Physician acceptance of new Medicare patients stabilizes in 2004-05

Despite an earlier Medicare payment rate reduction, the proportion of U.S. physicians accepting Medicare patients stabilized in 2004-05, with nearly three-quarters saying their practices were open to all new Medicare patients, according to a new study by the Center for Studying Health System Change (HSC). In 2004-05, 72.9 percent of physicians reported accepting all new Medicare patients, statistically unchanged from 71.1 percent in 2000-01. Only 3.4 percent of physicians reported that their practices were completely closed to new Medicare patients in 2004-05, also statistically unchanged from 2000-01. These trends indicate the decline in Medicare physician access observed between 1996-97 and 2000-01 leveled off in 2004-05. In fact, Medicare beneficiaries' access to primary care physicians increased between 2000-01 and 2004-05, reversing an earlier decline. Among privately insured patients, trends in physician access are similar to those for Medicare patients, suggesting that overall health system dynamics have played a larger role in physician decisions about accepting Medicare patients than have Medicare payment policies.     

Prevention and health promotion in primary care: baseline results on physicians from the INSURE Project on Lifecycle Preventive Health Services

The INSURE Project on Lifecycle Preventive Health Services is a 3-year feasibility study to develop and test a clinical model of preventive health services, including patient education, in primary medical care as an insurance benefit. Seventy-four primary care physicians in group practices were surveyed regarding their baseline attitudes toward, and practice of, preventive services. Physicians report that they tend to be conscientious in educating their patients about their health risks, although they spend little time in patient education. Physicians are not sanguine about their success in getting their patients to follow their recommendations and tend to harbor doubts about their own efficacy in these areas. Specialty differences exist in these parameters. Physicians evidence contradictory attitudes about prevention. They believe doctors should spend more time providing preventive services but also believe that the lack of insurance reimbursement is an obstacle to providing these services. The concept of structural or sociological ambivalence is advanced to explain this pattern.     

Cancer education among primary care physicians in an underserved community

INTRODUCTION: Urban minority groups, such as those living in north Manhattan, are generally underserved with regard to cancer prevention and screening practices. Primary care physicians are in a critical position to counsel their patients on these subjects and to order screening tests for their patients. METHODS: Eighty-four primary care physicians in two intervention communities who received educational visits about cancer screening and prevention were compared with 38 physicians in a nearby community who received no intervention. With pre- and post-test interviews over an 18-month period, the physicians were asked about their attitudes toward, knowledge of (relative to American Cancer Society guidelines), and likelihood of counseling and screening for breast, cervical, colorectal, and prostate cancers. RESULTS: Comparison of the two surveys of physicians indicated no statistically significant differences in knowledge of cancer prevention or screening. At post-test, however, intervention group physicians identified significantly fewer barriers to practice than control physicians (p<0.05). While overall, the educational visits to inner-city primary care physicians did not appear to significantly alter cancer prevention practices, there was a positive dose-response relationship among the subgroup of participants who received three or more project contacts. CONCLUSIONS: We uncovered significant changes in attitude due to academic detailing among urban primary care physicians practicing in north Manhattan. A significant pre-test sensitization effect and small numbers may have masked overall changes in cancer prevention and screening behaviors among physicians due to the intervention.     

Professional integrity in the age of managed care: views of physicians.

At the end of 1997, one quarter of the American public used health maintenance organizations. This paper reports findings on physicians' perspectives on the role of managed care in their professional practices. The research data come from mailed surveys to physicians who are selected from the Cigna Directory of Physicians practicing in the State of Ohio. Subjects were asked to explain what managed care meant to them, and how long they have been practicing medicine. Questions also focused on professional autonomy, quality of care and career aspirations for the future. The results from the study suggest that managed care has had a negative impact on how physicians practice medicine. Several of our respondents reported that they are playing the role of a "double agent" and feel a sense of frustration in doing so. The degree of antipathy toward managed care differs between primary care physicians and specialists.     

Social policy and professional self-interest: Physician responses to DRGS

Prospective hospital reimbursement based on Diagnosis Related Groups (DRGs) began in 1983 for Medicare patients, and many states are adopting similar systems for Medicaid recipients in an attempt to curb rising health care costs. Because of their unprecedented intrusiveness compared to previous cost-containment measures and because they explicitly introduce financial incentives to reduce services, DRGs have great potential to affect health care delivery.To determine the effects of DRGs on hospitals and physicians, six months of ethnographic fieldwork was carried out on the medicine and pediatrics services of a university-affiliated hospital during the first year of DRG-based reimbursement. Observations and interviews were used to discern institutional responses to DRGs and physician knowledge of, experience with, and reactions to this cost-containment effort.Our findings indicate that the hospital instituted many changes to protect its interests. Data gathered from patients' abstracts suggest providers are successfully dealing with the new system; the average length of stay for Medicare patients was reduced by 38% in the first year of prospective reimbursement, compared with a 15% reduction for other patients (P < 0.05)As a group, the physicians made no organized effort to educate themselves about the new cost-containment regulations. Their knowledge of DRGs was vague and included many misconceptions. Their response was not a coherent one taking broad social concerns into account. Cost-containment was viewed negatively, as a threat to the financial integrity of the hospital, patient care, and professional autonomy. They responded on a case-by-case basis, generally complying with the formal procedures associated with the new regulations, while attempting to avoid or minimize the constraints imposed on their behavior. Their response represents an adaptation aimed at maximizing reimbursement for the hospital while insuring adequate care for individual patients. The response appears to have moderated the impact of cost-containment regulations, without wholly neutralizing them.These attitudes and responses to prospective payment are ones which have been promoted and reinforced by medical practice and education for some time. Yet they keep physicians from taking a positive role in forming effective public policy for cost-containment in medicine. Until physicians think more about cost-containment and its larger policy implications and develop a set of defensible responses to it, they will be unlikely to make a valuable professional contribution toward one of the most pressing policy issues confronting medicine today.     

Complementary and alternative medical practices: training,experience, and attitudes of a primary care medical school faculty

BACKGROUND: Interest in alternative and complementary medical practices has grown considerably in recent years. Previous surveys have examined attitudes of the general public and practicing physicians. This study examined the training, experience, and attitudes of medical school faculty, who have the primary responsibility for the education of future family physicians. METHODS: A 24-item, self-administered questionnaire was distributed to all 200 faculty at a medical school with a mission of training primary care physicians. RESULTS: Of 30 therapies listed, 5 were considered legitimate medical practices by more than 70% of the faculty. Eighty-five percent of the respondents reported some training in alternative medical therapies, and 62% were interested in additional training. Eighty-three percent of the faculty reported personal experience with alternative therapies and most rated these as effective. Eighty-five percent of the respondents indicated that their general attitude toward alternative medicine is positive. CONCLUSIONS: The results indicate that respondents have had substantial exposure to complementary therapies, are interested in learning more about these therapies, and have generally positive attitudes toward alternative medical practices and their use. Because of the role of these therapies in prevention, the positive attitudes might reflect the mission of this medical school to train primary care physicians.     

Federal health policy and group practices: the double-edged sword

This article explores the various major federal policies affecting medical group practices and whether these policies support, are neutral, or detract from group practice operations. Policies reviewed will consist of the Stark I and II laws with their self-referral and group practice organizational requirements; the Clinical Laboratory Improvement Act; physician reimbursement policies through the Medicare fee schedule (Resource Based Relative Value Scale); and other Medicare reimbursement policies related to teaching physicians, home health, rehabilitation, and rehabilitation services. The article concludes with recommendations as to how federal health policy might be reformed to be more supportive of and compatible with group medicine.     

Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices

Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of out patient visits by trained research nurses involving 4, 454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.     

Effects of performance-based reimbursement in healthcare

The aim of this study was to assess changes in attitudes and behaviour related to efficiency and quality of care after introduction of performance-based reimbursement. The study consisted of two parts. Part One was performed in 1992-94 as a repeated cross-sectional study of physicians in Stockholm County Council working with a newly introduced performance-based reimbursement system. Part Two was a similar study conducted in 1994 in 11 Swedish councils without performance-based reimbursement. The results show a significant difference between the two groups of physicians in attitudes concerning changes in quality of care and premature discharge from hospital. Despite concern about quality and premature discharge, physicians in Stockholm were found to have changed their behaviour in that the average length of stay in 1994 was about one day shorter in Stockholm than in the other 11 county councils. This indicates that the performance-based reimbursement system may strengthen the incentive to increase efficiency.     

Primary care physician perceptions of the nurse practitioner in the 1990s.

OBJECTIVE: To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care. DESIGN: A mailed survey of primary care physicians in Iowa. SETTING AND PARTICIPANTS: Half (N = 616) of the non-institutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n = 259 [42.0%]). MAIN OUTCOME MEASURES: There were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by chi 2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs. RESULTS: In bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P < .001), had been in practice for fewer than 20 years (P = .045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P = .01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P = .03), and general practice physicians (P = .04) had significantly more favorable attitudes toward NPs than did other primary care physicians. CONCLUSIONS: The association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.     

Healing the poor: The influence of patient socioeconomic status on physician supply responses

A longstanding literature explores how altruism affects the way physicians respond to incentives and provide care. We analyze how patient socioeconomic status mediates these responses. We show theoretically that patient socioeconomic status systematically influences the way physicians respond to reimbursement changes, and we identify the channels through which these effects operate. We use two Medicare reimbursement changes to investigate these insights empirically. We confirm that a given physician facing an increase in reimbursement boosts utilization by more when treating richer patients. We show that average supply price elasticities vary from 0.02 to 0.18 for a given physician, depending on the patient’s socioeconomic status. Finally, we show that the Medicare reforms we study led to overall reimbursement increases that raised healthcare utilization by 10% more for high-income patients compared to their low-income peers.     

Geriatric medicine in the United States: New roles for physician assistants

The problem of adequate medical care for the nation's elderly is mounting as this population grows in numbers. While the overall U.S. population has tripled since 1900, the segment over 65 has increased eightfold. Because of the high incidence of chronic illness in persons over 65, they consume a disproportionate amount of health care. Contributing to the problem are pervasive attitudes of ageism in the U.S. culture (including those of physicians), with the result that old people in the U.S. receive fragmented and often substandard medical care, particularly in nursing homes. Although some stirrings of activity in geriatric medicine are apparent in medical schools, not nearly enough faculty are available to teach courses and the interest of medical students is low. Several trends indicate that physician assistants are prepared to help fill the gaps in health care of the elderly. First, as physician extenders, these allied health professionals have demonstrated that they can perform approximately 80% of primary care tasks carried out by physicians at no sacrifice of quality. Second, a large proportion of the current caseload of physician assistants is patients over the age of 65. Third, physician assistant training programs have incorporated a fivefold increase in geriatric courses into their curricula since 1980, and both students and graduates show a high interest in this field. Finally, reimbursement policies of third party payers indicate a trend toward underwriting more physician assistant services. For example, Medicare Part B recently included payment of physician assistants in nursing homes and hospitals.     

Decoding incident-to and provider-based billing: ensuring payment and avoiding liability

In this increasingly complex world of Medicare reimbursement, physicians must constantly review their billing practices to ensure compliance with all Medicare requirements. "Incident-to" billing and provider-based billing are two areas that present unique challenges for providers, especially those practicing in hospital-owned practices such as hospital outpatient departments. Both incident-to and provider-based billing limit providers' abilities to bill for and receive reimbursement in those practice settings. The Office of Inspector General's 2012 Work Plan Report identified both incident-to billing and place-of-service errors as two of the many areas for investigation and compliance efforts in 2012. This article focuses on identifying the unique point-of-service challenges presented by physicians practicing in hospital outpatient departments or hospital-owned clinics.     

Medicare balance billing restrictions: impacts on physicians and beneficiaries

Beginning in the late 1980s, states and the federal government restricted the ability of physicians to "balance bill" Medicare beneficiaries for charges in excess of the copayment and reimbursement amounts approved by Medicare. In this paper, I provide empirical evidence that this policy change resulted in a 9% reduction in out-of-pocket medical expenditures by elderly households. In spite of the change in marginal reimbursement to physicians, however, I find little evidence that the restrictions affected patterns of care. Thus, this restriction on the prices charged by physicians amounted to a transfer from affected physicians to affected patients.     

Why Do Rural Primary Care Physicians Sell Their Practices?

This study evaluates why rural primary care physicians sell their practices. A random sample of rural primary care practices in California, Utah, Ohio, Texas, and Virginia were surveyed to investigate changes in ownership of the practices during the period 1995-1998. These five states were selected because they represent areas with different experiences with physician-hospital integration and varied rates of managed care penetration. A series of logistic regressions were conducted to examine the factors that led independent physicians to sell their practices to either nonlocal buyers, local hospitals, or local physicians. Findings suggest that sales to nonlocal buyers represent the majority of practice ownership changes. The motivations for ceding control to nonlocal buyers center on managed care concerns, recruitment concerns, and administrative burdens. Sellers were also concerned about their level of net income prior to being acquired. However, the preacquisition financial concerns of sellers were not significantly stronger than the financial concerns of practices that remained independent. The environmental conditions that motivate rural physicians to sell their practices are not expected to improve. Therefore, additional sales of rural primary care practices to nonlocal buyers are expected. Further research is necessary to determine whether this shift in control will lead to changes in the quality or accessibility of care.     

Older patients in the acute care setting: rural and metropolitan nurses' knowledge, attitudes and practices

ABSTRACT: Many studies reporting nurses' knowledge of and attitudes toward older patients in long-term care settings have used instruments designed for older people. However, nurses' attitudes toward older patients are not as positive as their attitudes toward older people. Few studies investigate acute care nurses' knowledge of and attitudes toward older patients. In order to address these shortcomings, a self-report questionnaire was developed to determine nurses' knowledge of, and attitudes and practices toward, older patients in both rural and metropolitan acute care settings. Rural nurses were more knowledgeable about older patients' activities during hospitalisation, the likelihood of them developing postoperative complications and the improbability of their reporting incontinence. Rural nurses also reported more positive practices regarding pain management and restraint usage. However, metropolitan nurses reported more positive attitudes toward sleeping medications, decision making, discharge planning and the benefits of acute gerontological units, and were more knowledgeable about older patients' bowel changes in the acute care setting.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

The impact of PPS on hospital-sponsored post-acute services: a case study of Delaware Medicare providers

Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.     

Sex bias in the assessment of patient complaints

This study investigates the contention that physicians have prejudicial attitudes toward female patients. One hundred twenty of 220 (58 percent) primary care physicians returned questionnaires that recorded their attitudes toward two hypothetical patients, one with a headache, one with abdominal pain. By changing only the gender of nouns and pronouns, two otherwise identical versions of each case had been constructed, one case describing a female patient, one a male patient. The physician subjects recorded their attitudes on a semantic differential scale designed to measure three dimensions of attitudes toward patients: authenticity, impression of severity of illness, and emotionality. The physicians judged the female patients to be more emotional (P less than .05) but no less authentic or ill than the male patients.