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PubMedDate not supplied

Financial incentives and physicians' perceptions of conflict of interest and ability to arrange medically necessary services.

Many believe that physician payment mechanisms that include incentives to restrain utilization create conflicts of interest for physicians and result in the withholding of needed services. Pooled data from two rounds of the Community Tracking Study physician survey, a nationally representative telephone survey of physicians, are the basis of this analysis. We examine the association between explicit financial incentives linked to physician profiling and perceived conflict of interest, and the reported ability to obtain specific, medically necessary secondary services (referrals, hospitalizations and diagnostic imaging). Logistic regression models were employed to control for potentially confounding influences. After controlling for other factors, physicians subject to profiling linked with financial incentives were much less likely than physicians not affected by profiling to strongly agree that they can make clinical decisions in the best interests of their patients without the possibility of reducing their income. They were also less likely to report that they could always obtain selected medically necessary secondary services for their patients. Physicians subject to explicit financial incentives based on profiling are more likely than other physicians to perceive a conflict of interest. Physicians with financial incentives tied to profiling also experience greater difficulty obtaining medically necessary secondary services for their patients.

Attitude of Health Personnel↗
PubMed1980

Utilization of within-hospital services. A study of the effects of two forms of group practice.

This study examined the effect of group affiliation on the use of technical (length of stay, lab tests, etc.) and clinical (rendering and requesting consultations) resources by physicians practicing within a large acute care hospital. Comparisons in use were made between physicians in 1) a prepaid group practice (Colorado Permanente Medical Group [Kaiser]); 2) a fee-for-service group practice; and 3) "unaffiliated" physicians. Patient data were adjusted whenever possible for patient diagnosis and severity. In comparison to other physicians in the hospital, the prepaid group physicians utilized somewhat fewer technical resources, though the results were not statistically significant. Differences in the use of clinical resources were statistically significant, with the fee-for-service group physicians using consulting services the most and prepaid group physicians using them the least. The results indicate that 1) fee-for-service group structures may reinforce the incentives to share in consultation revenues; 2) prepaid group physicians may experience difficulty becoming integrated into the informal structures of physician practice patterns; and 3) the control of groups over the use of technical hospital resources may be substantially weakened when groups do not own or control the hospitals to which they admit their patients.

Analysis of Variance↗
PubMed1981

Effect of hospital-based primary care setting on internists' use of inpatient hospital resources.

Hospital-based primary care is expanding, yet the impact of the hospital setting on physician practice patterns and health care costs is unknown. This project compared the use of inpatient hospital resources between internists practicing in hospital-based and freestanding primary care clinics. All hospitalizations over a two-year period by internists in the Kaiser-Permanente Medical Care Program--Oregon Region were analyzed ( n = 5,623). Organizational and financial incentives were uniform for all internists. Results indicate that hospital-based internists use inpatient resources differently from other internists. The former are more likely to hospitalize, but their patients are likely to have a shorter length of stay and fewer laboratory tests or consultations. On average, the hospital-based internists used 44 more hospital days for every 1,000 doctor office visits than did other internists, suggesting the policy makers need to consider the influence of the hospital setting on the level of inpatient utilization. Further research on the causality of this relationship and its generalizability appears a strong priority.

Ambulatory Care Facilities↗
PubMed1981

Validity, reliability and implications of an index of inpatient severity of illness.

We discuss statistical characteristics of AS-SCORE, a recently developed index of illness severity for medical patients. The acronym "AS-SCORE" indicates the five major attributes of the index: age, system involved, stage of the disease, complications and response to therapy. The reliability of both the four-class system (k = .84) and the additive point scoring system (r = .92) was substantiated by two judges who independently classified and scored 105 records. We also tested the content validity of the four-class system and found that as severity increased there was a concomitant increase in hospital charges, laboratory charges, length of stay, number of consultations and mortality rates. In addition, we performed a regression analysis to determine the relative contributions of each of the attributes to the AS-SCORE value. We describe how we used the AS-SCORE severity of illness index to compare physician practice patterns and we suggest several other potential uses. We concluded that the AS-SCORE index is a reliable, valid and useful prototype method to assess differences in severity of illness for medical patients.

Abstracting and Indexing↗
PubMed1983

A cross-national study of differences in length of stay of patients with cardiac diagnoses.

To determine the reason for large regional differences in average hospital length of stay shown in federal discharge abstract data, the medical records of 482 cardiac patients from hospitals belonging to two metropolitan area PSROs of Baltimore, Maryland, and 438 cardiac patients from hospitals in the Metropolitan area PSRO from Portland, Oregon, were reviewed, stratified by diagnosis and complications, and compared for length of stay. Cardiac patients were hospitalized between 2.5 and 7 days longer in Baltimore than in Portland. Federal data on length of hospital stay were basically correct for the diagnostic categories studied. Length-of-stay differences could not be explained by patient differences and appeared to be due to differences in physician practice patterns.

Aged↗
PubMed1989

"How might a low-cost hospital system look?" Lessons from the Rochester experience.

An innovative, collaborative approach to promoting the effective and efficient delivery of hospital services and to maintaining the solvency of the nine participating hospitals in the greater Rochester, New York area has been successful. An evaluation of the early years (1980-1984) of the Hospital Experimental Payments Program (HEP) shows: 1) per capita hospital costs in Rochester increased at half the rate of increase of the national average; 2) by 1984, per capita hospital expenditures were at $446 compared with $521 nationally; 3) cost containment was achieved through a wide array of strategies such as changes in hospital resource allocation and physician practice patterns; and 4) during the same period, quality and access remained stable or improved. This project demonstrates that through self-control, hospitals can become efficient providers of health care.

Cost Control↗
PubMed1989

Physician supply and Medicaid participation. The causes of market failure.

This paper offers an explanation for the counterintuitive relationship between physician competition and Medicaid participation found by many investigators. Contrary to standard predictions, a number of studies have found strong negative relationships between the supply of physicians and Medicaid participation and equally strong positive relationships between supply and the concentration of Medicaid patients in small numbers of large Medicaid practices. The model advanced here argues that the residential segregation of Medicaid patients and differences in the minimum-efficient scale of practice for treatment of Medicaid and private patients create strong incentives for physicians in competitive urban areas to: 1) take either few Medicaid patients or 2) many and 3) make it costly to maintain a Medicaid practice share between these two extremes. In less competitive areas, these incentives are weaker, if not altogether absent.

Economic Competition↗
PubMed1990

The evolution of clinical policies.

Physicians use clinical policies as guidelines in the day-to-day management of patients. Some policies, by reducing otherwise complicated dilemmas to simple rules, encourage improved patient outcomes, but some are adopted without any evidence of benefit; some may be extended beyond their proper limitations and others are used despite accumulating data that they are at best useless and at worst dangerous. Four stages, development, diffusion, domination, and disillusionment, may be recognized in the evolution of clinical policies. Social rather than scientific forces play a central role, and at each step characteristic errors in both reasoning and research may occur. Attempts to improve patient outcomes by encouraging more appropriate research methodology and increasing the ability of physicians to critically appraise published studies may not be successful unless account is also taken of the social forces that influence the use and abuse of clinical policies.

Attitude of Health Personnel↗
PubMed1990

Simulated effects of incomes-based policies on the distribution of physicians.

As the United States enters a period of adequate physician supply (or even surplus), policies to ameliorate the maldistribution of physicians across communities and medical specialties will depend more heavily on explicit redistributional incentives. Targeted financial incentives are an obvious method for encouraging desirable practice choices. This paper simulates the effect of a series of incomes policies on the distribution of sample physicians across specialties, community sizes, and practice modes. The predictions are based on the estimated parameters of a simultaneous choice model for these three dimensions of a physician's practice. The results suggest that policies based on financial incentives are more effective than previous research has indicated.

Economics, Medical↗
PubMed1992

Recent developments and future issues in the use of health status assessment measures in clinical settings.

This paper provides a broad overview of the assessment of health status in clinical practice in three parts. Yesterday: The nation has undergone a paradigm shift in health-related thinking. The former paradigm emphasized only disease; the new emphasizes health, functioning, well-being, and disease. Measures of health and disease have evolved to reflect the new paradigm. Many are designed for clinical settings, based on measurement science, and are relatively brief. These newer measures have been used to document the natural history of disease, evaluate treatment effectiveness, and improve clinical case management. Today: Two barriers block full-scale use in clinical settings. The first barrier involves the meaning and interpretation of health status scores. Patients' scores are influenced by several types of patient mix variables and the timing of measurements. Interpretation is enhanced by valid normative data displaying the variability in health status among homogenous patient groups. The second barrier is utilization and mainstreaming. It involves all of the issues associated with changing the day-to-day behavior of clinicians and providers' routine processes to facilitate routine use of health status measures in clinical settings. Tomorrow: In the next decade, the nation will attempt to overhaul the health care system. As it does so, it will struggle with many issues: 1) clarifying the true aim of health care; 2) standardizing measures of health across patients, providers, and settings to evaluate benefit; 3) establishing cause and effect among structural-input factors, care delivery processes, and health outcomes valued by society; and 4) determining if and when cost containment actions have adverse effects on health outcomes. In this context, the importance of interpreting change in health status has a central role.

Activities of Daily Living↗
PubMed1992

Benefits and obstacles of health status assessment in ambulatory settings. The clinician's point of view. The Dartmouth Primary Care COOP Project.

In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

Activities of Daily Living↗
PubMed1992

Assessing physicians' compliance with guidelines for Papanicolaou testing.

In this study, population-based data were used to examine the appropriateness of Papanicolaou (Pap) testing from the perspective of the women being tested and their physicians. The approach used is unique in its assessment of overtesting and undertesting in the primary care setting. From the data base of the province of Manitoba's universal health insurance plan, 4-year health histories (1981 to 1984) were constructed for each woman from a random sample of the population of women who, in 1982, were between the ages of 25 to 64 years (n = 22,287). At the last visit to a general practitioner, gynecologist, or general surgeon in 1984 (termed the current visit), the authors determined whether a Pap test was given for each woman. Using decision rules from a Canadian task force report on cervical screening and previous health history, the authors evaluated the appropriateness of screening by determining whether a Pap test was given and was needed, or whether a women who had not received a Pap test required one. Overall, 55.7% of women were tested appropriately. Of the 5352 women who received a Pap test at the current visit, 62.8% were overtested. Of the 16,935 women not tested at the current visit, 38.5% required screening (i.e. were undertested). Characteristics of a physician's practice that were significantly related to compliance with the guidelines included having a high proportion of patients visiting for obstetric or gynecologic reasons. Variables that were associated with negative compliance were 1) being a gynecologist; and 2) having a high proportion of patients who lived in inner city or rural areas. Because physicians are paid a fee for every Pap smear taken and the guidelines were well disseminated, these results should be reasonably representative of fee-for-service practice in North America, where preventive care is not subject to user charges. This study supports previous findings that a passive approach to dissemination of guidelines is insufficient to effect practice.

Adult↗
PubMed1996

Physician practice style and rates of hospitalization for chronic medical conditions.

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P < 0.0001) and social (P < 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r = .34, P = 0.03) and social (r = .36, P = 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

Adult↗
PubMed1996

The relationship between resource constraints and physician problem solving. Implications for improving the process of care.

OBJECTIVES: Research suggests that physicians will engage in more vigilant problem-solving under conditions of resource constraints than under conditions of resource slack. Increased vigilance related to physicians' clinical strategies enhances care by disposing physicians toward more optimal care choices. The authors examine whether pressures for clinical resource constraints encourage increased and sustained vigilance in problem-solving among cardiologists treating acute myocardial infarction. METHODS: The physician problem-solving process is reconstructed from the medical records of all eligible cases of acute myocardial infarction treated by the physician sample set over a 6-year period. The sample period encompasses phases of both resource slack and resource constraints. The Herfindahl index is used to measure the relative amount of vigilant problem-solving activity exhibited in each of five major tactical areas of the physician care strategies in each year of the study. RESULTS: The results support the hypothesis that resource constraints initially promote a shift to increased vigilance in physician problem-solving. Only one of the five major tactical areas, however, is characterized by sustained vigilance over time. The other areas are, instead, associated with a substantial reduction in vigilant activity after the initial peak period. CONCLUSIONS: The results suggest that resource constraints do set the stage for improved clinical decision-making. Sustained vigilance, however, appears to apply only to those portions of the care strategy for which the physician can draw a clear link between optimizing clinical activity and reducing resource consumption. For those portions of the care strategy for which the physician cannot establish a clear link, ongoing pressures to conserve resources results in reduced vigilance and a potential reduction in quality of clinical decision-making.

Cardiology↗
PubMed1999

Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association.

BACKGROUND: Many internal medicine physicians report both primary and secondary specialties in the American Medical Association (AMA) Physician Masterfile. Usually, those represent combinations of general internal medicine and medical subspecialty practice. Whether reported specialty combinations can be used to assess the contribution of specialists to primary care is unknown. OBJECTIVES: To examine whether internists' primary and secondary specialties reported in the Masterfile reflect the amount of primary care that they provide, and whether changes over time in internists' reported specialties reflect changes in primary care provision. DESIGN: The Masterfile was used to identify internists' reported specialties in 1992 and in 1996. A mail questionnaire was used to assess the primary care content of physicians' practices. The association between reported specialties and the amount of primary care provided was evaluated using analysis of variance. SUBJECTS: A stratified random sample of internists in active clinical practice. MEASURES: The percentage of visits which were for the general medical care of patients for whom the physicians maintained ongoing responsibility. In addition, how often the physicians initiated the provision of preventive care for their regular patients, provided general medical care to these patients, and organized and coordinated the care received by these patients from other providers. RESULTS: There was a strong association between the internists' primary and secondary specialties reported in the Masterfile and measures of the primary care content of physicians' practices (P < 0.0001). In contrast, changes over time in internists' reported specialties were not associated with physicians' assessments of changes in the primary care content of their practices. CONCLUSIONS: Aggregate estimates of the availability of primary care in the US could be adjusted by taking into account the primary and secondary specialties reported by internal medicine physicians in the AMA Physician Masterfile.

American Medical Association↗
PubMed1999

Physician enthusiasm as an explanation for area variation in the utilization of knee replacement surgery.

BACKGROUND: Explanations for regional variation in the use of many medical and surgical treatments is controversial. OBJECTIVES: To identify factors that might be amenable to intervention, we investigated the determinants of regional variation in the use of knee replacement surgery. RESEARCH DESIGN: We examined the effect of the following factors: characteristics and opinions of surgeons; family physicians and rheumatologists; patients' severity of disease before knee replacement; access to knee-replacement surgery; surgeons' use of other surgical treatment; and county population characteristics. OUTCOMES MEASURE: County utilization rates of knee replacement in Ontario, Canada. RESULTS: Counties that had higher rates of knee replacement had older patients (P = 0.0001), higher percentage of medical school affiliated hospital beds (P = 0.04), with more male (P = 0.02) non-North American trained referring physicians (P = 0.002) and orthopedic surgeons who had higher propensities to operate and better perceptions of outcome (P = 0.0001). CONCLUSIONS: After controlling for population characteristics and access to care (including the number of hospital beds, and the density of orthopaedic and referring physicians), orthopaedic surgeons' opinions or enthusiasm for the procedure was the dominant modifiable determinant of area variation. Thus, research needs to focus on the opinions of surgeons which may be important in reducing regional variation for knee replacement.

Adult↗
PubMed1998

Comparison of parental and health care professional preferences for the acellular or whole cell pertussis vaccine.

OBJECTIVE: To compare the preferences of mothers, physicians and nurses for use of a new generic acellular pertussis vaccine which is less reactogenic than and as effective as a conventional whole cell vaccine, but which would require multiple injections rather than a single injection to deliver all other recommended vaccines. METHODS: A convenience sample of 400 mothers of 1-month-old infants, 100 immunizing physicians and 100 immunizing nurses were surveyed over a 2 1/2-month period. Information about pertussis and both whole cell and acellular pertussis vaccines was provided, and a questionnaire was used to assess knowledge and attitudes about pertussis vaccine, vaccine preference and reasons for selection. In addition to their own preferences health care professionals were asked to predict which vaccine mothers would prefer and to predict why mothers would choose a particular vaccine. RESULTS: Mothers preferred the acellular vaccine over the whole cell vaccine by a nearly 2:1 margin (57.3% vs. 29.5%). Health care professionals preferred the whole cell vaccine by the same 2:1 margin (61.1% vs. 29.3%). Only 19.1% of health care professionals predicted that mothers would accept the acellular vaccine if it meant multiple injections. More mothers were concerned by the common reactions caused by the whole cell vaccine (75.8% vs. 52%; P = 0.001); more health care professionals felt that multiple injections were stressful (89% vs. 70%; P = 0.001) and that they could be associated with long term effects (17% vs. 8.8%; P = 0.003). More health care professionals than mothers said that the need for multiple injections would influence their decision to accept the acellular vaccine (76.5% vs. 38.3%; P = 0.001). CONCLUSIONS: Mothers prefer a less reactogenic vaccine product even if it requires multiple injections. Health care professionals are more concerned about multiple injections and are poor predictors of mothers' vaccine preference. Multiple injections may be more a barrier to immunization for health care professionals than for mothers.

Choice Behavior↗