Use of out-of-plan services by Medicare members of HIP.
Use of out-of-plan services in 1972 by Medicare members of the Health Insurance Plan of Greater New York (HIP) is examined in terms of the demographic and enrollment characteristics of out-of-plan users, types of services received outside the plan, and the relationship of out-of-plan to in-plan use. Users of services outside the plan tended to be more seriously ill and more frequently hospitalized than those receiving all of their services within the plan. The costs to the SSA of providing medical care to HIP enrollees are compared with analogous costs for non-HIP beneficiaries, and the implications for the organization and financing of health services for the aged are discussed. (+info)
Empiric examination of physician behavior in a changing healthcare market.
We hypothesized that, in the current healthcare environment, medical providers have strong economic incentives to introduce new technology and treat patients more extensively. We examined physician reimbursement for medical procedures in Utah in the early 1990s, a period of increasing utilization of managed care methods, using a cross-section time series and a supply side model to analyze how physician behavior changed during this period of time. Our findings suggest that physicians have acted to maintain their revenue by requesting reimbursement for more procedures as the reimbursement level per procedure decreased. We conclude that increased volatility in reimbursement levels and increased adjudication pressure from payers provide signals to physicians to act strategically to protect their revenue stream. (+info)
Relationship between primary payer and use of proactive immunization practices: a national survey.
OBJECTIVE: To quantify the national use and determinants of proactive immunization practices by examining the relationship to the primary practice payer. STUDY DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. PATIENTS AND METHODS: A stratified random sample of family physicians, pediatricians, and general practitioners across the United States was selected from the American Medical Association master file of physicians list, which included nonmembers. The main outcome measures were use of reminder systems and assessment of immunization rates. RESULTS: Of the 1769 physicians who were contacted, 1236 participated. Use of reminder systems varied by the practice's primary payer: 31% of health maintenance organization (HMO), 41% of Medicaid, 27% of fee-for-service (FFS), and 28% of no predominant payment source physicians reported using a reminder system (P < 0.01). Use of computerized reminders also varied according to practice primary payer (HMO, 68%; Medicaid, 34%; FFS, 51%; and no predominant payment source, 42%; P < 0.01) as did assessment of immunization rates in the practice (HMO, 57%; Medicaid, 40%; FFS, 28%; and no predominant payment source, 30%; P < 0.01). A majority of Medicaid physicians (84%) required a physical examination before immunization, compared to 49% of HMO, 56% of FFS, and 63% of no predominant source physicians (P < 0.01). CONCLUSIONS: The primary payment source of a practice appears to influence use of proactive immunization practices. (+info)
Type of health insurance and the quality of primary care experience.
OBJECTIVES: This study examined the association between type of health insurance coverage and quality of primary care as measured by its distinguishing attributes--first contact, longitudinality, comprehensiveness, and coordination. METHODS: The household component of the 1996 Medical Expenditure Panel Survey was used for this study. The analysis primarily focused on subjects aged younger than 65 years who identified a usual source of care. Logistic regressions were used to examine the independent effects of insurance status on primary care attributes while individual sociodemographic characteristics were controlled for. RESULTS: The experience of primary care varies according to insurance status. The insured are able to obtain better primary care than the uninsured, and the privately insured are able to obtain better primary care than the publicly insured. Those insured through fee-for-service coverage experience better longitudinal care and less of a barrier to access than those insured through health maintenance organizations (HMOs). CONCLUSIONS: While expanding insurance coverage is important for establishing access to care, efforts are needed to enhance the quality of primary health care, particularly for the publicly insured. Policymakers should closely monitor the quality of primary care provided by HMOs. (+info)
Drivers of healthcare expenditures associated with physician services.
OBJECTIVE: To identify and rank the key contributors to increases in healthcare costs for physician services. STUDY DESIGN: We performed regression analysis using state-level physician cost data from the state health expenditure accounts maintained by the Centers for Medicare and Medicaid Services (CMS) and a national, private (commercial) health insurer. RESULTS: We estimated that during 1990 to 2000, nominal physician expenditures per capita grew 4.7% annually. Forty-two percent of this growth was attributable to general price inflation measured by the gross domestic product price deflator. The category of general economic variables and demographics was the next largest contributor to growth at 17%, followed by physician supply and provider structure (12%) and technology and treatment patterns (11%). Operating costs, health status, healthcare regulation, and health insurance benefit and product design comprised the remaining 18% of the growth. CONCLUSIONS: Because physicians are central to the healthcare system in the United States, efforts to contain physician spending reverberate through all healthcare services. The combined effect of an increase in the number and proportion of specialty care physicians, the continued development of clinical approaches for the control of chronic disease, and an aging population requiring intensive medical care imply that the current increase in healthcare expenditures could continue unabated, unless effective cost-control devices are deployed. To be effective, emerging strategies for influencing the affordability of healthcare services are likely to require a greater level of partnership between payers, providers, and other stakeholders. (+info)
Do physicians not offer useful services because of coverage restrictions?
Ethically, physicians should discuss all medically appropriate services with patients, but coverage restrictions can make these discussions difficult. In a national survey of physicians, we asked how often physicians elected not to offer their patients useful services because of health plan coverage rules. During the course of a year, 31 percent reported having sometimes not offered their patients useful services because of perceived coverage restrictions. Among these, 35 percent reported doing so more often in the most recent year than they did five years ago. It can be frustrating for doctors to discuss uncovered services with their patients, but open communication is necessary for shared decision making and to improve coverage decisions. (+info)
Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians.
OBJECTIVES: This study identified predictors of patient choice of a primary care medical doctor or chiropractor for treatment of low back pain. METHODS: Data from initial visits were derived from a prospective, longitudinal, nonrandomized, practice-based observational study of patients who self-referred to medical and chiropractic physicians (n = 1414). RESULTS: Logistic regression showed differences between patients who sought care from medical doctors vs chiropractors in terms of patient health status, sociodemographic characteristics, insurance, and attitudes. Disability, insurance, and trust in provider types were particularly important predictors. CONCLUSIONS: The study highlights the importance of patient attitudes, health status, and insurance in self-referral decisions. The significance of patient attitudes suggests that education might be used to shape attitudes and encourage cost-effective care choices. (+info)
Impact of provider continuity on quality of care for persons with diabetes mellitus.
BACKGROUND: Many patients with diabetes fail to receive recommended monitoring tests. One reason might be inadequate continuity of care. This study examined the association between provider continuity and completion of monitoring tests for patients with diabetes mellitus. METHODS: A cross-sectional analysis was conducted on claims data from a private national health plan for 1 year (January 1, 1999, through December 31, 1999). Participants had a diagnosis of diabetes mellitus and at least 2 outpatient visits during the study year (N = 1,795). The association was measured between continuity of care with an individual provider and completion of 3 diabetes monitoring tests: a glycosylated hemoglobin test, a lipid profile, and an eye examination. RESULTS: Eighty-one percent of patients had a glycosylated hemoglobin test, 66% had a lipid profile, and 28% had an eye examination during the study year. After controlling for demographics, number of diabetes visits, case mix, and diabetes complications, provider continuity was not significantly associated with the receipt of a glycosylated hemoglobin test (odds ratio [OR] = 0.61, 95% confidence interval [CI], 0.32-1.16), a lipid profile (OR = 0.97, 95% CI, 0.57-1.64) or an eye examination (OR = 0.60, 95% CI, 0.30-1.19). When continuity was measured only among primary care providers, there was no significant association for receipt of a glycosylated hemoglobin test (OR = 0.73, 95% CI, 0.41-1.33), a lipid profile (OR = 0.88, 95% CI, 0.53-1.47) or an eye examination (OR = 0.70, 95% CI, 0.35-1.36). CONCLUSIONS: This study found no association between provider continuity and completion of diabetes monitoring tests in a national privately insured population. Whereas continuity might benefit other aspects of health care, it does not appear to benefit improved monitoring for diabetes. (+info)