Hospitals' Negotiating Leverage with Health Plans: How and Why Has It Changed?

Objective.  To describe how hospitals' negotiating leverage with managed care plans changed from 1996 to 2001 and to identify factors that explain any changes.
Data Sources.  Primary semistructured interviews, and secondary qualitative (e.g., newspaper articles) and quantitative (i.e., InterStudy, American Hospital Association) data.
Study Design.  The Community Tracking Study site visits to a nationally representative sample of 12 communities with more than 200,000 people. These 12 markets have been studied since 1996 using a variety of primary and secondary data sources.
Data Collection Methods.  Semistructured interviews were conducted with a purposive sample of individuals from hospitals, health plans, and knowledgeable market observers. Secondary quantitative data on the 12 markets was also obtained.
Principal Findings.  Our findings suggest that many hospitals' negotiating leverage significantly increased after years of decline. Today, many hospitals are viewed as having the greatest leverage in local markets. Changes in three areas—the policy and purchasing context, managed care plan market, and hospital market—appear to explain why hospitals' leverage increased, particularly over the last two years (2000–2001).
Conclusions.  Hospitals' increased negotiating leverage contributed to higher payment rates, which in turn are likely to increase managed care plan premiums. This trend raises challenging issues for policymakers, purchasers, plans, and consumers.     

Medicaid Managed Care and Health Care for Children

Objective. Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures. Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys ( n =2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Study Design. Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Principal Findings. Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Conclusions. Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.     

Primary Care Service Areas: A New Tool for the Evaluation of Primary Care Services

Objective. To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians.
Data Source/Study Setting. The 1996–1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996).
Study Design. A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims.
Data Collection/Extraction Methods. Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes.
Principal Findings. The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005–1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical.
Conclusions. Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.     

Understanding pediatricians' views toward school-based BMI screening in Massachusetts: a pilot study

BACKGROUND: Massachusetts (MA) mandated body mass index (BMI) screening in schools in 2010. However, little is known about pediatricians' views on school‐based screening or how the pediatricians' perspectives might affect the school‐based screening process. We assessed MA pediatricians' knowledge, attitudes, beliefs, and practices concerning BMI screening. METHODS: An anonymous Web‐based survey was completed by 286 members of the MA Chapter of the American Academy of Pediatrics who provided primary care (40% response rate). RESULTS: Support for school‐based BMI screening was mixed. While 16.1% strongly supported it, 12.2% strongly opposed it. About one fifth (20.2%) believed school‐based screening would improve communication between schools and pediatricians; 23.0% believed school‐based screening would help with patient care. More (32.2%) believed screening in schools would facilitate communication with families. In contrast, pediatricians embraced BMI screening in practice: 91.6% calculated and 85.7% plotted BMI at every well child visit. Pediatricians in urban practices, particularly inner city, had more positive attitudes toward BMI screening in schools, even when adjusting for respondent demographics, practice setting, and proportion of patients in the practice who were overweight/obese (p < .001). CONCLUSION: These data suggest MA pediatricians use BMI screening and support its clinical utility. However, support for school‐based BMI screening was mixed. Urban‐based pediatricians in this sample held more positive beliefs about screening in schools. Although active collaboration between schools and pediatricians would likely help to ensure that the screenings have a positive impact on child health regardless of location, it may be easier for urban‐based schools and pediatricians to be successful in developing partnerships.     

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.     

Inequalities in Use of Health Services among Jews and Arabs in Israel

Objectives. To compare the levels of utilization of health services in Jews and Arabs taking into account differences in levels of socioeconomic status (SES) in a country with a National Health Insurance Law (NHIL).
Data Source/Study Setting. A cross-sectional National Health Interview Survey was carried out in Israel based on a random sample of telephone numbers as part of the EUROHIS project (WHO European Health Interview Survey 2003–2004).
Study Design. A random telephone survey included 9,352 interviews. Questions included use of health care services, health status, and socioeconomic variables.
Principal Findings. After adjusting for sex, age, income, education, marital status, and self-reported chronic diseases, Arabs more often reported visiting a family physician (odds ratio [OR]=1.56, 95 percent confidence interval [CI]=1.35–1.81) and less often reported visiting a specialist (OR=0.73, 95 percent CI=0.60–0.89) compared with Jews. In addition, the odds ratio for hospitalization was similar among Arabs and Jews (OR=1.16, 95 percent CI=0.97–1.38). SES was associated with utilization of health care services only in the Jewish population.
Conclusions. A different pattern of utilization of health care services was observed in Arabs and Jews. This was not explained by differences in socioeconomic levels. More research is needed regarding the distribution of services between Jews and Arabs.     

Barriers to colorectal cancer screening in rural primary care

BACKGROUND: Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening. METHODS: We surveyed patients (N = 801) over 50 years of age and primary care physicians (N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients. RESULTS: Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method. CONCLUSIONS: CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician-patient discussions of CRC.     

Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system

ObjectiveTo describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018).Data Sources/Study SettingProject records, surveys, Bureau of Labor Statistics compensation data.Study DesignLabor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback.Data Collection/Extraction MethodsPersonnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members.Principal FindingImplementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites.ConclusionsWhen spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.     

The effect of community-level unemployment on preventive oral health care utilization

Objective. To test the hypothesis that high community-level unemployment is associated with reduced use of preventive dental care services by a dentally insured population.
Data. The study uses monthly data on population dental visits and unemployment in the Seattle and Spokane areas from 1995 to 2004. Utilization data come from Washington Dental Services. Unemployment data were obtained from the Bureau of Labor Statistics and Washington's Employment Security Department.
Study Design. The study uses a Box–Jenkins Autoregressive Integrated Moving Average (ARIMA) method to measure the association between the variables over time. The approach controls for the effects of autocorrelation, seasonality, and confounding variables.
Findings. In the Seattle area, an unexpected 10,000 unit increase in the number of unemployed individuals is associated with a 1.24 percent decrease in preventive visits during the month (  p =.0043). In the Spokane area, a similar increase in unemployment is associated with a 5.95 percent decrease in preventive visits (  p =.0326). The findings persist when the independent variable is the number of initial unemployment insurance claims.
Conclusions. The analysis suggests that utilization of preventive dental care declines during periods of high community-level unemployment. Community-level unemployment may impede or distract populations from utilizing preventive dental services. The study's findings have implications for insurers, dentists, policy makers, and researchers.