Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans

We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18-64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.     

Variations in health services utilization by primary care patients.

This study analyses how both ambulatory care groups (ACGs) and physician characteristics explain the variability in health-service use among primary care patients in Spain. During the period 1996-1997, data derived from 52,152 patients and their 38 respective primary care physicians were collected. The response variables were as follows: number of visits; diagnostic tests requested; and referrals to a specialist. ACGs are an important variable that should be taken into account in order to explain health-service utilization. As for professionals, age and the post they hold are essential factors. Most of the unexplained variability is caused by patient characteristics.     

A multi-site study of medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.     

Migration, acculturation and utilization of primary health care

This study explored the roles of acculturation, urban-rural provenance and length of residence as determinants of the utilization pattern of first line health services by Moroccan, Turkish and Italian migrants in Belgium. Concurrently, utilization characteristics were recorded in Belgian reference patients. With increasing acculturation the demand for preventive care decreased, vague complaints became more prevalent, the delay before consulting for a curative problem shortened and the prognosis improved. There was no correlation between the occurrence of psychological problems and acculturation but, except for 15-44 year old female migrants, the rate of social problems was negatively associated with this study factor. Migrants with an urban background consulted earlier and presented more frequently vague complaints than migrants from rural provenance. We observed no significant influence of length of residence on utilization characteristics and only a marginal influence on morbidity pattern. Although acculturation seems to be a strong determinant of the migrant's utilization pattern of primary health care services, it does not consistently lead to a decrease of utilization differentials with the Belgian reference population. This may imply that there is a need for public health interventions targeted at ethnic minorities.     

初级卫生保健评价指标体系的运用分析

借鉴国家卫生部对中国农村初级卫生保健发展情况的中期评估经验,对上海市某区进行阶段性评估。根据此次评估经历,对研究所使用的评估指标体系进行分析和讨论,包括指标的可得性、敏感性和评价体系的适用性等,在此基础上,对初级卫生保健评价指标体系提出了相关修改建议。     

Discontinuity in care: Practice closures among primary care providers and patient health care utilization

We evaluate the consequences for patients of being matched to a new primary care provider due to practice closures. Using an event study and population-level data of patients and providers in Denmark, we find that the transition between providers is smooth; among re-matched patients, there is little change in primary care utilization at the extensive margin. Second, we document a 17% increase in fee-for-service per visit and a large increase in the probability that the patient initiates drug therapy targeting chronic and underdiagnosed diseases (hypertension, hyperlipidemia, and diabetes). Additionally, the re-matched patients are more likely to be admitted to inpatient care for these diseases. The increase in therapeutic initiation is not primarily because the new providers are relatively predisposed to prescribing these drugs. Instead, it appears that when patients match to new providers, there is a consequential reassessment of patients’ medical needs which leads to the initiation of new treatment.     

Determinants of preventive practices in fee-for-service primary care

A study of primary care physicians was conducted in the provinces of Quebec and New Brunswick, Canada, to ascertain their patterns of preventive practice with respect to cancer in four anatomic sites: breast, cervix, colon-rectum, and lung. The determinants of preventive practices among 552 fee-for-service physicians in both provinces are explored. Scales were created for the practice behaviors related to each type of cancer (dependent variables) and for knowledge and belief (independent variables). The content of these scales was delineated through factor analysis and their reliability assessed using Cronbach's alpha. Other variables were considered in the analysis, including continuing education activities, perceived barriers to prevention, and other sociodemographic and professional variables. Bivariate analysis and multivariate techniques were used. The explanatory factors were regrouped into cognitive, sociodemographic, and organizational determinants. Particular patterns were delineated for each cancer type. In a fee-for-service reimbursement setting without specific incentives for preventive practices, the creation of favorable organizational environments and the conveying of agreed-upon information to physicians are important ways of enhancing the integration of preventive activities into clinical practice. Identification of the sociodemographic determinants of preventive practices reveals the complexity of physicians' behaviors.     

The effect of medicaid eligibility on coverage, utilization, and children's health

I estimate the causal impact of Medicaid eligibility on take up, private health insurance coverage, healthcare utilization, and children's health by using a regression discontinuity design. In contrast to a standard regression discontinuity design, identification exploits multiple thresholds that arise from variation across states in income eligibility rules. Using data from the Panel Study of Income Dynamics and its Child Development Study supplement, I find that Medicaid eligibility increases take up by 10–13 percentage points on average, rising to 24–29 percentage points at lower income eligibility thresholds. There are significant crowding out effects of the same magnitude as those on take up rates. Medicaid eligibility increases the use of preventive health care by 11–14 percentage points but only at low income thresholds. Finally, I find that Medicaid eligibility has no significant effects on health outcomes in the short and medium run. Copyright © 2012 John Wiley & Sons, Ltd.     

Medicaid beneficiaries' experiences in HMO and fee-for-service health care

How do HMO-enrolled Medicaid beneficiaries' ratings of access to, and satisfaction with, their health care compare with the ratings of those beneficiaries receiving care in fee-for-service settings? Do poor single mothers report differences in access to, and satisfaction with, their HMO health care compared with those living in other family structures? These questions were examined with survey data from 961 California Medicaid recipients in 1991. Medicaid recipients enrolled in HMOs reported more difficulty gaining access to, and less satisfaction with, various aspects of the health care system. HMO-enrolled single mothers reported particularly negative experiences with their health care. The findings suggest a potential lack of fit between the health needs of the poor and the aims of managed health care.     

Home health care outcomes under capitated and fee-for-service payment

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.     

Mental health treatment and medical care utilization in a fee-for-service system: outpatient mental health treatment following the onset of a chronic disease

Charges for medical services of persons covered by the Blue Cross/Blue Shield Federal Employees Program from 1974 through 1978 who were first diagnosed as having one of four chronic diseases in 1975 and within one year began mental health treatment (MHT) were compared with persons who also were first diagnosed as having one of these diseases in 1975 but had no subsequent MHT. In the third year following the diagnosis, those having seven to 20 MHT visits had medical charges $309 lower and those having over 21 MHT visits had medical charges $284 lower than the comparison group. The savings in medical charges over three years of the group having seven to 20 MHT visits were a function of lower use of inpatient services and roughly equaled the cost of 20 MHT visits. Outpatient mental health treatment can be included in a fee-for-service medical care system to improve the quality and appropriateness of care and, if not extensive, may also serve to lower medical care costs.     

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women‐only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.     

The effect of distance to primary care physician on health care utilization and disease burden

BACKGROUND: The relationship of distance to care with total health care utilization and disease burden is not well understood among the managed care population. PURPOSES: The aim of this study was to examine the relationship between the distance from a patient's home to his or her primary care physician (PCP) and the patient's health characteristics. METHODOLOGY: This was a population-based study of commercial health maintenance organization (HMO) members enrolled in one medium-sized health plan in Michigan in 2001. This study measured health care utilization from all settings (per member per year [PMPY]). Disease burden measure was based on the Adjusted Clinical Group (ACG) system. Distance was defined as straight-line distance between a member's residency and his or her PCP. Both direct standardization and regression modeling were used to assess the effect of distance on utilization. FINDINGS: Both utilization and disease burden increased as distance increased, especially among members selecting PCPs in an academic health system (AHS). The difference in observed utilization between local (0-10 miles) and distant (>30 miles) members was 973 dollars (PMPY) for the AHS and 193 dollars (PMPY) for the community independent practice associations (IPA). Compared with age-sex adjustment, ACG adjustment reduced local-distant difference within the same practice group to a greater extent (281 dollars and 59 dollars remaining for the academic and community groups, respectively). Distance as a whole exerted a statistically significant positive effect on either disease burden score or utilization in regression modeling. PRACTICE IMPLICATIONS: HMO members consume more health care and had higher disease burden as their distance from their PCPs increased. The distance traveled by the individuals to their PCPs could be incorporated when adjusting managed care financial risk models. Other remedies include negotiating higher capitation rates for distant patients, carving out distant patients from any financial risk model, or excluding such patients from provider performance assessment.     

The effect of HMOs on fee-for-service health care expenditures: evidence from Medicare

This paper examines the relationship between HMO market share and fee-for-service health care expenditures using 1986-1990 county- and metropolitan statistical area-level data on Medicare expenditures and HMO market share. Fixed-effects estimates imply that fee-for-service expenditures are concave and decreasing in market share. Increases in market share from 20% to 30% are associated with 3-7% expenditure reductions. Instrumental variable estimates that exploit cross-sectional variation in HMO activity also indicate a concave relationship, with expenditures declining in market share for market shares above 15-18%, but imply larger expenditure responses to market share changes.     

儿童保健服务利用受益归属分析

目的对儿童保健服务利用进行受益归属分析,了解儿童保健服务的受益人群和受益程度。方法共调查989名儿童。运用Kakwani指数、利用需要比和集中指数等方法进行受益归属评价。结果儿童保健各项服务利用总体上是低经济收入组受益多。不同保健服务项目在不同母亲文化程度组间受益不同,产后访视低母亲文化程度组受益更多。在儿童健康体检服务利用上农村儿童受益更多。结论加强对儿童保健服务利用受益较少人群的关注,从经济政策支持和健康教育等方面入手,提高低收入家庭和低文化程度家庭儿童保健服务的利用率,促进利用均等化。     

Association between fee-for-service expenditures and morbidity burden in primary care

Background

In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined.

Objectives

To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures.

Methods

We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics.

Results

Out of the individual expenditures, 31.6 % were explained by age, gender and RUB, and around 18 % were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0–RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44 %; 3.8–9.4 % of the variation in expenditures was related to the GP clinic in which the patient was treated.

Conclusions

Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.     

我国基层医疗机构基本药物配备使用现况分析

通过对13个国家卫生服务调查样本城区或县开展机构调查、知情人访谈等,对基本药物制度试点机构基本药品配备使用等情况进行追踪调查。研究发现,国家基本药物已落实到试点地区基层医疗机构,但其配备率仍有待进一步提高;基本药物目录设置与临床用药仍存在一定的差异,国家基本药物目录的遴选仍需调整完善。