Cost-effectiveness of sumatriptan in a managed care population.
(9/1822)
We conducted an open-labeled study to determine whether sumatriptan is more cost-effective than other therapies used to treat migraine headache. We contacted by phone 220 sumatriptan users enrolled in QualMed, a health maintenance organization (HMO) in Spokane, Washington. Of these, 203 met the inclusion criteria and 164 (81%) completed our telephone survey. The main outcome measures were healthcare costs to the HMO and number of days free of migraine-related disability before and after sumatriptan treatment. Before sumatriptan treatment, 89% of patients reported severe migraine, compared with 63% after sumatriptan treatment. The number of monthly migraine disability days decreased from 6.5 days per month before sumatriptan to 3.9 days per month after sumatriptan. Healthcare utilization rates (ie, number of hospitalizations, emergency department visits) and costs were lower after the patients began taking sumatriptan. The number of different over-the-counter medicines and prescription medications (other than sumatriptan) taken for migraine disabilities decreased. Although total drug expenditures per month increased, the total migraine healthcare expenditure was 41% lower after sumatriptan was initiated. The cost-effectiveness ratio was 47% more favorable after patients started taking sumatriptan. Overall, patients reported fewer migraine-related disabilities, had lower migraine severity scores, and used fewer healthcare resources when taking sumatriptan. These changes resulted in a better cost-effectiveness ratio for migraine treatment. (+info)
Improving clinician acceptance and use of computerized documentation of coded diagnosis.
(10/1822)
After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility. (+info)
Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State.
(11/1822)
The perceived relationship between primary care physician compensation and utilization of medical services in medical groups affiliated with one or more among six managed care organizations in the state of Washington was examined. Representatives from 67 medical group practices completed a survey designed to determine the organizational arrangements and norms that influence primary care practice and to provide information on how groups translate the payments they receive from health plans into individual physician compensation. Semistructured interviews with 72 individual key informants from 31 of the 67 groups were conducted to ascertain how compensation method affects physician practice. A team of raters read the transcripts and identified key themes that emerged from the interviews. The themes generated from the key informant interviews fell into three broad categories. The first was self-selection and satisfaction. Compensation method was a key factor for physicians in deciding where to practice. Physicians' satisfaction with compensation method was high in part because they chose compensation methods that fit with their practice styles and lifestyles. Second, compensation drives production. Physician production, particularly the number of patients seen, was believed to be strongly influenced by compensation method, whereas utilization of ancillary services, patient outcomes, and satisfaction are seen as much less likely to be influenced. The third theme involved future changes in compensation methods. Medical leaders, administrators, and primary care physicians in several groups indicated that they expected changes in the current compensation methods in the near future in the direction of incentive-based methods. The responses revealed in interviews with physicians and administrative leaders underscored the critical role compensation arrangements play in driving physician satisfaction and behavior. (+info)
"Carving out" conditions from global capitation rates: protecting high-cost patients, physicians, and health plans in a managed care environment.
(12/1822)
The purposes of this study were (1) to develop a method for identifying individuals with high-cost medical conditions, (2) to determine the percentage of healthcare spending they represent, and (3) to explore policy implications of "carving out" their care from managed care capitation. Annual payments over a 2-year period to enrollees of three health plans--a traditional managed care organization, and a state Medicaid program--were determined by using a cross-sectional analysis of insurance claims data. The main outcome measures were the number of enrollees with total annual payments in excess of $25,000 and the contribution of these high-cost enrollees to each health plan's total costs. Forty-one groups of diagnosis and procedure codes representing a combination of acute and chronic conditions were included on the list of carve-out conditions. Pulmonary insufficiency and respiratory failure together accounted for the largest number of high-cost individuals in each health plan. Solid organ and bone marrow transplants, AIDS, and most malignancies that required high-dose chemotherapy were also important. The carve-out list identified more than one third of high-cost individuals enrolled in the Medicaid program, approximately 20% of high-cost managed care enrollees, and 10% of high-cost fee-for-service enrollees. These data confirm that it is possible to identify high-cost individuals in health plans by using a carve-out list. Carving out high-cost patients from capitation risk arrangements may protect patients, physicians, and managed care organizations. (+info)
Device evaluation and coverage policy in workers' compensation: examples from Washington State.
(13/1822)
Workers' compensation health benefits are broader than general health benefits and include payment for medical and rehabilitation costs, associated indemnity (lost time) costs, and vocational rehabilitation (return-to-work) costs. In addition, cost liability is for the life of the claim (injury), rather than for each plan year. We examined device evaluation and coverage policy in workers' compensation over a 10-year period in Washington State. Most requests for device coverage in workers' compensation relate to the diagnosis, prognosis, or treatment of chronic musculoskeletal conditions. A number of specific problems have been recognized in making device coverage decisions within workers' compensation: (1) invasive devices with a high adverse event profile and history of poor outcomes could significantly increase both indemnity and medical costs; (2) many noninvasive devices, while having a low adverse event profile, have not proved effective for managing chronic musculoskeletal conditions relevant to injured workers; (3) some devices are marketed and billed as surrogate diagnostic tests for generally accepted, and more clearly proven, standard tests; (4) quality oversight of technology use among physicians may be inadequate; and (5) insurers' access to efficacy data adequate to make timely and appropriate coverage decisions in workers' compensation is often lacking. Emerging technology may substantially increase the costs of workers' compensation without significant evidence of health benefit for injured workers. To prevent ever-rising costs, we need to increase provider education and patient education and consent, involve the state medical society in coverage policy, and collect relevant outcomes data from healthcare providers. (+info)
Risk-adjusted outcome models for public mental health outpatient programs.
(14/1822)
OBJECTIVE: To develop and test risk-adjustment outcome models in publicly funded mental health outpatient settings. We developed prospective risk models that used demographic and diagnostic variables; client-reported functioning, satisfaction, and quality of life; and case manager clinical ratings to predict subsequent client functional status, health-related quality of life, and satisfaction with services. DATA SOURCES/STUDY SETTING: Data collected from 289 adult clients at five- and ten-month intervals, from six community mental health agencies in Washington state located primarily in suburban and rural areas. Data sources included client self-report, case manager ratings, and management information system data. STUDY DESIGN: Model specifications were tested using prospective linear regression analyses. Models were validated in a separate sample and comparative agency performance examined. PRINCIPAL FINDINGS: Presence of severe diagnoses, substance abuse, client age, and baseline functional status and quality of life were predictive of mental health outcomes. Unadjusted versus risk-adjusted scores resulted in differently ranked agency performance. CONCLUSIONS: Risk-adjusted functional status and patient satisfaction outcome models can be developed for public mental health outpatient programs. Research is needed to improve the predictive accuracy of the outcome models developed in this study, and to develop techniques for use in applied settings. The finding that risk adjustment changes comparative agency performance has important consequences for quality monitoring and improvement. Issues in public mental health risk adjustment are discussed, including static versus dynamic risk models, utilization versus outcome models, choice and timing of measures, and access and quality improvement incentives. (+info)
Attitudes and interest in genetic testing for breast and ovarian cancer susceptibility in diverse groups of women in western Washington.
(15/1822)
OBJECTIVES: This paper examines the knowledge, opinions, and predictors of interest in genetic testing for breast cancer risk in a demographically diverse group of women in western Washington who participated in a randomized controlled trial (RCT) of breast cancer risk counseling methods. MATERIALS AND METHODS: Four groups of women were surveyed, all with some family history of breast cancer: (a) 307 white women; (b) 36 African-American women; (c) 87 lesbian/bisexual women; and (d) 113 Ashkenazi Jewish women. As part of the baseline questionnaire for the RCT, participants were asked about their familiarity with genetic testing for breast cancer risk, their interest in such testing and opinions of it, and actions they anticipated based on test results. RESULTS: Women in all four groups favored ready access to testing, believed the decision to be tested should be a personal choice, believed that genetic test results should stay confidential, and were not greatly concerned that this might not be possible. Women anticipated using such genetic test results to increase the frequency of various breast cancer screening methods (in all four groups, > 69% would increase mammogram frequency, > 85% would increase clinician exam, and > 92% would increase breast self exam). Women overwhelmingly rejected prophylactic surgery as a preventive measure (in all > 80% probably or definitely would not consider it). Significant predictors of interest in genetic testing for cancer risk included perceived risk, cancer worry, and beliefs about access to testing. CONCLUSIONS: These data will be of interest to health care providers, payers, public health professionals, legislators, and others as they consider issues associated with population testing for susceptibility to common diseases such as breast cancer. (+info)
CD-ROM use by rural physicians.
(16/1822)
A survey of 131 eastern Washington rural family physicians showed that 59.5% owned a personal computer with a CD-ROM drive. There was an inverse correlation between the physicians' years in practice and computer ownership: 10 years or less (80.6%), 11 to 20 years (72.2%), 21 to 30 years (55.6%), and more than 30 years (32.4%). Those physicians who owned a computer used their CD-ROM for entertainment (52.6%), medical textbooks (44.9%), literature searching software (25.6%), drug information (17.9%), continuing medical education (15.4%), and journals on CD-ROM (11.5%). Many rural doctors who owned computers felt that CD-ROM software helped them provide better patient care (46.8%) and kept them current on new information and techniques (48.4%). Indications for medical education, libraries and CD-ROM publishers are noted. (+info)