Measuring the "managedness" and covered benefits of health plans.
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STUDY AIMS: (1) To develop indexes measuring the degree of managedness and the covered benefits of health insurance plans, (2) to describe the variation in these indexes among plans in one health insurance market, (3) to assess the validity of the health plan indexes, and (4) to examine the association between patient characteristics and the health plan indexes. Measures of the "managedness" and covered benefits of health plans are requisite for studying the effects of managed care on clinical practice and health system performance, and they may improve people's understanding of our complex health care system. DATA SOURCES/STUDY SETTING: As part of our larger Physician Referral Study, we collected health insurance information for 189 insurance product lines and 755 products in the Seattle, Washington metropolitan area, which we linked with the study's data for 2,277 patients recruited in local primary care offices. STUDY DESIGN: Managed care and benefit variables were constructed through content analysis of health plan information. Principal component analysis of the variables produced a managedness index, an in-network benefits index, and an out-of-network benefits index. Bivariable analyses examined associations between patient characteristics and the three indexes. PRINCIPAL FINDINGS: From the managed care variables, we constructed three provider-oriented indexes for the financial, utilization management, and network domains of health plans. From these, we constructed a single managedness index, which correlated as expected with the individual measures, with the domain indexes, with plan type (FFS, PPO, POS, HMO), with independent assessments of local experts, and with patients' attitudes about their health insurance. For benefits, we constructed an in-network benefits index and an out-of-network benefits index, which were correlated with the managedness index. The personal characteristics of study patients were associated with the managed care and benefit indexes. Study patients in more managed plans reported somewhat better health than patients in less managed plans. CONCLUSIONS: Indexes of the managedness and benefits of health plans can be constructed from publicly available information. The managedness and benefit indexes are associated with the personal characteristics and health status of study patients. Potential uses of the managed care and benefits indexes are discussed. (+info)
Toward a redefinition of psychiatric emergency.
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OBJECTIVE: To compare three methods for rating legitimate use of psychiatric emergency services (PES) in order to develop criteria that can differentiate appropriate from inappropriate PES service requests. METHOD: Ratings of PES visits by treating physicians and ratings of the same visits made during review of medical records. STUDY DESIGN: Two previously used methods of identifying justified PES service use were compared with the treating physician's rating of the same: (1) hospitalization as visit outcome and (2) retrospective chart ratings of visit characteristics using traditional medico-surgical criteria for "emergent" illness episodes. DATA EXTRACTION METHODS: Data were extracted through use of a physician questionnaire, and medical and administrative record review. PRINCIPAL FINDINGS: Agreement between the methods ranged from 47.1 percent to 74.1 percent. A total of 21.7 percent of visits were rated as true health "emergencies" by the traditional definition, while 70.4 percent of visits were rated as "necessary" by treating physicians, and 21.0 percent resulted in hospitalization. Acuteness of behavioral dyscontrol and imminent dangerousness at the time of the visit were common characteristics of appropriate use by most combinations of the three methods of rating visits. CONCLUSIONS: The rating systems employed in similar recent studies produce widely varying percentages of visits so classified. However, it does appear likely that a minimum of 25-30 percent of visits are nonemergent and could be triaged to other, less costly treatment providers. Proposed criteria by which to identify "legitimate" psychiatric emergency room treatment requests includes only patient presentations with (a) acute behavioral dyscontrol or (b) imminent dangerousness to self or others. (+info)
Assessing immunization coverage in private practice.
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To achieve national health objectives of eliminating most childhood vaccine-preventable diseases by the year 2010, all health care providers will have to improve the immunization rates of their patients. Currently, immunization rates of children 19 to 35 months of age are less than national objectives, suggesting a need for optimized immunization services. A key strategy for improving age-appropriate immunization coverage by health care providers is the assessment of immunization coverage. Because most (62%), immunization services in the United States are delivered in the private sector, a concerted effort in private practice is critical to improving immunization rates. Assessment of immunization coverage of patients enrolled in private practice serves 1) to measure the overall performance of the practice in providing the standard of care, 2) to identify strategies for improving coverage, and 3) to document the quality of health services delivered (report card). Assessment of immunization coverage has been demonstrated in several practice settings to be highly effective in improving immunization rates. All types of physicians should benefit from assessing immunization coverage of their patients. Simple assessment tools are available at no cost to the public and can be obtained by contacting the Centers for Disease Control and Prevention. These tools include a manual self-assessment or a computerized software package (CASA) to fit the needs of the practice. (+info)
Hospital resource consumption in patients with diabetes and multivessel coronary disease undergoing revascularization.
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OBJECTIVE: To identify factors responsible for the variation in real hospital costs and length of stay for patients with diabetes undergoing coronary angioplasty or coronary bypass surgery. STUDY DESIGN: Retrospective study of patients with diabetes and coronary artery disease treated at a single hospital. PATIENTS AND METHODS: The study population included 1809 patients with diabetes and multivessel (2-vessel or 3-vessel) coronary artery disease who underwent an initial coronary angioplasty or coronary bypass surgery between 1988 and 1996. After accounting for the extent and severity of the patient's coronary artery disease, a sequential model was used to assess if diabetic characteristics were independently associated with higher hospital resource utilization during revascularization. RESULTS: Multivariate regression results indicated that for patients with diabetes who underwent coronary angioplasty, a baseline creatinine level of > or = 2.0 mg/dL was associated with significantly higher hospital costs and longer length of stay. For patients with diabetes who underwent a coronary bypass surgery only, a baseline creatinine level of > or = 2.5 mg/dL was associated with higher hospital costs and longer hospital length of stay. CONCLUSIONS: After controlling for coronary risk factors, selected diabetes-specific characteristics are associated with higher hospital resource utilization. Risk adjustments in hospital reimbursement may be needed to assure that patients with diabetes who have cardiovascular disease have access to revascularization procedures. (+info)
Liability and validity of the Appropriateness Evaluation Protocol in Turkey.
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OBJECTIVE: To assess the inter-rater reliability between nurses and the convergent validity of the Appropriateness Evaluation Protocol (AEP) in the Turkish context. METHODS: Two nurses applied the original AEP concurrently to a random subsample of 335 patient-days in internal medicine, general surgery, and gynaecology departments at a university hospital and a government teaching hospital, as a part of a larger study. Inter-rater reliability was tested by calculating overall agreement and specific agreements between nurse reviewers' AEP assessments. Validity was tested by comparing the assessments of the nurses based on the AEP with the implicit judgements of five expert physicians on a random subsample of 818 patient-days. Sensitivity, specificity, positive and negative predictive values of the AEP were calculated. Reliability and validity were also evaluated by the K statistic. RESULTS: In the reliability test, there was a high level of agreement between the two independent raters applying the AEP in the three departments studied: overall agreement = 90.7-97.6%; specific inappropriate agreement = 69.1-92.3%; specific appropriate agreement = 88.3-96.6%. In validity testing, the AEP had a sensitivity of 0.83-0.97, specificity of 0.62-0.80, and positive and negative predictive values of 0.84-0.88 and 0.73-0.95 respectively. Kappa coefficients in internal medicine and gynaecology indicated almost perfect agreement in reliability testing and moderate agreement in validity testing. In general surgery, the K coefficients showed substantial agreement in both tests. CONCLUSION: These results indicate that the AEP is a reliable and valid instrument to assess appropriateness of patient-days in Turkey. (+info)
The four basic types of evaluation: clinical reviews, clinical trials, program reviews, and program trials.
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Four basic types of evaluation, each appropriate in a distinctive situation, are the clinical review and the clinical trial, which are concerned with the care of the individual patient, and the program review and program trial, which deal with programs or services directed at groups or populations. Evaluative reviews are primarily motivated by concern with the welfare of the specific population served, and they appraise specific activities in specific settings as a basis for decisions concerning these activities. Clinical and program trials aim to generate knowledge of more general applicability, especially concerning causal relationships between care and outcomes. The types of evaluation differ in the questions they pose and in the methods used to answer them. Failure to draw a distinction between program reviews and program trials is a frequent cause of wasteful or unhelpful evaluative studies. (+info)
Controlling the cost of dental care.
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Methods for controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. The use of regulatory systems to monitor provider performance are necessary to prevent gross over-utilization but are unlikely to result in net savings of more than five per cent of total gross premiums. Theoretically, prepaid group dental practice (PGDP) may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of PGDPs presently in operation limit the importance of this alternative for the next five to ten years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost-effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects on improving oral health may not be easy for the public to accept but, until they do, expenditures for dental care will be difficult to control. (+info)
Fairness and rationing implications of medical necessity decisions.
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When healthcare coverage entails medical necessity review, patients, providers, payers, and government agencies must confront issues of fairness and rationing. To explore the ethical ramifications of medical necessity decisions, we provide 2 illustrative case. In the first case, we discuss the implications of rule-based rationing and in the second we consider the influence of a medical group's internal review council on decisions of medical necessity. Both case examples illustrate why there are no agreed-on rules for setting a threshold for approving or denying care based on medical necessity and suggest that more complex medical cases require a more complex review process. (+info)