Emergency room leavers

Emergency rooms are used frequently by patients who do not require urgent treatment. Furthermore, a small but sizable number of these patients in busy emergency rooms leave (walk out) before they are actually examined by medical personnel.Data were analyzed for all patients presenting to a university-affiliated hospital emergency room during a one-year period. Six hundred forty-four persons left the emergency room before being seen (leavers). Based on a code routinely assigned to their presenting complaint, patients were divided into urgent and nonurgent categories. A random sample of 100 leavers was matched with nonurgent stayers by age, sex, race, and shift of presentation. Information was collected from medical records and telephone interviews.A multiple discriminant analysis revealed the following profile of the leaver: a person who lives within 2 1/2 miles of the hospital has either Medicare/caid or no medical insurance, has no private physician, and has a nonserious presenting complaint. Stayers, on the other hand, have more serious complaints, tend to have medical insurance, more often have a private physician, and may live at any distance from the hospital. In addition, leavers presented with drug, alcohol, or psychiatric problems more frequently than stayers. Leavers, on the average, spend 90 minutes waiting for treatment they never receive. This study characterizes a small but problematic subgroup for emergency department planners and suggests the need for community-based health education and referral of such patients to primary care centers.Steven A. Wartman, M.D., Ph.D., is Director, Division of General Internal Medicine, Rhode Island Hospital, Providence, Rhode Island. Mary P. Taggart, M.A., is with Brown University, Providence, Rhode Island. Elaine Palm, Ph.D., is with Rhode Island College, Providence, Rhode Island. Address requests for reprints to Steven A. Wartman, M.D., Ph.D., Director, Division of General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02902.     

Rhode Island's got the Blues. But the state's Blues plan isn't the only one drawing fire over its reserves, executive perks and compensation

It's been a strained few months at Blue Cross and Blue Shield of Rhode Island. Outrage over corporate excess led to a flurry of reforms at the insurer, headed by Chairman Frank Montanaro, left, including banning loans to employees and dropping lavish perks. Other Blues have been catching flak for their burgeoning bottom lines, but executives say they need ample reserves since that's their only capital.     

The curtain goes up in North Dakota. Providers in Fargo battle for the limelight

The story of how Fargo, N.D., came to have three hospitals for the second time in its 125-year history makes great theater. Characters in the drama are Innovis Health, the new acute-care facility that starts admitting patients in two days, and its owners, the Dakota Clinic and Blue Cross and Blue Shield of Minnesota. Another main player is Dakota Heartland Health System--the culprit, some say, that led physicians and others at Innovis to do business with a wealthy insurer.     

The Vermont health risk survey and the design of community wide preventive health programs

A Vermont health risk survey was performed to gain information on health knowledge and behaviors of the population. Telephone interviews with 1,594 individuals ascertained respondents' demographic characteristics, preventive health behaviors, and health knowledge. Risk prevalence was obtained on five health risks: alcohol (12%), smoking (33%), lack of exercise (70%), overweight (39%), and non-use of seatbelts (86%). Low income, less education, and blue collar occupation status were associated with increased risks of smoking, lack of exercise, and non-use of seatbelts. Increased prevalence of certain risks are associated with the 18–24 year old age group; 32% of those males reported an alcohol risk and 94% reported non-use of seatbelts. Combined risk scores were increased in groups with low income, less education, and blue collar occupations. These variations in health behaviors by social group were not explained by differences in health knowledge. Design of primary prevention activities needs to (1) be community wide, (2) utilize information on the epidemiology of health behaviors, (3) influence diverse community groups and (4) intervene before risk behaviors are established.Lloyd F. Novick, M.D., M.P.H., is Director of the Arizona Department of Health Services, 1740 W. Adams, Phoenix, Arizona 85007.David Jillson, PH.D. is Senior Research and Statistics Analyst at the Vermont Department of Health, 60 Main Street, Burlington, Vermont 05401.Roberta Coffin, M.D. is Commissioner of the Vermont Department of Health, 60 Main Street, Burlington, Vermont 05401.Mary Freedman, M.A. is Director, Public Health Statistics, Vermont Department of Health, 60 Main Street, Burlington, Vermont 05401.This article was presented at the Association of State and Territorial Health Officials Annual Meeting April 24, 1984, in Little Rock, Arkansas.     

Perceived needs and unmet needs for formal services among people with HIV disease

This study presents estimates of the prevalence of perceived needs and unmet needs among people with HIV disease in the United States for six areas of community services: mental health, drug treatment, home care, housing, transportation, and entitlements. The prevalence of service needs and unmet needs within racial, gender, drug use history, and other subgroups was also examined. The study is based on a nonrandom cross-sectional sample of 907 people with HIV disease interviewed between November 1988 and May 1989 in nine major urban areas of the United States.Respondents reported high levels of need and unmet need across a variety of service areas. One third or more of all respondents reported a need for mental health services (57%), housing (39%), entitlements (34%), and transportation (32%). Within each of the six service areas, 40% or more reported unmet need. Women, people of color, and injected drug users were more likely to report unmet service need in a number of areas. Given the limitations of the sampling and the focus oncurrent needs, these estimates may represent a lower bound on the magnitude of service need and unmet need within this population.Dr. Piette is a Senior Research Associate at the Institute for Health Policy Studies, University of California-San Francisco. At the time this study was conducted, he served as the Project Coordinator for the Robert Wood Johnson Foundation (RWJF) Evaluation at Brown University. Dr. Fleishman is the Director of the RWJF Evaluation. Dr. Stein is Director of the HIV Clinic at Rhode Island Hospital, Providence Rhode Island. Dr. Mor is the Director of the Center for Gerontology and Health Care Research at Brown University. Dr. Mayer is Chief of Infectious Diseases, Memorial Hospital, Pawtucket, Rhode Island.This study was supported by a grant from the Robert Wood Johnson Foundation.     

Reducing medical service utilization by encouraging vaccines: randomized controlled trial

BACKGROUND: Vaccination against influenza is associated with reductions in hospitalizations for heart disease, cerebrovascular disease, pneumonia, or influenza, and the risk of death from all causes during the influenza season. DESIGN: Randomized controlled trial. PARTICIPANTS: All members enrolled in the Blue Cross Blue Shield Association's Government Wide Service Benefit Program in the states of Oklahoma, Rhode Island, Kentucky, California, Arizona, Utah, and Colorado in October 2002. The sample size was 339,220 members. INTERVENTION: Two identical influenza/pneumonia direct mail marketing pieces that encouraged members to receive influenza and pneumococcal vaccinations. The study period was October 15, 2002 through March 15, 2003 when most influenza cases occur. Data were collected in July 2003 and analyzed during August 2003. MAIN OUTCOME MEASURES: Administrative claims based on influenza/pneumonia inpatient admissions and emergency department (ED) visits. RESULTS: The intervention group experienced a 2.62% (p=0.010) higher rate of influenza vaccinations; 4.61% (p=0.080) higher rate of pneumonia vaccinations; 9.67% (p=0.136) lower rate of influenza/pneumonia inpatient admissions; and 22.64% (p=0.002) lower rate of influenza/pneumonia ED visits compared to the control group. The benefit-cost ratio (return on investment) from this intervention was estimated to be US dollar 2.21 per dollar spent. CONCLUSIONS: Administrative claims data suggest that members respond to health plan mailings with an increase in influenza vaccination rates. Health plans can cost-effectively impact medical service utilization and vaccination rates by mailing information to their members.     

Review of a health fair screening program in mid-michigan

Using sociodemographic data and findings from an evaluation survey, a Mid-Michigan health fair screening program is reviewed over a seven year period (1981–1987). Most participants were older adults, and nearly two-thirds were women. Very few participants named the media as a reason for attending the health fairs at which the screenings were given. Many had seen a physician within the past two years, yet very few reported that they had had a complete checkup. The implications of these findings and a rationale for health fairs as a mechanism for screening are discussed.Keith V. Bletzer is an Instructor in the Department of Social Science, Lansing Community College, Lansing, MI 48901-7210.Funding for the Health Fair Screening Program was provided by Blue Cross/Blue Shield of Michigan. The Program was sponsored by the Michigan Health Council.     

Worksite and communications-based promotion of a local walking path

Current research has shown relationships between the environment (eg, parks and trails) and levels of physical activity participation. This study was designed to implement and evaluate a communications based worksite campaign to promote awareness of an existing local walking path and to increase walking. Promotional materials were distributed for 1 month via flyers, email, website postings, and during bi-weekly information booths. Evaluations were conducted at baseline, during, and following the promotional campaign. Borderline statistically significant increases in walking activity from baseline were observed midway through the campaign (p = 0.069) and following the campaign (p = 0.075). Counts observed during the intervention were almost triple those at baseline and increased in the post-campaign phase to approximately three and a half times those at baseline. Sign recognition surveys revealed at baseline, 51% of the participants correctly identified the walking path signs, which increased to 65% during the campaign (p = .0674). Familiarity with physical activity messages around the workplace increased from 64.6% at baseline to 75.5% during the campaign (p = .097). This study shows initial promise of a theoretically based communications intervention to increase knowledge of physical activity and to promote walking.Melissa A. Napolitano is Assistant Professor of Psychiatry and Human Behavior and Staff Psychologist, Centers for Behavioral and Preventive Medicine, Brown Medical School and The Miriam Hospital, Providence, Rhode Island, Heather Lerch is a Health Promotion Specialist at MassMutual Benefits Management, Inc., Springfield, Massachusetts, George Papandonatos is Assistant Professor of Biostatistics, Brown University, Providence, Rhode Island, and Bess H. Marcus is Professor of Psychiatry and Human Behavior and Director, Centers for Behavioral and Preventive Medicine, Brown Medical School and The Miriam Hospital, Providence, Rhode Island     

"Ageless Heroes" define Blues' commitment to baby boomers. Campaign targets marketing to aging population

Blue Cross and Blue Shield Association, with the help of agency Age Wave Health Services Inc., develops a program called Ageless Heroes to convey the insurance company's commitment to the concept of healthy aging through National Awards competition and the television program featuring celebrity seniors.     

Regence HMO Oregon

Regence HMO Oregon is a large IPA-model HMO based in Portland, Ore. It serves commercial, Medicaid, and Medicare cost enrollees throughout Oregon and southern Washington. An affiliate of Blue Cross and Blue Shield of Oregon, Regence HMO Oregon built its rural enrollment by acquiring Capitol Health Care, an HMO with rural enrollment; by encouraging rural employers with traditional Blue Cross and Blue Shield of Oregon indemnity and PPO coverage to switch to HMO coverage; and by aggressively contracting with providers statewide to serve Oregon Health Plan (Medicaid) enrollees.     

Pre-diagnostic symptom recognition and help seeking among cancer patients

Failure to recognize symptoms which signal cancer may delay contact with the medical care system, thus decreasing the chances of diagnosis at an early stage of disease. We investigated the determinants of cancer symptom recognition and delay in seeking medical care in a population-based sample of 625 newly diagnosed lung, breast and colorectal cancer patients. Although the majority (79.5%) of patients reported noticing symptoms prior to diagnosis, one quarter of these patients (24.7%) delayed longer than three months in seeking medical care. Contrary to the findings of research based on clinic samples, logistic regression analysis revealed that no demographic or social support factors were predictive of symptom recognition or delay, with the exception that older colorectal cancer patients were less likely to notice symptoms, but also less likely to delay. Lung and colorectal patients diagnosed with advanced disease were more likely to notice symptoms than patients with local disease.Results of a content analysis of patients' remarks indicate that breast cancer patients were significantly more likely than lung or colorectal cancer patients to attribute their symptoms to cancer (p<.001). Symptoms common to lung and colorectal cancer appear to be attributed to other, less serious causes. Given the lack of demographic predictors of symptom recognition and delay in seeking care, we suggest that education programs address risk groups for specific cancers, rather than the general public as a whole, grouping together all cancers and cancer symptomatology.Vincent Mor, Ph.D. is Director at the Brown University Center for Gerontology and Health Care Research; Susan Masterson-Allen, M.A. is Sr. Project Coordinator at the Brown University Center for Gerontology and Health Care Research; Richard Goldberg, M.D. is Psychiatrist-in-Chief in the Department of Psychiatry, Rhode Island Hospital; Edward Guadagnoli, Ph.D. is Assistant Professor at the Brown University Center for Gerontology and Health Care Research; Margaret S. Wool, Ph.D. is Clinical Assistant Professor in the Department of Psychiatry, Rhode Island HospitalSupported in part by grant number CA 36560 from the National Cancer Institute     

Medicare-the development of publicly financed health insurance: Medicare's impact on the nation's health care system

It is useful for health care managers to understand Medicare's history and the impact on providers of ever-changing Medicare payment methods. Initially, Medicare payments resembled those of commercial insurance plans and Blue Cross Blue Shield plans. When Congress became concerned about the increasing costs of Medicare, new payment methods were created to limit payments to providers. The prospective payment system, imposed on hospitals in 1987 and later on nursing homes, home health agencies, and other services, has been adapted by commercial plans, Blue Cross Blue Shield associations, and state Medicaid programs. Changes in payer reimbursements require health care managers to adjust the department's charge master and exert more control of departmental costs. The story of Medicare's beginnings and development can provide some insight into the possibility of national health insurance, given the historic and current politics that limit publicly financed social programs. This article discusses the development of Medicare and its administration and serves as an introduction to the complex realities of health care reimbursement policy.     

Getting to no: how Kansas advocates derailed the Anthem steamroller

A battle royale has taken shape in Kansas about the future of its Blue Cross and Blue Shield plan. This past February, Kansas Insurance Commissioner Kathleen Sebelius rocked the corporate health care establishment by refusing to allow Anthem Insurance Company to buy the state's independent Blue Cross and Blue Shield plan. Then in June, a state judge overturned her decision. Now the case is headed to appeals court, where Sebelius will seek to have her decision reinstated. At the heart of the legal wrangling is the unprecedented manner in which advocates have asserted consumer interests, raising issues that will persist long after the courts hand down a final ruling. States of Health looks at how consumer advocates have responded to the proposed Blues transaction, a process that has strengthened the health consumer voice in Kansas--and offers important lessons for advocates in other states as well.     

Principles of medical record documentation

The following is an excerpt from a brochure titled "Principles of Medical Record Documentation" developed jointly by representatives of the American Health Information Management Association, the American Hospital Association, the American Managed Care and Review Association, the American Medical Association, the American Medical Peer Review Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Although their joint development of this brochure is not intended to imply either endorsement of, or opposition to, specific documentation requirements, all seven groups share the belief that the fundamental reason to maintain an adequate medical record is its contribution to the high quality of medical care.     

Self-reported referral patterns in practices of Family/General Practitioners,Internists, and Obstetricians/Bynecologists

A profile of referrals can help to define the characteristics of a physician's practice. Self-reported referral patterns in the practices of Family/General Practitioners (FP/GP), Internists (IM), and Obstetricians/Gynecologists (OB/GYN) in Maryland were assessed with a questionnaire mailed to an area sample of 1,715 physicians. A 65% response rate was obtained after three mailings (weighted N=1,487). Self-reported referrals received per month averaged 16% of patients seen (six percent FP/GP, 13% OB/GYN, 23% IM), and were more frequent among self-employed, younger, metropolitan and female physicians who spent less time in patient care. Self-reported referrals made per month averaged ten percent (10% FP/GP), 11% IM, and eight percent OB/GYN), and were higher for physicians in metropolitan areas. The correlation between percentage referrals received and percentage referrals made was r=.19 (r=.03 FP/GP, r=.21 IM, r=.25 OB/GYN). Self-reported practice referral patterns are similar to referrals reported in prior studies, and can be used to consider specialty differences in referral behavior of physicians.Jeffery Sobal, Ph.D., M.P.H. is an Assistant Professor in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Herbert L. Muncie, Jr., M.D. is an Associate Professor in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Carmine Valente, Ph.D. is the Director of the Center for Health Education, Inc., 1204 Maryland Avenue, Baltimore, Maryland, 21201. David M. Levine, M.D., Sc.D. is a Professor in the Department of Medicine at the Johns Hopkins University School of Medicine, Baltimore, Maryland 21205. Bruce R. DeForge, M.A. is a Research Associate in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Requests for reprints should be addressed to: Jeffery Sobal. The authors would like to thank the Department of Family Medicine at the University of Maryland School of Medicine (Grant 2D32PE13000 from the U.S. Department of Health and Human Services), the Center for Health Education, Inc., Johns Hopkins University School of Hygiene and Public Health, Blue Cross/Blue Shield of Maryland, Inc., and the Medical and Chirurgical Faculty of the State of Maryland for support for this research. An earlier version of this paper was presented at the annual meeting of the North American Primary Care Research Group.     

Geographic variation in primary care visits in Iowa.

OBJECTIVE. This study investigates the determinants of primary care office visit rates. DATA SOURCES. Blue Cross and Blue Shield of Iowa subscriber information was sorted by residence into geographic health service areas. Cost-sharing information was also obtained from Blue Cross. Physician supply data were obtained from The University of Iowa, Office of Community-Based Programs. Hospital data were reported by the Iowa Hospital Association. STUDY DESIGN. Cases were classified into ambulatory care groups (ACGs). Use rates were computed for each group in each service area. Ordinary least squares regression models were developed to model geographic variation in each ACG-specific primary care visit rate. PRINCIPAL FINDINGS. Regression models were not significant for five out of eleven ACGs studied. Out-of-pocket expense significantly affected utilization in three out of six. The number of primary care practices per capita had a significant effect on utilization in two ACGs. The supply of hospital outpatient services was significant in one ACG. CONCLUSIONS. Study findings reveal that some ACGs are price-sensitive and some are not. Policies aimed at changing levels of primary care use should taken into account whether varying cost-sharing will influence consumer behavior in the desired direction.     

Health care experience among employees prior to and after enrollment in a prepaid health insurance plan (HMO)

Company medical and benefit records of employees who were enrolled in prepaid health insurance plans (HMOs) in Minneapolis, Washington, D.C., and Seattle were reviewed for hospital and surgical utilization prior to as well as after their enrollment. Comparisons were made for the same calendar periods with closely matched employees who were covered by Blue Cross/Blue Shield (BC/BS). The results indicate that after enrollment the HMO subjects at each location had lower rates for hospital and surgical utilization than the BC/BS controls. For the period prior to enrollment, during which time coverage was through BC/BS, the prospective HMO subjects at two locations had lower hospital and surgical utilization than the controls. Possible explanations of this potential self-selection bias are discussed.     

Community Health projects as part of a core clinical clerkship: Teaching research skills in a community setting

Although medical student research has been advocated as a valuable learning experience and specific programs have been developed to offer research opportunities, only a minority of students have participated in these programs. We report a student research program that is integrated into a required six week clinical clerkship in Community Health, thus ensuring that all students participate in a research project. The program offers the additional advantage that research projects are student initiated and executed. Although the limited time frame usually results in pilot or exploratory studies, the program introduces students to all facets of a research project within a community setting and promotes independent learning. The program has been well received by students and may stimulate further research interests in some students.David B. Reuben, M.D. is Assistant Professor, Department of Community Health, Brown University Program in Medicine and Associate Physician, Division of General Internal Medicine, Rhode Island Hospital, Providence, Rhode Island 02902. Stephen R. Smith, M.D. is Associate Dean of Medicine, Brown University Program in Medicine, Providence, Rhode Island 02912.     

Assessing the role of the Blues plans' all-payer clearinghouses

A growing number of the nation's 67 Blue Cross and Blue Shield plans, many of which are dominant health insurers in their markets, are attempting to expand their electronic health care transactions business. At least a dozen plans have created claims clearinghouses designed to handle claims and other electronic transactions destined for any payer.     

The impact of participation in health promotion on medical costs: a reconsideration of the Blue Cross and Blue Shield of Indiana study

PURPOSE. The purpose of this study was to investigate whether participation in a comprehensive worksite health promotion program was associated with reduced employee health care costs. DESIGN. Four independent study groups, two treatment and two comparison, were identified based on type and date of first participation in the intervention. Two years of pre-program health cost data and five years of post-program data were collected for each subject. The Jonckheere-Terpstra statistical test was used to analyze the data. SETTING. The health promotion program was offered at Blue Cross and Blue Shield of Indiana corporate headquarters. The study period began on January 1, 1976, and continued through December 31, 1982. SUBJECTS. Seven hundred and forty-three men and women employed continuously by Blue Cross and Blue Shield of Indiana throughout a seven-year period were studied. INTERVENTION. The health promotion program consisted of four progressive phases which involved 1) health risk reduction mass education, 2) completion of a health risk appraisal and risk reduction counseling, 3) health promotion classes such as smoking cessation and nutrition education, and 4) follow-up and maintenance. MEASURES. The principal dependent variable was pre-program to post-program changes in health costs as measured by employee health care expense claims paid for by the company's health insurance plan. RESULTS. This study found that program participation was not associated with reduced health care costs. CONCLUSIONS. It would be prudent to remain guarded about the health cost savings effects of worksite health promotion programs.