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PubMed2002

Measuring patients' trust in their primary care providers.

Existing scales to measure trust in physicians have differing content and limited testing. To improve on these measures, a detailed conceptual model was constructed and a large item pool (n = 78) was generated following a detailed conceptual model and expert review. After pilot testing, the best-performing items were validated with a random national sample (n = 959) and a regional sample of HMO members (n =1,199). Various psychometric tests produced a 10-item unidimensional scale consistent with most aspects of the conceptual model. Compared with previous scales, the Wake Forest physician trust scale has a somewhat improved combination of internal consistency, variability, and discriminability. The scale is more strongly correlated with satisfaction, desire to remain with a physician, willingness to recommend to friends, and not seeking second opinions; it is less correlated with insurer trust, membership in managed care, and choice of physician. Correlations are equivalent with lack of disputes, length of relationship, and number of visits [corrected].

Clinical Competence↗

PubMedDate not supplied

An overview of Medicare reimbursement regulations for advanced practice nurses.

The federal government spends nearly 15% of the budget on Medicare services annually, and advanced practice nurses are eligible for reimbursement from that pool. The regulations governing reimbursement are complex because of the social, political, and financial pressures involved in their development. Although economic viability and due diligence considerations make it incumbent on advanced practice nurses to understand the rules, the profession, as a whole, has knowledge deficits in this area. The essentials of regulatory development and structure are reviewed and considerations for optimizing reimbursement are described.

Government Regulation↗

PubMedDate not supplied

Beyond Adam Smith and Marcus Welby: how CPARS works. Part 2.

Part 2 of this article details the workings of the Claims Pooling, Analysis and Reporting System (CPARS) piloted by the Lehigh Valley Coalition for "prudent purchasers" across Pennsylvania. Hardware, software, data storage and sample size are among the issues covered by the Coalition's President, who believes CPARS is an easy, cheap way for employers to get the reality-based data analysis they need to support a prudent purchaser strategy for containing health care costs.

Computers↗

PubMed1989

The external costs of a sedentary life-style.

Using data from the National Health Interview Survey and the RAND Health Insurance Experiment, we estimated the external costs (costs borne by others) of a sedentary life-style. External costs stem from additional payments received by sedentary individuals from collectively financed programs such as health insurance, sick-leave coverage, disability insurance, and group life insurance. Those with sedentary life-styles incur higher medical costs, but their life expectancy at age 20 is 10 months less so they collect less public and private pensions. The pension costs come late in life, as do some of the medical costs, and so the estimate of the external cost is sensitive to the discount rate used. At a 5 percent rate of discount, the lifetime subsidy from others to those with a sedentary life style is $1,900. Our estimate of the subsidy is also sensitive to the assumed effect of exercise on mortality. The subsidy is a rationale for public support of recreational facilities such as parks and swimming pools and employer support of programs to increase exercise.

Adult↗

PubMed1999

Factors associated with implementation of preventive care measures in patients with diabetes mellitus.

BACKGROUND: There is only limited information on the extent to which physicians' characteristics affect the level of care and implementation of guidelines in patients with diabetes mellitus. OBJECTIVE: To identify physician characteristics associated with implementation of measures for preventive care in patients with diabetes mellitus and the distribution of implementation of these measures among them. PATIENTS AND METHODS: A retrospective chart audit of 519 patients eligible for health maintenance organization insurance on December 31, 1994, representing patients with diabetes receiving care from 22 primary care physician-providers of a managed care medical group in suburban North Los Angeles, Calif, and seen by physicians between January 1993 and December 1994. A short retroactive questionnaire for participating physicians was also used. The outcome measures were (1) measurement of serum high-density lipoprotein cholesterol; (2) urinalysis for the detection of proteinuria; and (3) ophthalmology referral for dilated fundus examination. RESULTS: Over a period of 2 years 78% of the patients had a high-density lipoprotein cholesterol determination, 80% had a test for proteinuria, and 62% were referred to an ophthalmologist. After adjustment for patient pool differences, physicians who were perceived by the administration of the medical group as "fast," based on a blinded evaluation of their number of patient encounters per unit time, had an odds ratio of 0.60 (95% confidence interval [CI], 0.37-0.95; P=.03) to obtain a high-density lipoprotein cholesterol determination in their patients and an odds ratio of 0.53 (95% CI, 0.32-0.87; P=.01) to test their patients for proteinuria. In patients requiring insulin, of fast physicians, the odds ratio for a referral for ophthalmology screening was 0.25 (95% CI, 0.07-0.85; P= .03). Duration of time in practice of over 15 years and disagreement with practice guidelines were associated with better outcomes. There was no association between physician sex, internal medicine training, or number of patients with diabetes in the practice and the implementation of outcomes. There was a highly significant association between the implementation of an outcome and the implementation of the other 2, resulting in a nonhomogeneous distribution of health care delivery. Physicians' estimate of their rate of implementation of outcomes, as assessed by the questionnaires, overestimated their actual performance while being in proportion with the documented rates. Most physicians took responsibility for the nonimplementation, accepting that it was an oversight on their part as opposed to an encounter with patient resistance. CONCLUSIONS: Most physicians believe that the lack of implementation of the measures for preventive care in patients with diabetes mellitus is an oversight. The oversight is more prevalent in the practices of busy physicians. The result is a nonhomogeneous distribution of health care. Computer reminders might be the solution.

Diabetes Complications↗

PubMedDate not supplied

National health reform advocates retrench and prepare for Medicare.

With the failure of President Truman's efforts to pass compulsory health insurance for all, national health reform (NHR) advocates began to redirect their political attention to a politically powerful group of Americans who were simultaneously vulnerable from a health care point of view--the elderly. This effort culminated in the passage of Medicare under President Johnson. This article will focus on antecedents to passage of Medicare that can be found in the Eisenhower and Kennedy administrations. It will also discuss other facets of health reform proposals from the Eisenhower administration. While most proposals never became law, the legislative intent of many of them--outlawing cancellation of policies, a minimum standard health benefit package, establishment of regional health authorities, preference for prepayment plans, and establishment of a reinsurance pool administered by the federal government--is currently under active discussion by the Clinton health reform task forces.

Aged↗

PubMed1997

Managed care in the United States.

Medical care in the United States continues to consume an increasing amount of the Gross Domestic Product. To control the rising costs of health care many industries have turned to a controlled form of financing and delivery of health care--often referred to as managed care. Many types of managed care exist, including preferred provider organizations (PPO), exclusive provider organization (EPO), and health maintenance organizations (HMO). HMOs involve prepaid premiums, limited panels of providers and assumption of financial risk on the part of the providers. A variety of HMOs are currently operating in the United States. Managed care involves taking risks by those who administer it. Some methods of controlling patient and physician behaviour by taking risks are capitation, risk pools and withholds. With capitation the physician is paid a 'per member per month' fee regardless of whether the patient uses the service. Risk pools are concerned with who shares the risk; for example, the primary physician shares the financial risk with specialists. Withholds involve a fee-for-service with a portion withheld which may be returned to the provider if he/she is parsimonious. A concern expressed about HMOs is the possibility of restricted services. Moreover, hospital expenses make up a large portion of the total health care dollar. In 1995 the average length of stay for a Medicare patient was 6.1 days as opposed to 3.9 days for the non-Medicare patient. Indeed, HMOs were the leaders in the development of same-day surgery and out-patient treatment. Increasingly, in the United States, public and social insurance plans are turning to managed care as a method to control health care expenditure. Some government insurance plans, such as Medicare and Medicaid, also increasingly offer managed health options. The trend, for now, in the United States increases enrollment in managed care plans. Although this is occurring at a rapid pace, managed care will probably not be the final solution to provision of medical care in the United States.

Cost Control↗

PubMedDate not supplied

Lessons for providers from a purchaser's perspective.

On Jan. 1, 1991, the John Hancock National Transplant Program (JHNTP) became operational, matching kidney, heart, liver, and bone marrow transplant patients from a potential pool comprising more than two million covered lives, with organ transplant programs at 14 institutions across the country. Conceptualizing the program and selecting and contracting with the transplant centers took more than 18 months. This article shares some of the insights from that process that are pertinent to providers of transplant services and to others considering entering this or other forms of specialized contracting.

Competitive Bidding↗

PubMed2003

Policy implications of an annuity approach to integrating long-term care financing and retirement income.

The authors consider an integrated income and disability annuity as an alternative framework for long-term care financing, show that pooling disability and mortality risks can reduce the need for medical underwriting, and discuss private and public implications. Data from the National Mortality Followback Survey of 1986 were used to simulate current underwriting and minimal underwriting, excluding only those already eligible for benefits. Remaining disability, life expectancy, and premiums are compared under both underwriting assumptions. Under minimal underwriting, 98% of persons age 65 would be eligible to purchase disability protection through an integrated annuity, versus 77% under current underwriting. Premiums for both the income and disability components were lower with minimal underwriting. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the long-term care insurance market. Public policy should avoid the distortion of choices created by focusing exclusively on an insurance model.

Aged↗

PubMed1994

Government participation in physician negotiations in German economic policy as applied to universal health care coverage in the United States.

Systems of universal health care coverage in western industrial societies have usually established some form of government participation in negotiations over physician payment as a means of controlling costs. In the Federal Republic of Germany, a mixed private and public body. Concerted Action in Health Care sets a 'target' for physician and 'sickness fund' negotiators. This indirect form of government participation is effective in 'linking' fees with utilization during negotiations, avoiding inflationary trends inherent in fee-for-service systems. This target-setting factor is a necessary complement to negotiation of a 'pool' of money, wage level and technological adjustment factors, as contained in a model of German economic health care policy. These four elements of economic policy are recommended as cost control measures for office-based physician payments under conditions of universal health care coverage in the United States. Indirect government participation through setting 'targets' for negotiations is seen as consistent with established American institutional practices.

Cost Control↗

PubMed2001

Effects of cost-containment strategies within managed care on continuity of the relationship between patients with depression and their primary care providers.

BACKGROUND: Continuity of the relationship between patients and primary care providers (PCPs) is an important component of care from the consumer perspective that may be affected by variation in cost containment strategies within managed care. OBJECTIVE: To evaluate the effects of cost containment strategies on the continuity of the relationship between their patients with depression and their PCPs. DESIGN: Observational analysis of a 2-year panel of depressed patients who participated in a quality improvement intervention trial in 46 managed care practices. PARTICIPANTS: One thousand two hundred four patients with current depression who enrolled in a longitudinal study, completed the baseline survey, and were followed for 2 years. MAIN MEASURES: The dependent variable is probability of continuing the relationship between patients and their PCPs; explanatory variables include individual patient mental health benefits and cost-sharing, individual provider financial incentives, supply-side managed care policies, and patient ratings of the care received. RESULTS: The average duration of the patient-PCP relationship was significantly longer among depressed patients who initially had less generous benefits for specialty care (higher copays, P = 0.02 and fewer visits covered, P = 0.002) and for patients whose PCPs received a performance-based salary bonus from a risk pool (P = 0.07). CONCLUSIONS: For depressed patients, cost containment strategies, such as limits on specialty benefits and presence of clinician bonus payments typically used within managed care may increase, rather than decrease, PCP continuity. Whether increased PCP continuity is a desirable outcome depends on whether health care systems can provide high quality primary care and this merits further study.

Adult↗

PubMed2004

Graduated driver licensing for reducing motor vehicle crashes among young drivers.

BACKGROUND: Graduated driver licensing (GDL) has been proposed as a means of reducing crash rates among novice drivers by gradually introducing them to higher risk driving situations. OBJECTIVES: To examine the effectiveness of GDL systems in reducing crash rates of young drivers. SEARCH STRATEGY: Studies were identified through searches of MEDLINE, EMBASE, CINAHL, Healthstar, Web of Science, NTIS Bibliographic Database, TRIS Online, SIGLE, the World Wide Web, relevant conference proceedings, consultation with experts and authors, and reference lists. The search was not restricted by language or publication status. SELECTION CRITERIA: Studies were included if: 1) they compared outcomes pre- and post-implementation of a GDL program within the same jurisdiction, 2) comparisons were made between jurisdictions with and without GDL, or 3) both. Studies had to report at least one objective, quantified outcome. Two reviewers independently screened searches and assessed the full text of potentially relevant studies for inclusion using a standard form. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second. Additional data were requested from authors. Results were not pooled due to substantial heterogeneity between studies. Percentage change was calculated for each year after the intervention, using one year prior to the intervention as the baseline rate. Results were adjusted by internal controls. Analyses were stratified by different denominators (population, licensed drivers). Results were calculated for the different crash types (overall, injury, fatal, night-time, alcohol, and those resulting in hospitalization). Results were presented for 16 year-olds alone and all teenage drivers combined. MAIN RESULTS: We included 13 studies evaluating 12 GDL programs that were implemented between 1979 and 1998 in the US (n=7), Canada (3), New Zealand (1), and Australia (1). Programs varied in their restrictions during the intermediate stage: e.g. night curfews (8); limitations of extra passengers (2); roadway restrictions (1). Based on the Insurance Institute for Highway Safety classification scheme, no programs were good, six were acceptable, five were marginal, and one was poor. Reductions in crash rates were seen in all jurisdictions and for all crash types. Among 16 year-old drivers, the median decrease in per population overall crash rates during the first year was 31% (range 26-41%). Per population injury crash rates were similar (median 28%, range 4-43%). Results for all teenage drivers, rates per licensed driver, and rates adjusting for internal controls were generally reduced when comparing within jurisdictions. REVIEWERS' CONCLUSIONS: The existing evidence shows that GDL is effective in reducing the crash rates of young drivers, although the magnitude of the effect is unclear. The conclusions are supported by consistent direction of the findings, and the temporal relationship and plausibility of the association. The reviewers have made recommendations for primary research on GDL (e.g. study methods, standardized reporting of outcomes and results, long-term follow-up). The project has also shown what is needed to carry out systematic reviews of observational studies (e.g. quality assessment instruments).

Accidents, Traffic↗

PubMed1994

The hospital response to Medicare's Prospective Payment System: an econometric model of Blue Cross and Blue Shield plans.

This paper presents an empirical analysis of the impact that resulted from phase-in of Medicare's Prospective Payment System (PPS) on hospital utilization and payments for the Blue Cross and Blue Shield (BCBS) plans. A pooled cross-sectional time series econometric model was specified and estimated using quarterly hospital utilization and payments of the BCBS plans over the period 1980 to 1987. The results indicate that the implementation of PPS was significantly associated with a lower rate of hospital admissions, days and deflated inpatient payments for the BCBS plan members under age 65. A 1% increase in the proportion of hospital days reimbursed under PPS resulted in a .032% decrease in BCBS plan admissions per 1,000 members, a 0.017% decline in days per 1,000 members and a 0.016% decline in deflated inpatient payment per 1,000 members. The reductions in hospital utilization resulted in lower payments by BCBS plans to participating hospitals suggesting a positive spill-over effect of PPS for private insurers. This research underscores the importance of interaction between federal health policy and the private health insurance market.

Blue Cross Blue Shield Insurance Plans↗

PubMed1999

How the World Trade Organisation is shaping domestic policies in health care.

High up on the agenda of the World Trade Organisation (WTO) is the privatisation of education, health, welfare, social housing and transport. The WTO's aim is to extend the free market in the provision of traditional public services. Governments in Europe and the US link the expansion of trade in public services to economic success, and with the backing of powerful medico-pharmaceutical, insurance, and service corporations, the race is on to capture the share of gross domestic product that governments currently spend on public services. They will open domestic European services and domestic markets to global competition by government procurement agreements, dispute-settlement procedures, and the investment rules of global financial institutions. The UK has already set up the necessary mechanisms: the introduction of private-sector accounting rules to public services; the funding of public-sector investment via private-public partnerships or the private finance initiative; and the change to capitation funding streams, which allows the substitution of private for public funds and services. We explain the implications of these changes for European public-health-care systems and the threat they pose to universal coverage, solidarity through risk-pooling, equity, comprehensive care, and democratic accountability.

Delivery of Health Care↗

PubMed1993

Ultrasound measurements on os calcis: precision and age-related changes in a normal female population.

We performed ultrasound measurements in the calcaneus of 512 healthy women. Broadband ultrasonic attenuation (BUA) and speed of sound (SOS) were obtained with a Lunar Achilles ultrasonic instrument. Subjects studied were one group of 67 women working in our hospital (group A) and two groups which are part of two large prospective cohort studies (groups B and C). Group B consisted of 244 women aged 31-79 years randomly selected from a large insurance company, and group C consisted of 201 women aged 74-91 years randomly selected from the electoral rolls. Dual-energy X-ray absorptiometry (DXA) measurements of femoral neck and total body were performed with a Hologic QDR 2000 for group B and with a Lunar DPX Plus for group C. The in vitro precision of the Achilles, estimated by measuring a phantom daily for 45 days, was 0.84% for BUA and 0.12% for SOS. We assessed the in vivo short-term precision in 20 healthy volunteers working at the hospital, measured three times each. The coefficients of variation were 0.93% (+/- 0.21) for BUA and 0.15% (+/- 0.03) for SOS. The precision error was compared with the true variation, to obtain a standardized coefficient of variation. We analysed the three groups pooled together (n = 512) and found for BUA an average 20% decrease and for SOS a 5% decrease between the ages of 20 and 90 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

Increased cholecystectomy rates among Medicare patients after the introduction of laparoscopic cholecystectomy.

A study was undertaken of Medicare claims coded for cholecystectomy and those coded for laparoscopic cholecystectomy for the four year period 1990-1993 in New York State. During this time period there was a 28.12% increase in total cholecystectomies performed and an increase in the proportion of laparoscopic cholecystectomies from 15.86% to 50.0%. The increase in total cholecystectomies appears to be driven by a dramatic increase in laparoscopic procedures. Possible reasons for this increase include the performance of laparoscopy on patients previously assessed as too risky to undergo the conventional procedure, laparoscopy on mildly symptomatic patients who had previously put off a perceived higher risk open procedure and a possible broadening of indications for gallbladder surgery. The dramatic increase in the numbers of cholecystectomies performed in the early 1990s may be due in part to procedures performed on a large pool of procrastinating mildly symptomatic patients. If this is the case, then these increased rates should decline to baseline levels as soon as this pool of patients is exhausted. However, if surgeons are performing laparoscopy on asymptomatic patients with gallstones, then these rates may well be sustained. Such a broadening of indications for gallbladder surgery is of concern to many and has prompted the issuance of guidelines concerning the treatment of gallstones. Any broadening of indications for gallbladder surgery also has significant implications for health care costs and the use of health care resources.

Aged↗

PubMed1998

Identifying donor concerns to increase live organ donation.

Increasing organ donation from live donors is a means to increase the pool of kidneys available for transplantation. To increase the number of live kidney donors, the major concerns of donors must be determined and addressed. This article describes the health and socioeconomic concerns of 61 live kidney donors from the Johns Hopkins Institutions between February 1, 1995 and December 1, 1997. Seventy-five percent of donors reported they had concerns, the most common ones being the effect of donation on their future health, how many work days they would miss, the ability to return to the same activities, and the pain they would experience. Other reported concerns consisted of fear of dying, the risks to a future pregnancy with one kidney, the fear that a son or daughter may need a kidney in the future, and the impact of donation on the family health insurance premium. Interventional strategies including the use of the laparoscopic donor nephrectomy procedure are offered to address these concerns.

Absenteeism↗

PubMed2000

Empirical evidence on the demand for carve-outs in employment group mental health coverage.

BACKGROUND AND AIMS OF THE STUDY: The use of specialized behavioral health companies to manage mental/health benefits has become widespread in recent years. Recent studies have reported on the cost and utilization impacts of behavioral health carve-outs. Yet little previous research has examined the factors which lead employer-based health plans to adopt a carve-out strategy for mental health benefits. The examination of these factors is the main focus of our study. Our empirical analysis is also intended to explore several hypotheses (moral hazard, adverse selection, economies of scale and alternate utilization management strategies) that have recently been advanced to explain the popularity of carve-outs. METHODS: The data for this study are from a survey of employers who have long-term disability contracts with one large insurer. The analysis uses data from 248 employers who offer mental health benefits combined with local market information (e.g. health care price proxies, state tax rates etc), state regulations (mental health and substance abuse mandate and parity laws) and employee characteristics. Two different measures of carve-out use were used as dependent variables in the analysis: (1) the fraction of health plans offered by the employer that contained carve-out provisions and (2) a dichotomous indicator for those employers who included a carve-out arrangement in all the health plans they offered. RESULTS: Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. Our results gave less consistent support to the argument that carve-outs are demanded to control adverse selection, though only a few variables provided a direct test of this hypothesis. The role of economies of scale (i.e., group size) and the effectiveness of alternative strategies for managing moral hazard costs (i.e., HMOs) were confirmed by our results. DISCUSSION: We considered a number of different hypotheses concerning employers' demands for mental health carve-outs and found varying degrees of support for these hypotheses in our data. Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. LIMITATIONS: Our database includes a small number of relatively large employers and is not representative of employers nationally. Our selection criteria, concerning size and the requirement that some employees are covered by LTD insurance, probably resulted in a study sample that offers richer benefits than do employers nationally. Our employers also report a higher percentage of salaried employees relative to the national data. Another deficiency in the current study is the lack of detailed information on the socio-demographic and behavioral characteristics of covered employees. Finally, the cross-sectional nature of our analysis raises concerns about susceptibility of our findings to omitted variables bias. IMPLICATIONS FOR FURTHER RESEARCH: Research with more information on covered employee characteristics will allow for a stronger test of the general hypothesis that factors associated with a higher demand for services are also associated with a higher demand for carve-outs. Also, future analyses that capture the experience of states that have recently passed mandate and parity laws, and that use pooled data to control for omitted variables bias, will provide more definitive evidence on the relationship between these laws and carve-out demand.

Journal Article↗