacist prescribing, physician dispensing, and therapeutic substitution. These terms inadequately describe the concepts, especially when they are taken out of context of the total health-care process involving a physician-pharmacist team. Because of the success of this teamwork in acute-care institutions, ambulatory pharmaceutical services should involve cooperative activities of pharmacists in professional service administrative organizations (PSAOs) and physicians in independent practice associations. The cost-effectiveness of PSAOs is discussed. Marketing of drug products is changing as the physician-pharmacist interaction becomes integral to the drug therapy decision-making process. Drug distribution should not be viewed as less professional than clinical activities. Although the pharmacy profession is reorienting itself toward patient care and the rational use of drugs in society, it must maintain its authority over the drug distribution system.

Drug Prescriptions↗
PubMed1986

Medical screening and biological monitoring for the effects of exposure in the workplace. Review of 30 years of screening practices.

Increasingly larger proportions of our population are insured against health care costs through negotiated or mandated contracts involving active and retired workers and their dependents. Seeking to control and contain the dramatically rising costs, employers have begun ti demand full accountability from their third-party payers, in response to which the health care services delivery system is evolving health maintenance organizations, preferred provider organizations, independent practice associations, and variant aggregates of participants with more homogeneously predictable utilization rates and cost estimates. The resultant information base generates employer-specific data leading to earlier detection and identification of work-related and total premorbidity and morbidity, causing renewed emphasis on prevention through total, including work-site related, risk-factors reduction. The screening technology required for the implementation and evaluation of health risks assessment and reduction programs is reviewed. The technology has matured significantly over the past 30 years. Problem areas and action needs are identified.

Health Benefit Plans, Employee↗
PubMedDate not supplied

Minimum optimum scale of federally qualified health maintenance organizations.

From a policy standpoint it is important to identify the level of output at which average cost per unit is at its lowest. If minimum optimum scale is achieved at a very high output level, it would suggest that monopoly conditions should be allowed to prevail. If, however, minimum optimum scale is achieved at a low level of output, more organizations would be able to survive, allowing for competition in the marketplace. Using data published by the Office of Health Maintenance Organizations, the relationship between size and average cost was examined in federally qualified staff, group, and Independent Practice Association (IPA) health maintenance organizations (HMOs) and minimum optimum scale was identified for each organization. The findings support the hypothesis that least cost size is achieved at the lowest level of output in IPA HMOs. The hypothesis that minimum optimum scale would be achieved at a lower level of output in group rather than in staff HMOs was not supported. This may be due to the practice of some staff HMOs of employing part-time, salaried providers and purchasing unique services from other providers.

Health Maintenance Organizations↗
PubMed1986

Factors affecting choice of health care plans.

The research reported here examined the factors which affected the decision to remain with either Blue Cross of Washington and Alaska or Group Health Cooperative of Puget Sound, or to change to an independent practice association (IPA) in which the primary care physicians control all care. The natural setting allowed examination of the characteristics of families with experience in structurally different plans; a decision not influenced by premium differentials; the importance of the role of usual provider; and a family-based decision using multivariate techniques. An expected utility model implied that factors affecting preferences included future need for medical care; access to care; financial resources to meet the need for care; and previous level of experience with plan and provider. Analysis of interview and medical record abstract data from 1,497 families revealed the importance of maintaining a satisfactory relationship with the usual sources of care in the decision to change plans. Adverse selection into the new IPA as measured by health status and previous utilization of medical services was not noted.

Blue Cross Blue Shield Insurance Plans↗
PubMed1982

Antitrust and health care: provider controlled health plans and the Maricopa decision.

The health care industry is one which traditionally has discouraged its members from engaging in competition. For years, many within the profession have espoused a guild mentality and have viewed professional societies as the proper centers of health care's economic universe. This guild mentality has recently been challenged by proponents of a market mentality, theoreticians who argue that limited combinations of health care providers called "health plans," which serve insurance as well as service functions, can make the health care industry more efficient. Proponents of the guild mentality have been dealt a severe blow by the Supreme Court and its decision in Arizona v. Maricopa County Medical Society. There the Court found the price-fixing by two Arizona medical societies to be illegal per se under applicable antitrust law. This Article outlines the background on competition and the guild mentality in the health care industry. After a brief discussion of the standards of antitrust analysis, the Article analyzes the Maricopa case, by first summarizing the Court's use of strict antitrust criteria, and then by extending the analysis to an application of a more lenient standard. Next, the Article compares the provider controlled independent practice association ("IPA")--one form of insurance plan proposed by market model advocates--with the Maricopa-type plan. Finally, the Article concludes that, not only is the special form of IPA that qualifies as a "health plan" an excellent way to promote efficiency in the health care industry, but also its procompetitive goals and effect allow it to survive even the strictest, Maricopa-type antitrust scrutiny.

Arizona↗
PubMed1994

Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study.

OBJECTIVE: To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems. STUDY DESIGN: Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires. SETTING: A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. OUTCOMES MEASURES: Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics. RESULTS: Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs. CONCLUSIONS: The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.

Adult↗
PubMed1993

Office systems for promoting screening mammography. A survey of primary care practices.

BACKGROUND: Office tracking, scheduling, and reminder systems have been shown to improve utilization of screening mammography, but little is known about the use of these systems by primary care physicians. METHODS: We surveyed 132 primary care and obstetrics and gynecology practices affiliated with an independent practice association model health maintenance organization in central Massachusetts to determine their use of reminder, scheduling, and follow-up systems, and education and counseling services aimed at increasing screening mammography rates. RESULTS: The use of chart flags to remind physicians of a patient's need for mammography screening was reported by 30% of practices. Thirty-one percent reported the use of flow sheets, and 27% reported the use of mail or telephone patient reminders. At least one of these three systems was used by 57% of the practices, whereas 43% reported having none of these three systems. Variations in the use of these office systems were related to specialty type, physician number, and clinical staffing. The majority of practices (77%) reported using written educational materials, and 42% offered prevention counseling with nonphysician staff. Very few offices (8%) reported using mail or telephone reminders for previously scheduled appointments. CONCLUSIONS: Despite the proven effectiveness of reminder systems for screening mammography, many practices do not have a system in place. Promotion of reminder systems in primary care practices could have a substantial impact on mammography utilization.

Ambulatory Care Information Systems↗
PubMed1997

The dialysis facility of the future: the financial and social environment.

Changes in the delivery of care are being driven by the rapid advance of managed care. Nephrologists must continue to be advocates for the end-stage renal disease (ESRD) patient in a medical environment obsessed with costs. Reorganization of nephrology will be mandatory because capitation is on the immediate horizon. Fee-for-service care will diminish, and nephrologists must learn how to become the driving force for quality care in a cost-effective environment. The formation of nephrology Independent Practice Associations (IPAs) will create the structure that allows nephrologists to negotiate and accept global captitated contracts for ESRD care. Placing the patients' interests first will ultimately lead to reduced costs. Changes in the nephrology workforce over the next decade will dictate participation in a horizontal and vertical integration team approach to care of the patient with ESRD.

Cost-Benefit Analysis↗
PubMed1998

Trends in health care practitioner credentialing.

Once a risk management process limited to hospitals, the practice of practitioner credentialing has expanded to include many other health care organizations, including insurers, health maintenance organizations, preferred provider organizations, management services organizations, medical groups, and independent practice associations. Standards set by recognized accreditation bodies, including the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), National Committee for Quality Assurance (NCQA), and American Accreditation Health Care Commission/Utilization Review Accreditation Committee mandate a substantial effort to properly evaluate the credentials of health care practitioners. A sector of commerce called the credentials verification organization (CVO) industry has undertaken the mission to make the process of practitioner credentialing more consistent and efficient, faster, and less expensive.

Cost-Benefit Analysis↗
PubMed2004

Improving mortality of coronary surgery over first four years of independent practice: retrospective examination of prospectively collected data from 15 surgeons.

OBJECTIVE: To study the "learning curve" associated with independent practice in coronary artery surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: All NHS centres in north west England that carry out cardiac surgery in adults. PARTICIPANTS: 18 913 patients undergoing coronary artery surgery for the first time between April 1997 and March 2003, 5678 of whom were operated on by 15 surgeons in the first four years after their consultant appointment. MAIN OUTCOME MEASURES: Observed and predicted mortality (EuroSCORE) for surgeons in their first, second, third, and fourth years after appointment as a consultant compared with figures for established surgeons. RESULTS: Overall mortality decreased over the six years of study (P = 0.01). Of the patients operated on by established surgeons or newly appointed consultants, 265/13,235 (2.0%) and 109/5678 (1.9%), respectively, died (P = 0.71). There was a progressive decrease in observed mortality with time after appointment as a consultant from 2.2% in the first year to 1.2% in the fourth year (P = 0.049). This result remained significant after adjustment for time and case mix (P = 0.019). CONCLUSIONS: Mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established surgeons. There are significant decreases in crude and risk adjusted mortality in the four years after appointment. These findings should influence the nature of practice in newly appointed surgeons.

Adult↗