How Rural Physicians Compare on Cost and Quality Measures for Medicaid Ambulatory Care Episodes

This study compares the costs and quality of episodes of care for two common childhood illnesses, urinary tract infections (UTI) and otitis media (OM), across providers practicing in rural, small town, and urban counties in Alabama in 1992. The data source is Medicaid claims data for children under age 8 who were treated for these conditions. The study found that episodes cared for by rural providers were less expensive than episodes cared for in other locations, both because fewer rural episodes included outpatient facility charges and because fewer ancillary services were provided in rural settings. Researchers also found that, even controlling for physician characteristics and patient demographic and utilization factors, rural episodes were significantly less likely to include two process measures of quality of care: fewer rural UTI episodes included urine cultures, and fewer rural OM episodes included follow-up visits. This study suggest that, as a group, rural physicians may have a favorable cost profile but a potentially unfavorable care content profile, compared with other physicians. Both practice profile data and explicit care recommendations need to be available to physicians so thy can monitor, defend, or alter their clinical practices.     

Performance failure of an evidence-based upper respiratory infection clinical guideline.

BACKGROUND: We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization. METHODS: Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation. RESULTS: A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05). CONCLUSIONS: Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.     

Evaluating HMO/IPA contracts for family physicians: one group's experiences

This article reports the experience of a 15-person primary care group with two health maintenance organization/independent practice association (HMO/IPA) contracts. In 1986 the group received over $1.5 million in capitated payments from the plan to cover medical care of approximately 4,000 patients. The expenses exceeded the income for one plan. Analysis of primary care, specialty care, and ancillary services provides insight into factors that must be considered in evaluating HMO/IPA contracts. Eleven questions that should be asked before signing contracts and guidelines for utilization review and quality assurance are reviewed.     

Primary care program improves reimbursement. The Federally Qualified Health Center program helps hospitals improve services to the medically indigent

Under a program created by Congress in 1989, certain primary care treatment centers serving the medically and economically indigent can become Federally Qualified Health Centers (FQHCs). Recently enacted rules and regulations allow participants in the FQHC program to receive 100 percent reasonable cost reimbursement for Medicaid services and 80 percent for Medicare services. An all-inclusive annual cost report is the basis for determining reimbursement rates. The report factors in such expenses as physician and other healthcare and professional salaries and benefits, medical supplies, certain equipment depreciation, and overhead for facility and administrative costs. Both Medicaid and Medicare reimbursement is based on an encounter rate, and states employ various methodologies to determine the reimbursement level. In Illinois, for example, typical reimbursement for a qualified encounter ranges from $70 to $88. To obtain FQHC status, an organization must demonstrate community need, deliver the appropriate range of healthcare services, satisfy management and finance requirements, and function under a community-based governing board. In addition, an FQHC must provide primary healthcare by physicians and (where appropriate) midlevel practitioners; it must also offer its community diagnostic laboratory and x-ray services, preventive healthcare and dental care, case management, pharmacy services, and arrangements for emergency services. Because FQHCs must be freestanding facilities, establishing them can trigger a number of ancillary legal issues, such as those involved in forming a new corporation, complying with not-for-profit corporation regulations, applying for tax-exempt status, and applying for various property and sales tax exemptions. Hospitals that establish FQHCs must also be prepared to relinquish direct control over the delivery of primary care services.     

Hospitalization for urinary tract infections and the quality of preventive health care received by people with spina bifida

BackgroundThe preventive health care needs of people with disabilities often go unmet, resulting in medical complications that may require hospitalization. Such complications could be due, in part, to difficulty accessing care or the quality of ambulatory care services received.ObjectiveTo use hospitalizations for urinary tract infections (UTIs) as a marker of the potential quality of ambulatory care services received by people affected by spina bifida.MethodsMarketScan inpatient and outpatient medical claims data for 2000 through 2003 were used to identify hospitalizations for UTI, which is an ambulatory care sensitive condition, for people affected by spina bifida and to calculate inpatient discharge rates, average lengths of stay, and average medical care expenditures for such hospitalizations.ResultsPeople affected by spina bifida averaged 0.5 hospitalizations per year, and there were 22.8 inpatient admissions with UTI per 1000 persons with spina bifida during the period 2000–2003, in comparison to an average of 0.44 admission with UTI per 1000 persons for those without spina bifida. If the number of UTI hospitalizations among people affected by spina bifida were reduced by 50%, expenditures could be reduced by $4.4 million per 1000 patients.ConclusionsConsensus on the evaluation and management of bacteriuria could enhance clinical care and reduce the disparity in UTI discharge rates among people affected by spina bifida compared to those without spina bifida. National evidence-based guidelines are needed.     

Inactivated influenza vaccine does not reduce all cause respiratory illness in children with pre-existing medical conditions

BackgroundThe effectiveness of inactivated influenza vaccine (IIV) immunization in preventing all cause respiratory illness (RI) in children with pre-existing medical conditions has not been fully established and varies from season to season. This study aims to quantify the overall impact of IIV immunization on primary care attended RI episodes in children with pre-existing medical conditions, using robust observational data spanning twelve influenza seasons.MethodsElectronic records of IIV eligible children aged 6 months to 18 years were extracted from primary care databases over the years 2004–2015. IIV eligibility criteria according to Dutch guidelines included (chronic) respiratory and cardiovascular disease and diabetes mellitus. For each year, information on IIV immunization status, primary care attended RI episodes (including influenza, acute respiratory tract infections and asthma exacerbations) and potential confounders were collected. Generalized estimating equations were used to model the association between IIV status and occurrence of at least one RI episode during the influenza epidemic period with “current year immunized” as reference group. Robustness of findings were assessed by performing various sensitivity analyzes in which (i) seasons with a mismatch between the dominant circulating influenza virus and vaccine strain were excluded, (ii) influenza periods were further restricted to weeks with at least 30% influenza virus positive specimens in sentinel surveillance (instead of 5%), (iii) propensity scores were used to adjust for confounding.ResultsIn total, 11,797 children (follow-up duration: 38,701 child-years) were eligible for IIV for ≥ one season with 29% immunized at least once. The adjusted odds for primary care attended RI episodes during the influenza epidemic period did not differ between current season immunized versus not immunized children (adjusted OR:1.01; 95%CI:0.90–1.13). The various sensitivity analysis showed comparable results.ConclusionsIIV immunization in children with pre-existing medical conditions does not reduce all cause RI episodes encountered in primary care during the influenza season.     

Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses

PURPOSE Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices.METHODS As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting–clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews.RESULTS The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (β =−0.149; P = .008); preferred to seek care from a physician (β =1.067; P <.001) and receive same day care (β =−2.789; P<.001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more.CONCLUSIONS Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.     

A day in the life: a case series of acute care palliative medicine--the Cleveland model

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.     

Small-area variations in the treatment of prevalent medical conditions: a comparison of three cities in the Northeast

This article presents a small-area variation study that examines utilization differences for primary care physicians (PCPs) in treating a homogeneous set of prevalent medical conditions. The study used secondary data collected over a 24-month period from a large, Northeastern region independent practice association. The diagnostic cluster methodology was used to examine geographic differences for PCPs in treating prevalent medical conditions. This methodology groups International Classification of Diseases, 9th revision (ICD-9), codes into diagnostic clusters based on clinical homogeneity with respect to generating a similar clinical response from the physician. For each diagnostic cluster, diagnostic episode clusters (DECs) were formulated. Each DEC links all services incurred in treating a patient's medical condition within a specific period of time. Differences in use rates across small areas were tested using t tests. The data showed little variation in the physician office visit rate across small areas. However, services generated from these office visits exhibited large rate variations. The most significant small-area differences were for hospital inpatient days and surgical procedures. Pattern-of-treatment differences exist across small areas for the homogeneous set of prevalent medical conditions treated by PCPs.     

Use and costs of care in retail clinics versus traditional care sites

Retail clinics have generated much interest, promising convenient, lower-cost service for the treatment of minor conditions than conventional care sites can offer. Using health plan claims data, we describe utilization trends, patient mix, and cost per episode of care for the five conditions most frequently treated at a retail clinic chain in the Minneapolis-St. Paul area, as compared with other care settings. Retail clinic use for these conditions is increasing at about 3 percent per year and offers savings of $50-$55 per episode. However, it accounts for only 6 percent of such episodes, and the impact on overall cost and quality remains undetermined.     

Estimating Determinants of Multiple Treatment Episodes for Substance Abusers

BACKGROUND: Health services researchers have increasingly used hazard functions to examine illness or treatment episode lengths and related treatment utilization and treatment costs. There has been little systematic hazard analysis, however, of mental health/substance abuse (MH/SA) treatment episodes. AIMS OF THE STUDY: This article uses proportional hazard functions to characterize multiple treatment episodes for a sample of insured clients with at least one alcohol or drug treatment diagnosis over a three-year period. It addresses the lengths and timing of treatment episodes, and the relationships of episode lengths to the types and locations of earlier episodes. It also identifies a problem that occurs when a portion of the sample observations is ?possibly censored. Failure to account for sample censoring will generate biased hazard function estimates, but treating all potentially censored observations as censored will overcompensate for the censoring bias. METHODS: Using insurance claims data, the analysis defines health care treatment episodes as all events that follow the initial event irrespective of diagnosis, so long as the events are not separated by more than 30 days. The distribution of observations ranges from 1 day to 3 years, and individuals have up to 10 episodes. Due to the data collection process, observations may be right censored if the episode is either ongoing at the time that data collection starts, or when the data collection effort ends. The Andersen-Gill (AG) and Wei-Lin-Weissfeld (WLW) estimation methods are used to address relationships among individuals multiple episodes. These methods are then augmented by a probit censoring model that estimates censoring probability and adjusts estimated behavioral coefficients and related treatment utilization and treatment costs. There has been little systematic hazard analysis, however, of mental health/substance abuse (MH/SA) treatment episodes. RESULTS: Five sets of variables explain episode duration: (i) individual; (ii) insurance; (iii) employer; (iv) binary, indicating episode diagnosis, location, and sequence; and (v) linkage, relating current diagnoses to previous diagnoses in a sequence. Sociodemographic variables such as age or gender have impacts at both the individual and at the firm level. Coinsurance rates and deductibles also have impacts at the individual and the firm levels. Binary variables indicate that surgical/outpatient episodes were the shortest, and psychiatric/outpatient episodes were the longest. Linkage variables reveal significant impacts of prior alcoholism, drug, and psychiatric episodes on the lengths of subsequent episodes. DISCUSSION: Health care treatment episodes are linked to each other both by diagnosis and by treatment location. Both the AG and the WLW models have merit for treating multiple episodes. The AG model permits more flexibility in estimating hazards, and allows researchers to model impacts of prior diagnoses on future episodes. The WLW model provides a convenient way to examine impacts of sociodemographic variables across episodes. It also provides efficient pooled estimates of coefficients and their standard errors. LIMITATIONS: The insurance claims data set covers 1989 through 1991, predating current managed care plans. It cannot identify untreated substance abusers, nor can it identify those with out-of-plan use. It provides treatment information only if services are covered by the insurance plan and are defined with a substance abuse diagnosis code. Like medical records, insurance claims will not specify substance abuse treatment received within the context of other health care (and thus identified by a non-substance abuse diagnosis code) or community services. IMPLICATIONS FOR POLICY AND RESEARCH: This article characterizes multiple health treatment episodes for a sample of insured clients with at least one alcohol or drug treatment diagnosis within a three-year period. We identify both individual and employer effects on episode length. We find that episode lengths vary by the diagnosis type, and that the lengths (and by inference cost and utilization) may depend on the treatments that occurred in previous episodes. We also recognize that health care or illness episodes may be ongoing at times of health care events prior to the ends of data collection periods, leading to uncertain episode lengths. Corresponding estimates of costs or utilization are also uncertain. We provide a method that adjusts the episode lengths according to the probability of censoring.     

重症监护室医院获得性泌尿道感染病原菌分析

目的了解重症监护室(ICU)医院获得性泌尿道感染及病原菌情况,为预防和控制ICU患者泌尿道医院感染提供科学依据。方法对2013年32所医院ICU泌尿道医院感染目标监测资料进行分析。结果共监测ICU住院患者23 680例,发生医院获得性泌尿道感染157例,医院获得性泌尿道感染率为0.66%;导尿管使用率为80.83%,导尿管相关泌尿道感染发病率为1.25‰。共检出菌株162株,其中真菌66株,占40.74%;革兰阴性(G-)菌51株,占31.48%;革兰阳性(G+)菌45株,占27.78%。结论 ICU医院获得性泌尿道感染病原菌以真菌为主,医院应尽早采取综合干预措施,控制ICU医院获得性泌尿道感染。     

Care-seeking behavior for upper respiratory infections

BACKGROUND: Many recent efforts to reduce unnecessary medical services have targeted care of upper respiratory infections (URIs). We tested whether patients who seek care very early in their illness differ from those who seek care later and whether they might require a different approach to care. METHODS: We surveyed by telephone 257 adult patients and 249 parents of child patients who called or visited one of 3 primary care clinics within 10 days (adults) or 14 days (parents) of the onset of uncomplicated URI symptoms. Those who contacted the clinic within the first 2 days of illness were compared with those who made contact later. RESULTS: Although 28% of adults and 41% of parents contacted their clinic within the first 2 days of symptom onset, we found very few differences in the characteristics of the caller or patient between those who called early and later. The illnesses of those who called early were not more severe, and they did not have different beliefs, histories, approaches to medical care, or needs. The only clinician-relevant difference was that adult patients calling in the first 2 days had a greater desire to rule out complications (84.7% vs 64.1% calling in 3-5 days and 70.6% calling after 5 days of illness, P < or = .05). CONCLUSIONS: Those who seek medical care very early for a URI do not appear to be different in clinically important ways. If we are going to reduce overuse of medical care and antibiotics for URIs, clinical trials of more effective and efficient strategies are needed to encourage home care and self-management.     

The United States medical profession: an abnormal form of the division of labour

Abstract During the last century, the US medical profession, once dominated by general practitioners, has been transformed into a body of highly specialised physicians. Sweeping technological advances have fueled this evolution in which broadly trained primary care physicians who provide relatively inexpensive comprehensive medical care have become a professional minority. This country's specialty-oriented system of medical education has produced far more specialised doctors than are required to meet the need for their services among the general population. As a result, medical specialists have invaded the province of primary care physicians. They now compete with generalists for patients who do not have conditions requiring sophisticated specialised medical procedures. Their intrusion into the field of primary care, for which they have not been trained, is bitterly resented by general physicians. This largely unregulated division of labour has been insensitive to patient need and has disrupted the collaboration between general and specialty physicians which previously served the public interest.     

At What Cost? Payment for Abortion Care by U.S. Women

BackgroundMost U.S. abortion patients are poor or low-income, yet most pay several hundred dollars out of pocket for these services. This study explores how women procure these funds.MethodsiPad-administered surveys were implemented among 639 women obtaining abortions at six geographically diverse healthcare facilities. Women provided information about insurance coverage, payment for service, acquisition of funds, and ancillary costs incurred.FindingsOnly 36% of the sample lacked health insurance, but at least 69% were paying out of pocket for abortion care. Women were twice as likely to pay using Medicaid (16% of abortions) than private health insurance (7%). The most common reason women were not using private insurance was because it did not cover the procedure (46%), or they were unsure if it was covered (29%). Among women who did not use insurance for their abortion, 52% found it difficult to pay for the procedure. One half of patients relied on someone else to help cover costs, most commonly the man involved in the pregnancy. Most women incurred ancillary expenses in the form of transportation (mean, $44), and a minority also reported lost wages (mean, $198), childcare expenses (mean, $57) and other travel-related costs (mean, $140). Substantial minorities also delayed or did not pay bills such as rent (14%), food (16%), or utilities and other bills (30%) to pay for the abortion.ConclusionsPublic and private health insurance plan coverage of abortion care services could ease the financial strain experienced by abortion patients, many of whom are low income.     

Women with cardiovascular risk after preeclampsia: is there follow-up within the Unified Health System in Brazil?

Objectives

to identify women with cardiovascular risk, five years after a preeclampsic episode (PE), and identify the follow-up of these women within the Unified Health System (Sistema Único de Saúde - SUS), in the city of Natal/RN.

Methods

a quantitative and exploratory study conducted at the Januário Cicco University Maternity Ward/RN. The sample consisted of 130 women, 65 with a PE episode and 65 who were normotensive.

Results

we found statistical significance with regard to body mass index, weight, family history of cardiovascular disease (CVD) and cardiovascular complications when comparing women with previous PE to normotensive women. The groups were unaware of their cardiovascular risk factors and, in addition, they reported difficulties in accessing primary health care (PHC) services.

Conclusions

women with a PE history are at increased risk of developing CVD, unaware of late PE complications, and lacked customized care when compared to normotensive patients.     

海口市老年人健康状况及居家养老医疗服务需求调查分析

目的 了解海口市老年人健康状况及居家养老医疗服务需求,为制定卫生规划提供科学依据。方法 采用多阶段整群随机抽样方法抽取海口市60岁以上老年人3 601名,通过入户问卷调查了解老年人基本情况、慢性病患病情况、养老方式选择以及对居家医疗服务需求。结果 共回收有效问卷3 544份,有效应答率98.42%。老年人文化程度主要以小学及以下为主,占43.68%,93.28%的老人与配偶和(或)子女同住,6.30%的老人独居;4.77%的老年人生活不能自理,30.11%的老年人部分自理需要照顾。60岁以上老年人慢性病患病率为65.83%,其中高血压、糖尿病、冠心病、脑卒中、精神或心理疾病、慢性阻塞性肺疾病、消化系统疾病、骨及关节疾病以及其他疾病患病率依次为31.94%、13.54%、2.51%、2.51%、0.90%、2.20%、3.02%、4.23%和17.41%。78.89%老年人选择居家养老并有居家养老医疗服务需求,11.91%老年人选择机构养老。二元logistic回归分析结果显示家庭关系、自评健康状况与居家养老医疗服务需求存在相关性;居家养老医疗服务费用可接受范围在1 000元以下的占70...     

Children Who Are Medically Fragile in North Carolina: Using Medicaid Data to Estimate Prevalence and Medical Care Costs in 2004

Objectives: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0–19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. Methods: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. Results: 1,914 children ages 0–19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0–19. Conclusions: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.     

Access to primary care: the role of race and income

The study has two objectives: (1) to examine the racial differences in access provided by Municipal Health Services Clinics to the Medicare low-income beneficiaries, i.e., those also eligible for Medicaid (dual eligibles), and compare it with access provided to non-dually eligible patients; (2) to examine the racial and income disparities in access for primary and ancillary care services. The Municipal Health Services Program (MHSP) started in 1979 in five cities with the objective to improve access to primary care services. The study's method for measuring access combines use and need of care in a single index. The study finds that the clinics provided better access to dual eligibles than to non-dual eligibles and to nonwhite than to white dual eligibles. However, this was a result of higher use of ancillary services by the clinic nonwhite patients. This was particularly true in large clinics such as Baltimore, where inadequate targeting of the low-income group and higher ancillary use were more significant problems than racial disparity in access.