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PubMed1998

Women's preferences for specialists who provide cancer screening and general medical care.

In order to determine what types of specialists women prefer for medical care, we examined responses from a cross-sectional survey of adult female patients in a health plan of the independent practice association model in the Minneapolis-St. Paul metropolitan area (n = 1,204). The response rate for the survey was 90%. The women expressing a preference (60% of responders) overwhelmingly preferred to see obstetrician-gynecologists for their breast examinations and Pap smears and strongly preferred family physicians or internists for the remainder of their cancer screening and general medical care. Thus, the majority of women expressed preferences for physicians of different specialties to provide their medical care.

Adult↗

PubMed1999

Treating depression in staff-model versus network-model managed care organizations.

OBJECTIVE: To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers' depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Chi-Square Distribution↗

PubMed1999

Methods for analyzing referral patterns.

OBJECTIVE: To develop a sound method to identify patient and physician characteristics that influence specialty referrals. DESIGN: A retrospective cohort analysis of medical claims data from 1996 supplemented with surveys of primary care physicians. SETTING: A 600-member independent practice association in southeastern Michigan that provided care for 90,000 members of an HMO. PATIENTS: Five cohorts, each of 2,000 to 6,000 patients with diagnoses that could be referred to cardiologists, ophthalmologists, pulmonologists, orthopedists, or general surgeons. MAIN RESULTS: The referral rates for the different cohorts ranged from 1% to 7%. The discriminatory ability of the multivariate logistic models (c-statistic) ranged from 0.66 to 0.79. The likelihood of referral was associated with the patient's diagnoses and medications and with the referring physician's age, years out of medical school, satisfaction with the specialty being referred to, and the importance of making or confirming a diagnosis. CONCLUSIONS: Because these methods were not difficult to implement and the results were credible, we believe that other organizations should be able to use them.

Cohort Studies↗

PubMed1979

Cost containment through risk-sharing by primary-care physicians.

A new type of independent practice association has been organized to encourage primary-care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician or pediatrician and must be referred by that physician for all specialized care. The primary-care physician authorizes payment from his own account for all care provided to his patients. He shares any dificit or surplus remaining at the end of the year. After four years of operation, United Healthcare has 610 primary-care physicians treating 23,000 patients. Total hospital use during 1978 and 293 bed-days per 1000 patients, as compared with 479 for Blue Cross. The hospital-admission rate per 1000 was 88, as compared with 101 for Blue Cross. Average lengths of stay were 3.3 and 4.7 dyas, respectively. This plan represents another means to control costs in the private medical marketplace.

Consumer Behavior↗

PubMed1995

Potential effects of managed care on specialty practice at a university medical center.

BACKGROUND: The growth of managed care presents a challenge to academic medical centers, because the demand for the services of specialists is likely to continue decreasing. We estimated the number of enrollees the University of Michigan Medical Center would need in its health maintenance organization (HMO) system in order to provide revenue equivalent to the total revenue it received for professional specialty care in 1992. METHODS: Rates of utilization and payment were based on the medical center's experience with managed care in 1992 in its independent practice association HMO, in which 25,000 members had capitated coverage and received primary and all specialty care from university physicians, and 15,000 members received primary care and most specialty care from physicians outside the university. We assumed that persons not enrolled in Medicare were all enrolled in managed-care plans. Primary care activity was excluded from the calculations of expense, revenue, and numbers of faculty members. RESULTS: If all specialty services were provided by the university to HMO members, all the 21 specialties examined except obstetrics and gynecology and emergency services would require an enrollment of more than 250,000 to support the 1992 level of professional revenue and maintain the number of faculty members. If university services were provided only for referrals from a loosely affiliated network of community physicians in the HMO system, all the 19 specialties examined except plastic surgery would require an HMO enrollment of more than 1 million. In a combined model in which all specialty services were provided to 100,000 HMO members and network referrals were provided to 500,000 members, substantial changes in faculty composition would be needed in all the departments studied. CONCLUSIONS: Because of the large number of HMO members required, unless other changes occur, it is unrealistic to expect that the University of Michigan Medical Center could create an HMO or network large enough to support the specialty practice of the current number of faculty members at the 1992 level of financing.

Academic Medical Centers↗

PubMed1999

Barriers to compliance with screening guidelines for diabetic retinopathy.

OBJECTIVE: To identify barriers to compliance with guidelines for diabetic retinopathy screening. METHODS: The population studied included 4410 adults, aged 31 to 64, enrolled in an Independent Practice Association (IPA) plan in Upstate New York, who were diagnosed with diabetes, and their Primary Care Physicians (408 PCPs). Claims data were used to calculate variables characterizing patients and their PCPs. Logistic regression models were estimated to identify factors associated with higher probability of screening. RESULTS: 34% of patients were screened in 1993. The probability of screening was significantly higher for older patients, for women, for patients who visit their PCPs more often and for those living in areas of higher average education and lower percentage of blacks. However, only 16% of diabetic patients received an annual screen in two consecutive years (1992 and 1993). The probability of consecutive annual screening was significantly associated only with gender and patient expenditures per month. CONCLUSION: The very low rate of diabetic retinopathy screening has implications for quality of life of patients with diabetes, long term costs of caring for them and social costs due to lost productivity. Interventions to increase screening rates are needed and should target both patients and their Primary Care Physicians.

Adult↗

PubMed2000

Group therapy program development: clinician-administrator collaboration in new practice settings.

Despite being practiced widely and applied to many conditions, group therapy is underutilized in some segments of the market. One important reason for its underuse is the lack of a model for group program development. Program development requires an integrated effort involving many disciplines. Effective collaboration between clinicians and administrators is an essential but underappreciated component in the development of group programs in independent practice associations.

Health Facility Administrators↗

PubMed1999

Direct health care costs for treatment of diabetes mellitus and hypertension in an IPA-group-model HMO.

The differences in direct health care costs and use between HMO enrollees with both diabetes mellitus and hypertension and enrollees with either disease alone were studied. Two years' worth of medical and pharmacy claims data from a hybrid (independent practice association and group)-model HMO were evaluated. Diagnoses were determined from medical claims data and cross-referenced with prescription information from pharmacy claims data. Aggregate costs associated with each disease, including pharmacy costs, costs of physician office visits, and laboratory costs, were compiled. Comparisons were made of all costs (any cost incurred by the health plan for the member, regardless of disease) and disease-specific costs. The frequency of comorbid conditions was identified. A total of 6195 patients (670 with diabetes and hypertension, 1756 with diabetes alone, and 3769 with hypertension alone) were assessed. Patients with both diseases incurred much higher costs per year than patients with diabetes or hypertension alone (mean costs, $13,446, $8,493, and $8,424, respectively). Hospitalization costs contributed the greatest amount to total costs, while emergency room costs contributed the least. Disease-specific costs for diabetes and hypertension represented less than one quarter of total health care costs per patient. Average disease-specific costs were highest for patients with both diseases ($2,955), followed by costs for patients with hypertension alone ($1,803) and patients with diabetes alone ($689). The percentage spent on prescriptions was much higher for disease-specific costs than for total costs. The three most common comorbid conditions were dyslipidemia, coronary artery disease, and chronic obstructive pulmonary disease, with the frequency of cerebrovascular disease and myocardial infarction more than double in patients with diabetes and hypertension compared with patients with either disease alone. The cost of care for a patient with both diabetes and hypertension, although not double that for a patient with diabetes or hypertension alone, was higher than the cost of treating either disease.

Data Collection↗

PubMed1999

ASHP survey of ambulatory care responsibilities of pharmacists in managed care and integrated health systems--1999.

The results of a 1999 national survey of the ambulatory care responsibilities of pharmacists in managed care organizations (MCOs) and integrated health systems are reported and compared with the results of a similar survey conducted in 1997. Four hundred MCOs and integrated health systems participated in the telephone survey. The survey elicited data about organizational structure and pharmacist functions in the ambulatory care environment. Survey recipients were asked about 24 specific ambulatory pharmacist functions. The performance of functions was related to five "enabling" factors: pharmacists on interdisciplinary teams, automated dispensing systems, integrated electronic medical records, and "very supportive" medical staff and senior management. Thirteen functions were reported to be routine activities for more than 50% of the respondents, compared with nine functions in 1997. The top four functions-using pharmacoeconomic data to make formulary decisions, conducting medication management programs, tracking adverse drug reactions, and providing written information with each new prescription-were performed in 75% or more of organizations. Some 15-18% of respondents indicated they would add specialized pharmacy-managed clinics, services to determine patient use of herbal products and dietary supplements, and Internet prescription services within 12 months, suggesting this expansion is likely to continue. Enabling factors supported expansion. Two clusters of functions were identified that related to either population-focused or patient-focused activities, and these were supported differentially by enabling factors. Group-model and staff-model HMOs had the most enabling factors and the greatest scope of pharmacist functions. Independent practice associations had fewer enabling factors and a different mix of pharmacist functions, with an emphasis on population-focused functions, suggesting that a second model of ambulatory care pharmacist activity may be emerging. Ambulatory care functions of pharmacists in integrated health-system settings have expanded broadly since 1997.

Ambulatory Care↗

PubMed2001

ASHP survey of ambulatory care responsibilities of pharmacists in managed care and integrated health systems--2001.

The results of a 2001 national survey of the ambulatory care responsibilities of pharmacists in managed care organizations (MCOs) and integrated health systems are reported and compared with the results of similar surveys conducted in 1997 and 1999. Three hundred and seventy-six MCOs and integrated health systems participated in the telephone survey. The surveyelicited data about organizational structure and pharmacist functions in the ambulatory care environment. Survey respondents were asked about 24 specific ambulatory care pharmacist functions. The performance of functions was related to five "enabling" factors: pharmacists on interdisciplinary care teams, automated dispensing systems, integrated electronic medical records, very supportive medical staff, and very supportive senior management. Twenty previously measured functions decreased since 1999. Decreases were greatest in negotiating pharmaceutical contracts (-28%), administering immunizations (-27%), and immunization screening (-24%). Enabling factors supported continued expansion. Two clusters of functions, patient-related and population-related activities, were identified and supported differentially by enabling factors. Group-model and staff-model HMOs had the most enabling factors and the broadest scope of pharmacist functions. Independent practice associations had fewer enabling factors and a different mix of functions, with an emphasis on population-focused functions. Ambulatory care functions of pharmacists have expanded to new areas and have decreased in more traditional areas, perhaps because of the current pharmacist shortage and the increase in the number of prescriptions and patients.

Ambulatory Care↗

PubMed1997

The Tufts partnership for managed care education.

The authors describe the formation and the academic activities of the Tufts Managed Care Institute, a collaborative venture of Tufts University School of Medicine and Tufts Health Plan, an independent-practice-association (IPA)-model health maintenance organization (HMO). In 1994, the dean of the medical school and the CEO of the HMO recognized the need for collaboration to prepare students and practitioners for high-quality, cost-effective practice in a managed care environment. They established an advisory committee to oversee a six-month feasibility study to interview experts and opinion leaders and identify critical characteristics of the ideally prepared managed care practitioner. In 1995, with start-up funding from the HMO, the institute began its operations as a freestanding enterprise with board representation from the two sponsoring institutions. While many of the institute's programs have been developed for practicing physicians and other health care professionals, this article focuses on the academic activities. For medical students, the approach has been to blend managed care principles and practices into existing courses, problem-based learning cases, and clerkships, rather than creating separate managed care courses. For primary care residents, the institute has a grant to develop managed care curricula in conjunction with Tufts-affiliated residency training programs. Faculty development is accomplished through dedicated workshops and seminars, and through increased dialogue between traditional faculty and managed care professionals. In all of its programs and activities the institute has fostered greater contact and collaboration between colleagues from both sides of the health plan-academia "divide." Operationally, the institute structure, with dedicated full-time administrative staff, provides the singular focus necessary to establish managed care education as a top priority for the partnership. At the same time, sustaining this freestanding organization and infrastructure requires increased resources. Initial responses to the institute's programs and activities have been positive, both from the local Tufts community and from external parties. Yet the partnership must establish methods to evaluate the institute's long-term impact in its efforts to help practitioners succeed in a transforming landscape.

Academic Medical Centers↗

PubMed1996

Profiling primary care physician resource use: examining the application of case mix adjustment.

Growing emphasis on managed care has led to increased interest in physician practice profiling. Standardized techniques for conducting profiling are not yet well established. One particularly challenging methodologic issue, case mix adjustment, is explored here using actual cost profiles derived from primary care physicians at two independent practice association (IPA)-model health maintenance organizations (HMOs). Specifically, this article examines how the ambulatory care group case mix methodology can be applied to profiling and illustrates that it provides more depth of information with which to assess performance than does standard demographic adjustment alone. This analysis suggests both the potential and methodologic limitations of profiling at the individual physician level.

Ambulatory Care↗

PubMed1984

Ambulatory mental health services utilization in three provider plans.

This article examines the use of mental health services in three insurance plans: Blue Cross (BC), a health maintenance organization (HMO), and an independent practice association (IPA) in which the primary care physician was to manage all care for an individual. Approximately 7.3% of the enrollees in all three plans used some mental health care in the 18-month study period. The percent of enrollees with mental health utilization was lower in BC than in the other two plans, but the total quantity of mental health care use per enrollee and per user was much higher in BC than in the HMO and the IPA. Use was highest in the 19-44-year-old age group, and there were no significant differences between men and women in use of mental health services. There were substantial differences by race in all three plans: white persons were more likely to use any mental health care and had more visits than nonwhite persons after seeking mental health use. A similar study was conducted in the early 1970s on a poverty-level population enrolled in BC and the HMO. The findings of this study are similar, except that in the low-income study mental health care use was lower, and males used less mental health care than females. These differences might be attributable to the difference in enrollees' socioeconomic status in the two studies or to the increasing acceptability of mental health care utilization, particularly for males.

Adolescent↗

PubMed1984

Comparative aspects of medical practice. Organizational setting and financial arrangements in four delivery systems.

Effects of financial arrangement and organizational setting on the socioeconomic aspects of four health care delivery systems are assessed. Analysis of variance tests are used to analyze differences between group and solo fee-for-service practices, prepaid group practices, and independent practice associations. Solo fee-for-service physicians tended to be older, to be non-board-certified, to prefer autonomy over earnings, and to have more patient visits, longer hours, and shorter waits for an appointment. Prepaid group physicians tended to be younger, to prefer a specific practice location and predictable schedule, to have lower incomes and expenses coupled with fewer patient visits, shorter work weeks, and longer patient waiting times. If current trends continue, new physicians may develop practice arrangements combining elements of fee-for-service and prepayment.

Adult↗

PubMed1986

Inpatient length of stay in Twin Cities health plans.

In this paper we examine the relationship between inpatient length of stay and the patient's type of health insurance. The data consist of discharges in seven diagnosis-related groups (DRGs) from community hospitals in Minneapolis and St. Paul during 1982. After controlling for the effects of the patient's age, sex, medical condition, and severity of illness, as well as the hospital's size, teaching and ownership status, and average annual occupancy rate, we must reject the null hypothesis that the patient's type of health plan is unrelated to inpatient length of stay in Twin Cities community hospitals. We find that, in most cases, patients in prepaid group practices and independent practice associations exhibit significantly shorter lengths of stay than similar patients in Blue Cross and commercial health insurance plans, while Medicare and Medicaid patients exhibit significantly longer lengths of stay than those of similar commercially insured patients.

Blue Cross Blue Shield Insurance Plans↗

PubMed1991

Behavioral interventions to increase adherence in colorectal cancer screening.

This investigation was a randomized controlled trial to determine the impact of health education interventions on the return of mailed fecal occult blood (FOB) tests (FOBT adherence) in a colorectal cancer screening program. The study sample included 2,201 men and women aged 50 to 74 years who were members of an Independent Practice Association (IPA)-type health maintenance organization (HMO). Subjects were randomly assigned to a "usual care" Control Group (advance letter, screening kit, reminder letter), and Treatment Groups 1 (usual care + reminder call), 2 (usual care + self-held screening booklet + reminder call), or 3 (usual care + self-held screening booklet + instruction call + reminder call). Bivariate analysis revealed significant differences in adherence (P less than .001) across study groups: Control Group (27%), Group 1 (37%), Group 2 (37%), Group 3 (48%). In addition, a significant positive association between age and adherence (P less than .001) was found. Logistic regression analysis revealed an interaction between sex and treatment. Adherence among men in all treatment groups increased significantly (P less than .0001) in relation to Control Group males. Men in Group 3 also were more likely to adhere than those in Group 2 (P less than .01) or Group 1 (P less than .01). Among women, adherence was significantly higher in Group 3 than in Group 2 (P less than .03), Group 1 (P less than .025), or the Control Group (P = .0008). The primary reason cited for nonadherence was perceived inconvenience of the FOB testing procedure.

Aged↗

PubMed1996

Disenrollment of Medicare cancer patients from health maintenance organizations.

OBJECTIVES: There is concern that financial incentives in health maintenance organizations (HMOs) might result in pressures to induce sicker members to disenroll. The authors compared disenrollment rates of Medicare HMO enrollees with cancer with disenrollment rates for cancer-free enrollees, using Medicare enrollment files linked to population-based tumor registry data from the Surveillance, Epidemiology, and End Results (SEER) Program. METHODS: The authors identified all aged Medicare beneficiaries who enrolled in an HMO located in a SEER reporting area during 1985 to 1989. Time to disenrollment was analyzed using a proportional hazards model. RESULTS: Overall, cancer patients were no more likely to disenroll than others. However, persons diagnosed with cancer after enrollment were less likely to disenroll than other persons in Independent Practice Association (IPA) mode HMOs (relative risk [RR] = 0.79). Persons diagnosed with cancer after enrollment in group- and staff-model HMOs were about equally likely to disenroll as other persons (RR = 0.91). Persons diagnosed with cancer less than 18 months before enrollment were at high risk for disenrollment from both IPA and group-/staff-model HMOs (RR = 1.47 and 1.35). There was substantial variation among HMOs in overall disenrollment rates and in RRs for disenrollment by cancer patients. CONCLUSIONS: The low disenrollment rates of patients diagnosed after enrollment do not support the contention that features intrinsic to managed care make HMOs unattractive to the seriously ill. Monitoring of selective disenrollment could be used as a screen for possible access and quality problems.

Aged↗

PubMed2000

Physician referral rates: style without much substance?

BACKGROUND: Primary care physicians (PCPs) exhibit widely varying referral rates, resulting in dramatic differences in the exposure of their patients to specialists. The relationships between this physician behavior and costs and patient outcomes are unknown. OBJECTIVES: To examine the relationships between PCP referral rates and costs, risk of avoidable hospitalization, health status, and satisfaction. DESIGN: Cross-sectional analyses of claims and patient survey data. SETTING AND SUBJECTS: Independent practice association (IPA)-style managed care organization in the Rochester, NY, metropolitan area. The 1995 claims data included 457 PCPs in the IPA and 217,606 adult patients assigned to their panels. Approximately 50 consecutive patients of each of a random sample of 100 PCPs completed a patient survey in 1997-1998. MEASURES: From the claims data, total expenditures per panel member, the risk of avoidable hospitalization, and physician referral rate were measured. Measures derived from the survey included SF-12 scores, satisfaction, and physician referral rate. RESULTS: The relationship between physician referral rate and per-panel-member costs was not statistically significant after case-mix adjustment of the referral rate. There was no relationship between the case-mix-adjusted referral rate and risk of avoidable hospitalization. In the survey data, there was no adjusted relationship between the physicians' referral rate and their patients' self-rated physical or mental health. There was a modest direct relationship between patient satisfaction and survey-derived referral rate. CONCLUSIONS: Despite stable, wide variations in PCP referral rates, there are few discemible relationships between this physician behavior and costs and patient outcomes. Efforts to constrain PCP referrals to specialists may be misguided.

Adult↗