Beneath the calm surface: the changing face of physician-service use in British Columbia, 1985/86 versus 1996/97.
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BACKGROUND: Although expenditures on health care are continually increasing and often said to be unsustainable, few studies have examined these trends at the level of services delivered to individual patients. We analyzed trends in the various components that contributed to changes in overall expenditures for physician services in British Columbia from 1985/86 to 1996/97. METHODS: We obtained data on all fee-for-service payments to physicians in each study year using the British Columbia Linked Health Data set and analyzed these at the level of individual patients. We disaggregated overall billing levels by year into the following components: number of physicians seen by each patient, number of visits per physician, number of services rendered on each visit and average price of those services. We removed the effect of inflation on fees by adjusting to those in 1988. We used direct age-standardization to isolate and measure the effect of demographic changes. We used the Consumer Price Index to determine the effects of inflation. RESULTS: Total payments to fee-for-service physicians in British Columbia rose 86.3% over the study period. The increase was entirely accounted for by the combined effects of population growth (28.9%), aging (2.1%) and general inflation (41.4%). Service use per capita rose 10.5%; this increase was offset by a decline of 9.4% in inflation-adjusted fees. The average cost of age-adjusted per-capita services rendered by general or family practitioners (GP/FPs) increased very little (3.3%) over the 11-year period, compared with a nearly one-third (31.8%) increase for medical specialists. Although there was a dramatic increase in the number of GP/FPs seen on average by each patient (32.9%), this increase was offset by the combination of decreases in the number of visits per physician (-14.9%), the number of services provided per visit (-8.0%) and the "real cost" of each service provided (-3.5%). Visits to medical specialists increased by about 20% over the study period in all age groups. However, for each person 65 years of age or over receiving any services, the average fee-adjusted expenditures increased 24.8%, almost 4 times the rate of increase for people younger than 65. The use of surgical services grew 26.5% for seniors while declining -2.0% for people under age 65. INTERPRETATION: These findings suggest a form of "homeostasis" in aggregate-level service use and cost. The supposed inflationary effects of population aging and increasing "abuse of the system" by patients were not found. (+info)
Does payment drive procedures? Payment for specialty services and procedure rate variations in 3 HMOs.
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OBJECTIVE: To study how payment for specialty services affects the rates of performance of invasive procedures by physicians in a number of specialties. STUDY DESIGN: Observational study. PATIENTS AND METHODS: Administrative data from 1996-1997 and 1997-1998 from 3 large health maintenance organizations (HMOs) in the Midwestern and western United States were used to study variations in procedure rates associated with different methods of paying for cardiology, gastroenterology, ophthalmology, orthopedic, and ear, nose and throat services within each HMO. The age-, sex-, and comorbidity adjusted probabilities of undergoing selected, potentially discretionary procedures, were compared within each plan by payment method. RESULTS: After adjustment, rates under fee-for-service payment tended to be higher than those under capitation or salary payment, whereas there was no clear pattern for salary versus capitation payment. Even within a single specialty in a single plan, however, rates did not always follow the same pattern for different procedures. CONCLUSIONS: The payment method for specialty services used by these 3 health plans was variably associated with how likely patients were to undergo a variety of invasive procedures. The effects of contract payment methods for specialty services on health care costs, quality, and outcomes should be further studied, but such studies will challenge the capabilities of health plan data systems. (+info)
What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?
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OBJECTIVE: To examine the effects of internal medicine specialty and physician experience on inpatient resource use and clinical outcomes on an academic general medicine service. DESIGN: A 1-year retrospective cohort study. SETTING: The University of Michigan Hospitals, Ann Arbor, Michigan. PATIENTS: Two thousand six hundred seventeen admissions to the general medicine service from July 2001 to June 2002, excluding those for whom data were incomplete (n = 18). MEASUREMENTS AND MAIN RESULTS: Length of stay (LOS) and total hospital costs were used to measure resource utilization. Hospital mortality and 14-day and 30-day readmission rates were used to measure clinical outcomes. Adjusted mean LOS was significantly greater for rheumatologists (0.56 days greater; P =.002) and endocrinologists (0.38 days greater; P =.03) compared to general internists. Total costs were lower for general internists compared to endocrinologists ($1100 lower; P =.01) and rheumatologists ($431 lower; P =.07). Hospitalists showed a trend toward reduced LOS compared to all other physicians (0.31 days lower; P =.06). The top two deciles of physicians stratified by recent inpatient general medical experience showed significantly reduced LOS compared to all other physicians (0.35 days lower; P =.04). No significant differences were seen in readmission rates or in-hospital mortality among the various physician groups. CONCLUSIONS: General internists had lower lengths of stay and costs compared to endocrinologists and rheumatologists. Hospitalists showed a trend toward reduced LOS compared to all other physicians. Recent inpatient general medicine experience appears to be a determinant of reduced inpatient resource use. (+info)
The alignment and blending of payment incentives within physician organizations.
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OBJECTIVE: To analyze the blend of retrospective (fee-for-service, productivity-based salary) and prospective (capitation, nonproductivity-based salary) methods for compensating individual physicians within medical groups and independent practice associations (IPAs) and the influence of managed care on the compensation blend used by these physician organizations. DATA SOURCES: Of the 1,587 medical groups and IPAs with 20 or more physicians in the United States, 1,104 responded to a one-hour telephone survey, with 627 providing detailed information on physician payment methods. STUDY DESIGN: We calculated the distribution of compensation methods for primary care and specialty physicians, separately, in both medical groups and IPAs. Multivariate regression methods were used to analyze the influence of market and organizational factors on the payment method developed by physician organizations for individual physicians. PRINCIPAL FINDINGS: Within physician organizations, approximately one-quarter of physicians are paid on a purely retrospective (fee-for-service) basis, approximately one-quarter are paid on a purely prospective (capitation, nonproductivity-based salary) basis, and approximately one-half on blends of retrospective and prospective methods. Medical groups and IPAs in heavily penetrated managed care markets are significantly less likely to pay their individual physicians based on fee-for-service than are organizations in less heavily penetrated markets. CONCLUSIONS: Physician organizations rely on a wide range of prospective, retrospective, and blended payment methods and seek to align the incentives faced by individual physicians with the market incentives faced by the physician organization. (+info)
Physician race and ethnicity, professional satisfaction, and work-related stress: results from the Physician Worklife Study.
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There are limited data about minority physicians' professional satisfaction and job stress. In this study, we describe by race and ethnicity, satisfaction, and job stress among a national sample of physician. We analyzed data from 2,217 respondents to the Physicians' Worklife Survey (PWS), a career satisfaction survey of physicians drawn from the AMA Physician Masterfile. Scales measuring overall job and career satisfaction and work-related stress were constructed from Likert-response items. We examined the association between physician ethnicity and each of these scales. Respondents included 57 black, 134 Hispanic, 400 Asian or Pacific Islander, and 1,626 white physicians. In general, minority physicians appeared to serve a more demanding patient base than did white physicians. Hispanic physicians reported significantly higher job (p=0.05) and career (p=0.03) satisfaction compared to white physicians but no significant difference in stress. Asian or Pacific Islander physicians averaged lower job satisfaction (p=001) and higher stress (p<0.01) compared to white physicians. Black physicians did not differ significantly from white physicians on any of the three measures. Significant racial and ethnic variations were found with respect to several specific satisfaction domains: autonomy, patient care issues, relations with staff, relations with the community, pay, and resources. (+info)
Are primary care services a substitute or complement for specialty and inpatient services?
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OBJECTIVE: To determine whether strategies designed to increase members' use of primary care services result in decreases (substitution) or increases (complementation) in the use and cost of other types of health services. STUDY SETTING: Encounter and cost data were extracted from the Department of Veterans Affairs (VA) administrative data sources for the period 1995-1999. This timeframe captures the VA's natural experiment of increasing geographic access to primary care by establishing new satellite primary care clinics, known as Community-Based Outpatient Clinics (CBOCs). STUDY DESIGN: We exploited this natural experiment to estimate the substitutability of primary care for other health services and its impact on cost. Hypotheses were tested using ordinary least squares (OLS) regression, which was potentially subject to endogeneity bias. Endogeneity bias was assessed using a Hausman test. Endogeneity bias was accounted for by using instrumental variables analysis, which capitalized on the establishment of CBOCs to provide an exogenous identifier (change in travel distance to primary care). DATA COLLECTION: Demographic, encounter, and cost data were collected for all veterans using VA health services who resided in the catchment areas of new CBOCs and for a matched group of veterans residing outside CBOC catchment areas. PRINCIPAL FINDINGS: Change in distance to primary care was a significant and substantial predictor of change in primary care visits. OLS analyses indicated that an increase in primary care service use was associated with increases in the use of all specialty outpatient services and inpatient services, as well as increases in inpatient and outpatient costs. Hausman tests confirmed that OLS results for specialty mental health encounters and mental health admissions were unbiased, but that results for specialty medical encounters, physical health admissions, and outpatient costs were biased. Instrumental variables analyses indicated that an increase in primary care encounters was associated with a decrease in specialty medical encounters and was not associated with an increase in physical health admissions, or outpatient costs. CONCLUSIONS: Results provide evidence that health systems can implement strategies to encourage their members to use more primary care services without driving up physical health costs. (+info)
The pediatric subspecialty workforce: public policy and forces for change.
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Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas. (+info)
Effects of a malpractice crisis on specialist supply and patient access to care.
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OBJECTIVE: To investigate specialist physicians' practice decisions in response to liability concerns and their perceptions of the impact of the malpractice environment on patient access to care. SUMMARY BACKGROUND DATA: A perennial concern during "malpractice crises" is that liability costs will drive physicians in high-risk specialties out of practice, creating specialist shortages and access-to-care problems. METHODS: Mail survey of 824 Pennsylvania physicians in general surgery, neurosurgery, orthopedic surgery, obstetrics/gynecology, emergency medicine, and radiology eliciting information on practice decisions made in response to rising liability costs. RESULTS: Strong majorities of specialists reported increases over the last 3 years in patients' driving distances (58%) and waiting times (83%) for specialist care or surgery, waiting times for emergency department care (82%), and the number of patients forced to switch physicians (89%). Professional liability costs and managed care were both considered important contributing factors. Small proportions of specialists reported that they would definitely retire (7%) or relocate their practice out of state (4%) within the next 2 years; another third (32% and 29%, respectively) said they would likely do so. Forty-two percent of specialists have reduced or eliminated high-risk aspects of their practice, and 50% are likely to do so over the next 2 years. CONCLUSIONS: Our data suggest that claims of a "physician exodus" from Pennsylvania due to rising liability costs are overstated, but the malpractice situation is having demonstrable effects on the supply of specialist physicians in affected areas and their scope of practice, which likely impinges upon patients' access to care. (+info)