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PubMed2000

Are women being counseled about estrogen replacement therapy?

The U.S. Preventive Services Task Force and several medical professional associations have published guidelines recommending that all women be counseled around the time of menopause about the benefits and risks of estrogen replacement therapy (ERT) so that they may make an informed decision about its use. Despite the proliferation of ERT counseling guidelines, little is known about whether these guidelines are being followed. There were 1,500 female members (aged 40 to 69) of a Northeastern U.S. Independent Practice Association--model Health Maintenance Organization who were surveyed, and 51 percent reported that a health care provider had talked with them about the benefits and risks of ERT. In multivariate analyses, a woman's demographic characteristics (age, race, income), stage of menopause, severity of menopausal symptoms, and body weight were the major correlates of receipt of ERT counseling. Women at greater risk for osteoporosis or heart disease were no more likely to be counseled, although those with diagnosed osteoporosis were. What appear to be selective ERT counseling practices will need to be modified if the goal of providing universal ERT counseling to midlife women is to be attained.

Adult↗

PubMed1992

Contractual arrangements between residency programs and HMOs.

BACKGROUND: Although one out of seven health maintenance organizations (HMOs) is directly involved in graduate medical education (GME), either as an accredited sponsoring organization or through a contractual agreement with an academic medical center or teaching hospital to serve as an ambulatory rotation site, relatively little is known about the extent to which HMOs have provider contracts with faculty or residents of GME programs. Such provider contracts are not agreements to collaborate on the education of residents, but rather contractual arrangements under which individual physicians or groups (who happen to be residents or faculty) agree to provide services to HMO enrollees in return for some form of compensation. METHODS: In 1990, the Group Health Association of America conducted a survey of a sample of residency training programs in family medicine, internal medicine, and pediatrics to ascertain the extent to which (1) residents and faculty of residency training programs are participating physicians in HMOs; and (2) HMO enrollees are serving as the patient base for GME in ambulatory settings. RESULTS: Overall, 42% of the residency program respondents indicated that they contract with HMOs to provide services to enrollees. Nearly two thirds (64%) of family practice programs have provider contracts as compared with 28% of pediatrics programs and 24% of internal medicine programs. Provider contracts with independent practice associations are by far the most common, followed by group, network, and staff model contracts, in that order. CONCLUSIONS: It is apparent that provider contractual arrangements between HMOs and primary care residency programs are quite common, especially in the area of family practice. These contractual arrangements have probably resulted in a more predictable and stable patient revenue base for residency programs. The long-term effects on provider practice styles and the financing of graduate medical education are less clear.

Contract Services↗

PubMed2000

Wrestling with typology: penetrating the "black box" of managed care by focusing on health care system characteristics.

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain--financial features, structure, care delivery and management policies, and products--and by key roles in the health care system--sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

Data Collection↗

PubMed1997

Why do patients of female physicians have higher rates of breast and cervical cancer screening?

OBJECTIVE: Women are more likely to receive breast and cervical cancer screening if they see female physicians. We studied whether this is due to differences between male and female physicians, or to differences in their patients. SETTING: Large midwestern, independent practice association style of health plan. DESIGN: We surveyed male and female primary care physicians matched for age and specialty and a stratified random sample of three of each physician's women patients. Physicians reported on their practice setting, their attitudes and practices regarding prevention, and their comfort and skill with various examinations. Patients reported on their sociodemographic characteristics, their attitudes and practices regarding prevention, and their preferences for physician gender. Claims data were used to calculate mammography and Pap smear screening rates for the physicians. PARTICIPANTS: We studied 154 female and 190 male internists and family physicians and 794 of their patients. MEASUREMENTS AND MAIN RESULTS: We compared the responses of male and female physicians and their patients and used multivariable analysis to identify the patient and physician factors that accounted for the differences in screening rates between male and female physicians. Female physicians were more likely to ask new patients about components of prevention, to believe in the effectiveness of mammography, to feel more personal responsibility for ensuring that their patients received screening, and to report more comfort in performing Pap smears and breast examinations. Patients of female physicians were more educated and less likely to be married, but did not differ in other sociodemographic characteristics. They had similar attitudes and practices regarding prevention, except that patients of male physicians were more likely to smoke. Significantly more patients of female physicians preferred a female for some component of care. In multivariable analyses, practice organization, patient preference for a female physician, and prevention orientation of female physicians accounted for up to 40% of screening rate differences between female and male physicians for Pap smears, and 33% for mammography. CONCLUSIONS: Differences in beliefs of male and female physicians and patient preference for a female provider contribute independently to the higher rate of breast and cervical cancer screening by female physicians.

Adult↗

PubMed1994

Use and effectiveness of transdermal nicotine in primary care settings.

OBJECTIVE: To assess the use and effectiveness of transdermal nicotine patches by smokers receiving care in primary care settings. DESIGN: Telephone survey of a convenience sample of patients. SETTING: Primary care settings in western New York. SUBJECTS: Two hundred eighty-four adult members of an independent practice association health maintenance organization who received a prescription for transdermal nicotine between January 1, 1992, and June 30, 1992. MAIN OUTCOMES: Patient reports regarding advice received from physicians about the use of the nicotine patch, cessation methods used in addition to the patch, usual daily use of the patch, side effects experienced while wearing the patch, and smoking behavior while using the patch and after discontinuing therapy. RESULTS: Most patients reported getting proper advice from their physician about how to use the nicotine patch and possible side effects. The majority of those who used the patch said they used it every day for 24 hours. Side effects associated with using the patch were common but did not cause many subjects to discontinue therapy. Half of the patients who had completed patch therapy were not smoking, including 43% of patients who had not been using the patch for 4 months or longer. CONCLUSION: Transdermal nicotine patches appear to be an effective cessation aid for smokers receiving care outside specialized smoking cessation programs. Proper pretreatment screening to identify patients who are motivated to stop smoking is critical to the success of nicotine patch therapy.

Administration, Cutaneous↗

PubMed1996

Use of clinical practice guidelines in managed care physician groups.

There is increasing interest in the use of clinical guidelines as a tool to improve the quality and cost-effectiveness of health care. Yet, relatively little data are available regarding the use of guidelines by health care provider organizations. We developed a written descriptive survey investigating the development, implementation, and evaluation of clinical guidelines that was administered to medical directors or their designees from physician medical groups and independent practice associations. Eighty-seven percent of physician organizations were reported to be developing or implementing clinical guidelines. The reasons most often cited for developing clinical guidelines were quality improvement and cost containment. Local expert opinion or judgment was rated as the most important influence in the development of clinical guidelines, followed by medical and scientific literature and externally developed guidelines. Feedback of information was the most popular method of increasing compliance with clinical guidelines, although 19% of physician organizations reported imposing sanctions on physicians who did not use guidelines. Most of the physician organizations surveyed have embraced clinical guidelines. Local development or adaptation of clinical guidelines may be common. There has been disproportionately little attention paid to guideline implementation and to evaluation of guideline effects relative to their development.

California↗

PubMed1999

Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective.

BACKGROUND: Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective. METHODS: This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/ independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated. RESULTS: A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity. CONCLUSION: In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study.

Activities of Daily Living↗

PubMed1998

Selection and exclusion of primary care physicians by managed care organizations.

CONTEXT: Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory. OBJECTIVE: To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care. DESIGN: Cross-sectional mail survey of a probability sample of primary care physicians. SETTING: A total of 13 large urban counties in California. PARTICIPANTS: Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice. MAIN OUTCOME MEASURES: Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts. RESULTS: Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice. CONCLUSIONS: Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.

California↗

PubMed2004

Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting.

BACKGROUND: Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting. METHODS: In 2000, a self-administered survey was mailed to a stratified, random sample of 1340 PCPs in a large, network model health maintenance organization in California. RESULTS: The survey response rate was 67%. PCPs indicated that 79% of their standard-risk patients were screened for CRC. PCP-reported median rates of recommendation for the use of specific screening tests were 90% for FOBT and 70% for FS. In logistic regression models, perceived barriers to the use of FOBT and FS included patient characteristics (e.g., education) and PCP-related barriers (e.g., failure to recall that patients were due for testing). Perceived facilitators of the use of FOBT and FS included interventions targeting certain aspects of the health care system (e.g., reimbursement) and interventions targeting certain aspects of the tests themselves (e.g., provision of evidence of a test's effectiveness). Assignment of high priority to screening, integrated medical group (as opposed to independent practice association) affiliation, and the proportion of patients receiving routine health maintenance examinations were positively associated with reported test use. CONCLUSIONS: CRC screening tests appear to be underused in the managed care setting examined in the current study. The perceived barriers and facilitators that were identified can be used to guide interventions aimed at increasing recommendations for, as well as actual performance of, CRC screening.

Adult↗

PubMed1985

Use of outpatient somatic health services by patients who use or need mental health services in three provider plans.

A major topic in mental health (MH) research addresses the problem that patients who use mental health services have inappropriately high levels of somatic use, and examines whether provision of mental health services can decrease the inappropriate use (the so-called offset effect). However, the research showing higher somatic use by mental health patients has usually been unable to control for the patients' health status, or for their mental health status. In this paper we examine use of somatic health services by enrollees in three provider plans as a function of both mental health use and mental health need. In two of the provider plans (an HMO and a prepaid independent practice association), MH users used significantly more outpatient somatic services than non-MH patients, after control for age and sex, and after control for the number of chronic conditions they had. People with MH need, however, did not use significantly more MH services than those without MH need. In the third plan, a Blue Cross/Blue Shield type of plan, results were different; MH users did not have significantly higher somatic utilization after control for chronic conditions, and those with MH need did have significantly higher somatic utilization after control for age and sex, but not after control for the number of chronic conditions. These results suggest that the form of inappropriate use of outpatient somatic services, and the nature of an offset effect, may be specific to the type of insurance provided.

Adult↗

PubMed1990

Effects of HMOs on the creation of competitive markets for hospital services.

Why do health maintenance organizations (HMOs) use particular hospitals, and do they concentrate patients in hospitals where they obtain low prices? We answered these questions with a study of six HMOs in four large metropolitan areas in 1986. A two-part model was estimated for the probability that a hospital would be used and the demand for general inpatient admissions at hospitals that were used. Four staff-network plans in our study do shop for hospital services on the basis of price more than was generally believed. However, two independent practice association (IPAs) plans use more hospitals in the community and do not concentrate patients effectively at hospitals that offer the lowest prices.

Bed Occupancy↗

PubMed2004

Health promotion in physician organizations: results from a national study.

BACKGROUND: Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. CONCLUSIONS: Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.

Data Interpretation, Statistical↗

PubMed1982

Organizational and financial influences on patterns of surgical care.

Rates of surgery for similar patient groups are lower in well-established prepaid group plan forms of HMO than in either independent practice association forms of HMO or in traditional fee-for-service care arrangements. The biologic outcomes of care are at least as good in prepaid group plan settings as in other settings. The implications of these conclusions for the future are discussed.

Consumer Behavior↗

PubMedDate not supplied

Cost of acid peptic disorders in a managed-care organization.

The purpose of this study was to determine the cost of managing ambulatory patients with symptoms of acid peptic disorders in a managed-care organization under actual clinical conditions. Study data were collected in a large independent practice association model health maintenance organization in Gainesville, Florida, from prescription records maintained in a computerized database and from patient medical records. Patients had to be started on a histamine2-receptor antagonist (H2RA) or the proton pump inhibitor omeprazole between 1992 and 1994. A total of 113 patients qualified for inclusion in the study; 57 received H2RAs, 27 received omeprazole, and 29 received combination therapy. The costs of procedures, physician visits, and drug therapy were considered in the economic evaluation. Costs were evaluated using two methods: the capitation total cost (CTC) and the fee-for-service total cost (FSTC). The mean CTC and FSTC for managing a patient with acid peptic symptoms for 6 months were $382 +/- 356 (range, $14 to $1820) and $456 +/- 368 (range, $52 to $1925), respectively. Drug costs represented 52% of the total FSTC and 62% of the total CTC. Drug costs were followed by the costs for encounters with primary care physicians, endoscopy, referral to specialists, and upper gastrointestinal (UGI) tract procedures. Documented outcomes were available for 85 patients. Compared with patients receiving H2RAs (n = 41), patients receiving omeprazole (n = 18) had significantly lower FSTCs ($317 +/- 219 compared with $423 +/- 307, respectively); diagnostic testing costs (for endoscopy, $0 compared with $44 +/- 119, respectively; for UGI procedures, $22 +/- 42 compared with $55 +/- 54, respectively); physician encounter costs ($66 +/- 40 compared with $86 +/- 38, respectively); and referral to specialist costs ($0 compared with $18 +/- 60, respectively). Patients receiving omeprazole also had more positive clinical outcomes than patients receiving H2RAs (78% compared with 49%, respectively), resulting in a more favorable cost of producing a successful outcome compared with patients receiving an H2RA. The cost of success was $407 for patients treated with omeprazole compared with $869 for patients treated with H2RAs. The findings of this analysis conducted under actual clinical conditions support findings of randomized clinical trials showing the cost-effectiveness of proton pump inhibitors.

Adult↗

PubMed1998

Declining professional dominance?: trends in the proletarianisation of primary care in New Zealand.

This paper explores the relevance of the proletarianisation thesis to the emergence of new forms of managed primary care in New Zealand. This concern is of particular interest because of primary care sector has persisted virtually unchanged, since the birth of the welfare state in 1938, despite numerous past state attempts at reform. Since 1993 collective action on the part of general practitioners has resulted in the formation of Independent Practice Associations (IPAs). In terms of Light's (1993) idea of countervailing trends to proletarianisation, IPA development represents a pre-emptive strategy designed to prevent the introduction of the kind of managerialism imposed on the secondary sector where some loss of autonomy has been sustained by health care professionals. At the macro-level, therefore, there has been little change in GP autonomy although at the micro-scale there has been some loss of freedom as the development of IPAs ironically has meant that the degree of control by GPs over the content of their work has changed. The results suggest that the notion of the profession acting as a countervailing force has been borne out. Furthermore, the proposition inherent in modern organisation-environment relations literature, that organisations not only adapt to their environment but may actively seek to change it receives some support.

Family Practice↗

PubMed2000

Physician-hospital partnerships: incentive alignment through shared governance within a performance improvement structure.

BACKGROUND: Producing accessible, appropriate, and accountable medical care that improves the health of the populations served requires collaborative physician-organization relationships within which performance measurement across the continuum of care occurs. Governance and shared responsibility for performance improvement (PI) through organizational structure and process have proven to be particularly complex challenges. REDESIGN OF THE PI SYSTEM: The Health Alliance of Central New York, based in Syracuse, New York, which consists in part of Crouse Hospital; ambulatory medical care sites and physicians; a physician organization, a physician-hospital organization, and an independent practice association; in February 1997 established a plan for a redesign of the PI system. IMPLEMENTING THE MODEL: In April 1998 the development of joint performance indicators, the Family of Measures, was undertaken. Recommendations for improvements necessary to correct process failures are referred to the medical staff executive committee and/or the appropriate coordinating committee, which then charges the appropriate service-line PI Council(s) with the responsibility for making those improvements. DISCUSSION: Systemwide PI with collaborative decision making by process stakeholders has been a major cultural transition requiring a degree of organizational readiness. Support of the most senior levels of management is critical. Institutional silos do not support shared, participatory decision making and cannot be overcome without strong support from senior management and in many cases the direct support and involvement of the CEO. Integrating information systems represents a considerable challenge: to find hardware and software that will interface properly to produce desired results, to successfully interface computer support personnel into the PI process, and to ensure the commitment to the financial resources to meet the information system requirements. In addition, meaningful and material reengineering requires substantial physician input. Simply reducing length of stay or cost per case is not an outcome that is by and large a strong motivator for physicians. Projects must have meaning at the level of the individual physician to raise interest and create buy-in. Enduring success will be achieved only through achievement of material and salient improvements (for both physicians and the institution) in combination with careful alignment of physician and institutional incentives.

Cooperative Behavior↗

PubMed1997

Asthma: benchmarking for quality improvement.

BACKGROUND: Linked medical and pharmacy claims can be used to identify patients with asthma and benchmark current practice standards. METHOD: This was a 3-year study of five independent practice association style health maintenance organizations with an annual enrollment of 870,000. More than 28,000 members were identified with claims for asthma. OBJECTIVE: The intent of this study was to benchmark current asthma practice. Before quality improvement projects can be implemented baseline data are required. RESULTS: The prevalence of asthma varied by geographic regions. Specialty care was associated with greater use of anti-inflammatory medications and more refills of these drugs. Refill rates for inhaled corticosteroids for all patients was low. Specialty care of asthmatic members was associated with a lower rate of emergency service events and hospitalizations. CONCLUSIONS: Linked medical and pharmacy claims' databases can be used to benchmark current practice performance and serve as a reference for quality improvement programs. Appropriate use of specialty care may improve asthma outcomes.

Adolescent↗

PubMed2002

The determinants of HMOs' contracting with hospitals for bypass surgery.

OBJECTIVE: Selective contracting with health care providers is one of the mechanisms HMOs (Health Maintenance Organizations) use to lower health care costs for their enrollees. However, are HMOs compromising quality to lower costs? To address this and other questions we identify factors that influence HMOs' selective contracting for coronary artery bypass surgery (CABG). STUDY DESIGN: Using a logistic regression analysis, we estimated the effects of hospitals' quality, costliness, and geographic convenience on HMOs' decision to contract with a hospital for CABG services. We also estimated the impact of HMO characteristics and market characteristics on HMOs' contracting decision. DATA SOURCES: A 1997 survey of a nationally representative sample of 50 HMOs that could have potentially contracted with 447 hospitals. PRINCIPAL FINDINGS: About 44 percent of the HMO-hospital pairs had a contract. We found that the probability of an HMO contracting with a hospital increased as hospital quality increased and decreased as distance increased. Hospital costliness had a negative but borderline significant (0.10 < p < 0.05) effect on the probability of a contract across all types of HMOs. However, this effect was much larger for IPA (Independent Practice Association)-model HMOs than for either group/staff or network HMOs. An increase in HMO competition increased the probability of a contract while an increase in hospital competition decreased the probability of a contract. HMO penetration did not affect the probability of contracting. HMO characteristics also had significant effects on contracting decisions. CONCLUSIONS: The results suggest that HMOs value quality, geographic convenience, and costliness, and that the importance of quality and costliness vary with HMO. Greater HMO competition encourages broader hospital networks whereas greater hospital competition leads to more restrictive networks.

Cardiology Service, Hospital↗