Health behaviors and quality of care among Latinos with diabetes in managed care

OBJECTIVES: We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care. METHODS: Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos. RESULTS: Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care. CONCLUSIONS: Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.     

Quality of diabetes care among low-income patients in North Carolina.

BACKGROUND: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. METHODS: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. RESULTS: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. CONCLUSIONS: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.     

Quality of care for primary care patients with depression in managed care

OBJECTIVE: To evaluate the process and quality of care for primary care patients with depression under managed care organizations. METHOD: Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months. RESULTS: Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P < .005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate anti-depressant use. CONCLUSIONS: Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.     

Quality management in managed care

Managed care creates a corporate environment in which competitiveness demands close attention to quality. Although the health care sector may benefit from solutions derived in other industries, it attaches unique importance to noneconomic, intangible factors. Adequate cost-utility analysis must take such factors into account instead of relying on artificial numerical values.     

Medicaid enrollee switching among managed care plans

This case-study (n=41,969) of voluntary switching among Mecklenburg County, North Carolina Medicaid managed care plans showed a low switching rate of 14.5 per 100 member-years over 33 months, or 5.3 averaged annually. Population, plan and plan characteristics, claims and telephone survey data were examined to better understand this important behavioral measure. Switching in Medicaid managed care, which is little studied, is contrasted with the extensive literature on middle class switching. Policy implications included the suitability of Medicaid populations for managed care and the need for more research on switching and disenrollment and the Medicaid innovation of neutral health benefits advising.     

Financial vulnerability among Medicare managed care enrollees

Consumer Assessment of Health Plans Survey (CAHPS) data show that Medicare managed care plans often receive low satisfaction scores from certain vulnerable populations. This article describes findings from a qualitative study with beneficiaries about their Medicare managed care experiences. Focus groups were stratified by participant race/ethnicity and self-described health status. Yet participants did not describe their concerns in terms of their race, ethnicity, or health condition, but rather their access to financial resources. Our findings suggest that researchers consider how socioeconomics creates health care vulnerability for racial and ethnic minorities, females, people with disabilities, and other economically marginalized persons.     

Quality of care problems among medicare and medicaid patients

The purpose of this study was to characterize quality of care problems among Medicare and Medicaid inpatients in New York State. The patients selected for this study comprised 1991 and 1992 Medicare and all 1992 Medicaid inpatients in whom quality of care problems with actual or potential adverse effects were found. The patients in this study were drawn from public, proprietary, voluntary and teaching hospitals.A total of 1000 quality of care problems with either actual or potential adverse effects were found in 706 Medicare patients. Two hundred and seventy-five (275) quality of care problems with actual or potential adverse effects were found in 154 Medicaid patients. Premature death occurred in 53 (7.4%) of the 706 Medicare and in 42 (27.2%) of the 154 Medicaid patients. Treatment problems and monitoring failures accounted for the majority of quality of care problems with actual or potential adverse effects for both Medicare (63.0%) and Medicaid (75.7%) patients. Among Medicare patients, the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use were among the leading causes of quality of care problems. Attending physicians were associated with the majority of Medicare quality of care problems while house staff and attending physicians were associated with the majority of those among Medicaid patients.The results of this study indicate that there are several leading causes of quality of care problems among Medicare and Medicaid patients. Treatment problems and monitoring failures together comprise the majority of such problems. Among Medicare patients, it was found that most quality of care problems were associated with the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use. Most quality of care problems among Medicaid patients were associated with these categories as well as with labor and delivery problems, and poor discharge planning.The results of this study reflect the peer-review process in which providers are given an opportunity to respond to physicianreviewer decisions about the presence of actual or potential adverse effects. Such a process, which permits the presentation of additional data and information by providers, produces fewer final adverse outcome determinations than a process uniquely based on chart review.The quality of care problems observed in this study are amenable to focused educational interventions. Such remedial interventions could yield significant improvements in the quality of care for all patients.     

Quality in managed care: developments and considerations

With the rapid movement of both individuals and groups away from fee-for-service health care into managed care, concerns have been expressed appropriately that the quality of care may be affected adversely. Over the past several years, a number of developments have taken place to respond to these concerns. This quality movement in managed care has not been without some issues and considerations, however. This article first describes the National Committee for Quality Assurance (NCQA) and the prominent role it has played in this movement. Next, quality improvement study design is addressed in the context of assuring quality, controlling costs, and achieving NCQA accreditation. The effect that capitation, as a payment strategy for providers, has on data quality is then described. Fourth, the value of partnering is explored. Finally, the newest version of NCQA's performance measurement template is discussed: the Health Plan Employer Data and Information Set, version 3.0.     

Barriers to care among racial/ethnic groups under managed care

We describe barriers to care reported by racial/ethnic groups and explore the extent to which barriers vary between persons enrolled in managed care and those in non-managed care plans, using data from the 1996 Medical Expenditure Panel Survey (MEPS). Most respondents expressed satisfaction with their care; however, a substantial percentage reported experiencing barriers. Minorities, particularly Hispanics and Asian Americans, were more likely than non-Hispanic whites were to report barriers. Managed care enrollees across racial/ethnic groups faced different types of barriers than non-managed care enrollees did. Although managed care enrollees were more likely to report having a usual source of care and greater continuity of care, they also reported more difficulties obtaining care and less satisfaction with their care.     

Quality of cardiac surgeons and managed care contracting practices

OBJECTIVE: To evaluate the association between contracting practices of managed care organizations (MCOs) with cardiac surgeons and the quality of the cardiac surgeons. DATA SOURCES/STUDY SETTING: The study included all cardiac surgeons offering coronary artery bypass graft (CABG) surgery and 78 percent of MCOs in New York State in 1998. Primary data: The MCOs' panel composition with respect to hospitals and cardiac surgeons. Secondary data: New York State (NYS) Cardiac Surgery Reports. STUDY DESIGN: Statistical analyses of the probability of a contract between cardiac surgeons and MCOs conditional on the surgeon's risk-adjusted mortality rates (RAMR), outlier and low volume status, and controlling for other confounding variables, were performed. PRINCIPAL FINDINGS: Contract probability exhibited a tendency to decrease with RAMR, low volume and low-quality outlier status and to increase with high-quality outlier status. These effects were statistically significant for RAMR and high-quality outliers in Downstate and for low volume in Downstate and Upstate. CONCLUSIONS: In some, but not all cases, MCOs are seeking higher-quality providers. Further research is required to understand regional variability and the effect of market structure on the quality profile of MCOs.     

Perceptions of diabetes among patients in an urban health care system

Objectives. A major problem facing health care providers today is adherence to treatment regimens by patients. Adherence is of even greater significance for patients with diabetes who shoulder a great deal of responsibility in their disease management. Perceptions of diabetes have been found to play a major role in adherence. The effects of race and socioeconomic status on the disease perceptions remain unclear. This exploratory study encompassed two themes: (1) assessing perceptions of diabetes among African American and white American adults with diabetes who were patients in 1994 in a large Midwestern urban health care system and (2) examining the psychometric properties of the measurement instruments used to study perceptions. Design. A stratified random sampling scheme (by race and socioeconomic status (SES)) was used. Diabetes perceptions were measured using three scales from the Meaning of Illness Questionnaire assessing the impact loss and stress associated with diabetes. Perceptions of physician efficacy were also measured. The study population consisted of 50 (68% response rate) African American and white American patients aged 18-65 years. Results. No differences in SES were found between the African American and white American participants ( p = 0.44). However the African Americans in the study indicated a greater sense of loss associated with diabetes than the white Americans in the study ( p < 0.05). In the combined racial group the reliability coefficients as measured by Cronbach's alpha were 0.76 0.78 0.68 and 0.68 for the Impact Loss Stress and Perceptions of Physician Efficacy scales respectively. However the results of within-racial-group analyses tell a different story. The Impact scale fitted the African American and white American subgroups although there was some item variation by racial group. The Loss scale did not fit the white American subgroup and the Stress and Perceptions of Physician Efficacy scales did not fit the African American subgroup.     

Professional commitment among US physician executives in managed care

This paper examines professional commitment among physician executives working in managed care settings in the United States. The rise of an 'administrative elite' in medicine is central to the notion that physicians preserve their professional dominance despite changes in their prestige, work and employment status. Implicit in the notion of Freidson's restructuring perspective, physician executives presumably remain dedicated to professional interests in their management roles. The findings of a national survey support this assumption. Physician executives maintain meaningful, stable levels of professional commitment over time in management and the organization. This commitment is positively related to work-related characteristics involving favorable perceptions of the management job and physical and mental 'connection' to the practice of medicine. Belief in one's ability to successfully deliver appropriate clinical care, however, moderates the positive association between involvement in the management job and professional commitment. The findings provide a rationale for the maintenance of professional loyalty among physicians in management rooted in the work-related perceptions and activities of the individual physician executive.     

Exploring dual commitment among physician executives in managed care

The growth of a medical management specialty is a significant event associated with managed care. Physician executives are lauded for their potential in bridging the clinical and managerial realms. They also serve as a countervailing force to help the medical profession and patients maintain a strong voice in healthcare decision making at the strategic level. However, little is known about their work loyalties. These attitudes are important to explore because they speak to whose interests physician executives consider and represent in their everyday management roles. If physician executives are to maximize their effectiveness in the healthcare workplace, both physicians and organizations must view them as credible sources of authority. This study examines organizational and professional commitment among a national sample of physician executives employed in managed care settings. Data used for the analysis come from a national survey conducted through the American College of Physician Executives in 1996. The findings support the notion that physician executives can and do express simultaneous loyalty to organizational and professional interests. This dual commitment is related to other work attitudes that contribute to success in the management role. In addition, it appears that situational factors increase the chances for dual commitment. These factors derive from a favorable work environment that includes both organizational and professional socialization in the management role. The results of the study are useful in specifying the training and socialization needs of physicians who wish to do management work. They also provide a rationale for collaboration between healthcare organizations and rank-and-file physicians aimed at cultivating physician executives who are credible leaders within the healthcare system.     

Smoking and functional status among Medicare managed care enrollees

BACKGROUND: Smoking is a major determinant of health status and outcomes. Current smoking has been associated with lower scores on the Short Form-36 Health Survey (SF-36). Whether this occurs among the elderly and disabled Medicare populations is not known. This study assessed the relationships between smoking status and both physical and mental functioning in the Medicare managed-care population. METHODS: During the spring of 1998, data were collected from 134309 elderly and 8640 disabled Medicare beneficiaries for Cohort 1, Round 1 of the Medicare Health Outcomes Survey. We subsequently used these data to calculate mean standardized SF-36 scores, self-reported health status, and prevalence of smoking-related illness, by smoking status, after adjusting for demographic factors. RESULTS: Among the disabled, everyday and someday smokers had lower standardized physical component (PCS) and mental component (MCS) scores than never smokers (-2.4 to -4.5 points; p <0.01 for all). Among the elderly, the lowest PCS and MCS scores were seen among recent quitters (-5.1 and -3.7 points, respectively, below those for never smokers; p <0.01 for both), but current smokers also had significantly lower scores on both scales. For the elderly and disabled populations, MCS scores of long-term quitters were the same as nonsmokers. Similar patterns were seen across all eight SF-36 scales. Ever smokers had higher odds of reporting both less-than-good health and a history of smoking-related chronic disease. CONCLUSIONS: In the elderly and disabled Medicare populations, smokers report worse physical and mental functional status than never smokers. Long-term quitters have better functional status than those who still smoke. More effort should be directed at helping elderly smokers to quit earlier. Smoking cessation has implications for improving both survival and functional status.     

Quality oversight and improvement in Medicaid managed care.

New York State has been collecting performance data from managed care plans that serve the Medicaid population since 1993. The data come to the state via the Quality Assurance Reporting Requirements--a series of quality of care, access, and utilization measures, largely based on the Health Plan Employer Data and Information Set, as well as several New York State-specific measures. In addition to collecting the data, the state publishes the information, works with plans that have below average rates of performance and provides a number of program and financial rewards to plans for rates that demonstrate high quality care. An analysis conducted on quality of care measures indicates that: (1) performance rates are increasing over time, (2) Quality Assurance Reporting Requirements rates are generally higher than national benchmarks, (3) the disparity between commercial plan rates and Medicaid rates is diminishing, and (4) the variability in performance across plans is decreasing. The analysis conducted indicates that the performance measurement system constructed in New York is an effective means to monitor health plan performance, while at the same time enabling the state and local health units to monitor population health and accomplishment of key public health objectives (complete immunization, cancer screening, etc.)     

远程会诊在医疗服务机构中的应用

目的：在我国医疗卫生改革背景下探讨远程会诊对＂看病难、看病贵＂现象的积极影响和作用。方法：结合远程会诊工作经验,通过例举对远程会诊的优点、不足以及作用和发展现状,对远程会诊进行科学分析。结果：远程会诊是一种能产生多重效益、经济实用、利国利民的就医新模式、新趋势,能有效缓解＂看病难、看病贵＂的突出问题。结论：随着科技发展和医药应用成本的降低,具有我国特色的远程会诊新就医模式将在解决＂看病难,看病贵＂的问题上发挥越来越多的优势。     

Hospital selection by managed care insurers

This article focuses on which factors influence the ability of hospitals to attract managed care patients. Data for the analysis were obtained from a national sample of 235 acute care hospitals in 1996. The results indicate that the costs of inpatient care, participation in an integrated delivery system network, and hospital size were the critical factors in determining the ability of hospitals to obtain managed care business.