Where is the financial safety net for managed care physicians?
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OBJECTIVE: Empiric research on mechanisms by which managed care physicians attempt to mitigate financial risk is lacking. We assumed the perspective of a managed care plan in investigating the relationship between risk sharing and the match between a physician's capitation payments and costs of care. DESIGN: The study design was a family of payment simulations using 2 years of managed care claims data. METHODS: Claims from a cohort of 82,525 managed care patients were used, with year 1 data determining a capitation rate for year 2 primary care services. The net provider payment in year 2 was examined under scenarios that might modify financial outcomes, including stop-loss insurance, age- and gender-adjustment of capitation, and risk pooling within independent practice associations. RESULTS: The size of a provider's patient panel was positively correlated with net per capita payment (r = 0.22; P < 0.0001 without risk modification strategies). The variance of the ratio of net to total revenue was utilized as a proxy for the degree of risk assumed in caring for a panel of capitated enrollees. Risk modification strategies reduced this variance measure, with risk pooling producing the largest effect, especially for providers of panels of fewer than 135 patients. In contrast, age- and gender-adjustment of capitation payments had little effect on reimbursement outcomes. CONCLUSIONS: Short of increasing the pool of capitated patients, risk modification strategies appear limited in their ability to produce more equitable reimbursement to providers with small patient panels. With many providers assuming substantial risk in pursuing managed care contracts, these dynamics may favor organizational forms of medical practice that facilitate large patient panels within a single plan. (+info)
Electronic imaging and clinical implementation: work group approach at Mayo Clinic, Rochester.
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Electronic imaging clinical implementation strategies and principles need to be developed as we move toward replacement of film-based radiology practices. During an 8-month period (1998 to 1999), an Electronic Imaging Clinical Implementation Work Group (EICIWG) was formed from sections of our department: Informatics Lab, Finance Committee, Management Section, Regional Practice Group, as well as several organ and image modality sections of the Department of Diagnostic Radiology. This group was formed to study and implement policies and strategies regarding implementation of electronic imaging into our practice. The following clinical practice issues were identified as key focus areas: (1) optimal electronic worklist organization; (2) how and when to link images with reports; (3) how to redistribute technical and professional relative value units (RVU); (4) how to facilitate future practice changes within our department regarding physical location and work redistribution; and (5) how to integrate off-campus imaging into on-campus workflow. The EICIWG divided their efforts into two phases. Phase I consisted of Fact finding and review of current practice patterns and current economic models, as well as radiology consulting needs. Phase II involved the development of recommendations, policies, and strategies for reengineering the radiology department to maintain current practice goals and use electronic imaging to improve practice patterns. The EICIWG concluded that electronic images should only be released with a formal report, except in emergent situations. Electronic worklists should support and maintain the physical presence of radiologists in critical areas and direct imaging to targeted subspecialists when possible. Case tools should be developed and used in radiology and hospital information systems (RIS/HIS) to monitor a number of parameters, including professional and technical RVU data. As communication standards improve, proper staffing models must be developed to facilitate electronic on-campus and off-campus consultation. (+info)
Costing for long-term care: the development of Scottish health service resource utilization groups as a casemix instrument.
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OBJECTIVE: to create a casemix measure with a limited number of categories which discriminate in terms of resource use and will assist in the development of a currency for contracting for the provision of health care. DESIGN: nursing staff completed a questionnaire providing clinical data and also gave estimates of relative patient resource use; ward-based costs were collected from appropriate unit managers. SETTING: National Health Service continuing-care wards in 50 Scottish hospitals. SUBJECTS: 2783 long-stay patients aged 65 years and over. RESULTS: inter-rater reliability was assessed using 1402 patients; percentage agreement between raters for individual variables varied from 68% for feeding to 97% for clinically complex treatments. Nursing costs gave 62% agreement given categories of high, medium and low. The Scottish health service resource utilization groups (SHRUG) measure was developed using 606 cases, and 67% consistency was achieved for the five categories. The relative weights for the SHRUG categories ranged from 0.56 to 1.41. The five categories explain 35% of variance in costs. CONCLUSIONS: the five SHRUG casemix categories show good discrimination in terms of costs. The SHRUG measure compares favourably with diagnosis-related groups in the acute sector and with other casemix instruments for long-term care previously piloted in the UK. SHRUG is a useful measurement instrument in assessing the resource needs of elderly people in long-term care. (+info)
Rewarding teaching faculty with a reimbursement plan.
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OBJECTIVE: To develop a system for measuring the teaching effort of medical school faculty and to implement a payment system that is based on it. DESIGN: An interventional study with outcomes measured before and after the intervention. SETTING: A department of internal medicine with a university hospital and an affiliated Veterans Administration hospital. INTERVENTION: We assigned a value in teaching units to each teaching activity in proportion to the time expended by the faculty and the intensity of their effort. We then calculated total teaching units for each faculty member in the Division of General Internal Medicine and for combined faculty effort in each subspecialty division in the Department of Medicine. After determining the dollar value for a teaching unit, we distributed discretionary teaching dollars to each faculty member in the Division of General Internal Medicine and to each subspecialty division according to total teaching units. MEASUREMENTS AND MAIN RESULTS: The distribution of discretionary teaching dollars was determined. In the year after the intervention, there was a substantial redistribution of discretionary teaching dollars among divisions. Compared with an increase in total discretionary dollars of 11.4%, the change in allocation for individual divisions ranged from an increase of 78.2% to a decrease of -28.5%. Further changes in the second year after the intervention were modest. The distribution of teaching units among divisions was similar to the distribution of questions across subspecialties on the American College of Physicians In-Training Examination (r =.67) and the American Board of Internal Medicine Certifying Examination (r =.88). CONCLUSIONS: It is possible to measure the value of teaching effort by medical school faculty and to distribute discretionary teaching funds among divisions according to the value of teaching effort. When this intervention was used at our institution, there were substantial changes in the amounts received by some divisions. We believe that the new distribution more closely approximates the desired distribution because it reflects the desired emphasis on knowledge as measured by two of the most experienced professional groups in internal medicine. We also believe that our method is flexible and adaptable to the needs of most clinical teaching (+info)
The intensity of physicians' work in patient visits--implications for the coding of patient evaluation and management services.
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BACKGROUND: Clinicians use visit codes to bill for services involving the evaluation of patients and the management of their care. The existing guidelines for coding and documenting these services, as well as proposed revisions, have been criticized as complex, clinically irrelevant, and costly. We investigated whether easily measured characteristics of physician-patient visits accurately reflect differences in the amount of work performed. Such characteristics might provide the basis for a simple and equitable physician-payment scheme. METHODS: We collected information about the amount of physicians' work, the time spent in encounters with patients, and characteristics of patients and visits for 19,143 physician-patient visits in the practices of 339 urologists, rheumatologists, and general internists. Physicians recorded the actual time involved in evaluating the patient and managing his or her care during each visit and estimated the work involved in relation to a standardized, hypothetical visit. We used multivariate linear regression to identify factors related to differences in the total amount of work and to calculate work and work intensity (work per minute) for different types of visits. RESULTS: The duration of the face-to-face encounter with the patient or family (encounter time) was strongly predictive of the total amount of work. Total work, however, did not increase in direct proportion to encounter time. Visits with shorter encounter times were more intense than longer ones, in part because the work involved in providing fixed services, such as review of records and entry of information, did not vary in direct proportion to the length of the face-to-face encounter. Work intensity was greater for new patients than for established patients, for patients referred by other physicians than for those who were not, and for patients with new rather than previously existing problems. CONCLUSIONS: A simple coding scheme based on time spent by the physician in the face-to-face encounter and a limited set of characteristics of the visit would accurately reflect total work in actual practice. A fee structure based on these factors and the inverse relation between work per minute and the encounter time would provide equitable payment while encouraging efficiency and discouraging "upcoding" of services. (+info)
Quantifying physician teaching productivity using clinical relative value units.
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OBJECTIVE: To design and test a customizable system for calculating physician teaching productivity based on clinical relative value units (RVUs). SETTING/PARTICIPANTS: A 550-bed community teaching hospital with 11 part-time faculty general internists. DESIGN: Academic year 1997-98 educational activities were analyzed with an RVU-based system using teaching value multipliers (TVMs). The TVM is the ratio of the value of a unit of time spent teaching to the equivalent time spent in clinical practice. We assigned TVMs to teaching tasks based on their educational value and complexity. The RVUs of a teaching activity would be equal to its TVM multiplied by its duration and by the regional median clinical RVU production rate. MEASUREMENTS: The faculty members' total annual RVUs for teaching were calculated and compared with the RVUs they would have earned had they spent the same proportion of time in clinical practice. MAIN RESULTS: For the same proportion of time, the faculty physicians would have generated 29,806 RVUs through teaching or 27, 137 RVUs through clinical practice (Absolute difference = 2,669 RVUs; Relative excess = 9.8%). CONCLUSIONS: We describe an easily customizable method of quantifying physician teaching productivity in terms of clinical RVUs. This system allows equitable recognition of physician efforts in both the educational and clinical arenas. (+info)
A value analysis model applied to the management of amblyopia.
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PURPOSE: To assess the value of amblyopia-related services by utilizing a health value model (HVM). Cost and quality criteria are evaluated in accordance with the interests of patients, physicians, and purchasers. METHODS: We applied an HVM to a hypothetical statistical ("median") child with amblyopia whose visual acuity is 20/80 and to a group of children with amblyopia who are managed by our practice. We applied the model to calculate the value of these services by evaluating the responses of patients and physicians and relating these responses to clinical outcomes. RESULTS: The consensus value of care for the hypothetical median child was calculated to be 0.406 (of 1.000). For those children managed in our practice, the calculated value is 0.682. Clinically, 79% achieved 20/40 or better visual acuity, and the mean final visual acuity was 0.2 logMAR (20/32). Value appraisals revealed significant concerns about the financial aspects of amblyopia-related services, particularly among physicians. Patients rated services more positively than did physicians. CONCLUSIONS: Amblyopia care is difficult, sustained, and important work that requires substantial sensitivity to and support of children and families. Compliance and early detection are essential to success. The value of amblyopia services is rated significantly higher by patients than by physicians. Relative to the measured value, amblyopia care is undercompensated. The HVM is useful to appraise clinical service delivery and its variation. The costs of failure and the benefits of success are high; high-value amblyopia care yields substantial dividends and should be commensurately compensated in the marketplace. (+info)
Trends in Medicaid physician fees, 1993-1998.
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This study uses data on Medicaid physician fees in 1993 and 1998 to document variation in fees across the country, describe changes in these fees, and contrast how they changed relative to those in Medicare. The results show that 1998 Medicaid fees varied widely. Medicaid fees grew 4.6 percent between 1993 and 1998, lagging behind the general rate of inflation. This growth was greater for primary care services than for other services studied. Relative to Medicare physician fees, Medicaid fees fell by 14.3 percent between 1993 and 1998. Medicaid's low fees and slow growth rates suggest that potential access problems among Medicaid enrollees remain a policy issue that should be monitored. (+info)