Accuracy of patient recall for self‐reported doctor visits: Is shorter recall better?

In health economics, the use of patient recall of health care utilisation information is common, including in national health surveys. However, the types and magnitude of measurement error that relate to different recall periods are not well understood. This study assessed the accuracy of recalled doctor visits over 2‐week, 3‐month, and 12‐month periods by comparing self‐report with routine administrative Australian Medicare data. Approximately 5,000 patients enrolled in an Australian study were pseudo‐randomised using birth dates to report visits to a doctor over three separate recall periods. When comparing patient recall with visits recorded in administrative information from Medicare Australia, both bias and variance were minimised for the 12‐month recall period. This may reflect telescoping that occurs with shorter recall periods (participants pulling in important events that fall outside the period). Using shorter recall periods scaled to represent longer periods is likely to bias results. There were associations between recall error and patient characteristics. The impact of recall error is demonstrated with a cost‐effectiveness analysis using costs of doctor visits and a regression example predicting number of doctor visits. The findings have important implications for surveying health service utilisation for use in economic evaluation, econometric analyses, and routine national health surveys.     

Smoking and use of primary care services: findings from a population-based cohort study linked with administrative claims data

ABSTRACT: BACKGROUND: Available evidence suggests that smokers have a lower propensity than others to use primary care services. But previous studies have incorporated only limited adjustment for confounding and mediating factors such as income, access to services and health status. We used data from a large prospective cohort study (the 45 and Up Study), linked to administrative claims data, to quantify the relationship between smoking status and use of primary care services, including specific preventive services, in a contemporary Australian population. METHODS: Baseline questionnaire data from the 45 and Up Study were linked to administrative claims (Medicare) data for the 12-month period following study entry. The main outcome measures were Medicare benefit claimed for unreferred services, out-of-pocket costs (OOPC) paid, and claims for specific preventive services (immunisations, health assessments, chronic disease management services, PSA tests and Pap smears). Rate ratios with 95 % confidence intervals were estimated using a hierarchical series of models, adjusted for predisposing, access- and health-related factors. Separate hurdle (two part) regression models were constructed for Medicare benefit and OOPC. Poisson models with robust error variance were used to model use of each specific preventive service. RESULTS: Participants included 254,382 people aged 45 years and over of whom 7.3 % were current smokers. After adjustment for predisposing, access- and health-related factors, current smokers were very slightly less likely to have claimed Medicare benefit than never smokers. Among those who claimed benefit, current smokers claimed similar total benefit, but recent quitters claimed significantly greater benefit, compared to never-smokers. Current smokers were around 10 % less likely than never smokers to have paid any OOPC. Current smokers were 15-20 % less likely than never smokers to use immunisations, Pap smears and prostate specific antigen tests. CONCLUSIONS: Current smokers were less likely than others to use primary care services that incurred out of pocket costs, and specific preventive services. This was independent of a wide range of predisposing, access- and health-related factors, suggesting that smokers have a lower propensity to seek health care. Smokers may be missing out on preventive services from which they would differentially benefit.     

Racial/ethnic disparities in the use of preventive services among the elderly

OBJECTIVES: Minorities have worse health outcomes compared to whites, which are partially explained by racial/ethnic disparities in use of health services. Less well known, however, are whether these disparities persist among the elderly, the only group that possesses near universal health insurance coverage by Medicare, and how variation in Medicare coverage affects the receipt of preventive services. The scope of racial/ethnic disparities in the use of preventive services in the elderly was assessed, and the impact of the type of health insurance coverage on the use of preventive services was measured. METHODS: Data were derived from the 2001 California Health Interview Survey, a random-digit-dial population-based survey, collected between November 2000 and October 2001. Analysis for this project was conducted in 2004. The association of race/ethnicity and type of health insurance with receipt of preventive services was assessed using bivariate and multivariate logistic regression models. RESULTS: African Americans and Latinos were significantly less likely to be vaccinated for influenza, and Asian Americans were significantly less likely to obtain a mammogram compared to whites, while controlling for other explanatory factors. Moreover, those with Medicare plus Medicaid coverage were significantly less likely to use all four preventive services compared to those with Medicare plus private supplemental insurance. CONCLUSIONS: Despite near-universal coverage by Medicare, racial/ethnic disparities in the use of some preventive services among the elderly persist. Further research should focus on identifying potential cultural and structural barriers to receipt of preventive services aimed at designing effective intervention among high-risk groups.     

Veterans using and uninsured veterans not using Veterans Affairs (VA) health care

OBJECTIVES: The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans. METHODS: The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured. RESULTS: Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year. CONCLUSIONS: Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.     

Update on Medicare‐funded allied health chronic disease management consultations in dietetics and the five most referred professions in 2010

Aim: Uptake of Medicare‐funded chronic disease management items has increased exponentially since the programme commenced in 2004. We aim to report on national utilisation of the five most referred of 13 allied health services and to examine patient uptake rates. Methods: Annual statistics generated from national Medicare billing data from January 2010 to December 2010 were extracted from the Medicare public database and compared by profession, state and per capita population. Results: The five most utilised individual services were: (in decreasing order) podiatry, physiotherapy, dietetics, chiropractic and speech pathology. They provided 94% of all allied health consultations nationally, on referral from general practitioners. Per capita utilisation revealed wide variation in uptake by state and territory; some states had far less services than the national average. Patterns of referral instanced by age range and gender of clientele differed between professions. Most dietetics clients were middle aged (45–74 years) and this fits with expectations of chronic disease incidence. There was inequity of access to group services for the management of type 2 diabetes, with most services (85%) provided in South Australia and New South Wales. Conclusion: Dietetics providers have maintained and improved their referral rate and continue to be the third most utilised Medicare chronic disease management allied health service. Six years into the programme, further exploration is warranted to understand the reasons for wide variation in rates of patient uptake for the service provider professions.     

Keratinocyte cancers in South Australia: incidence,geographical variability and service trends

Objectives: To determine the incidence, multiplicity, geographical variability and service trends of keratinocyte cancers (KC) in South Australia (SA). Methods: Medicare Australia data with a unique identifier were used to assess the number of people treated over years 2010–2014. A maximum of one KC service claim per year was used to determine incidence. Age‐standardised rates were estimated as were KC service activity trends. Results: There were 497,581 services to 204,183 SA residents for KC, solar keratoses, locally aggressive skin tumours or suspicious skin lesions. Of these, n=159,137 services were for KC (77,502 people). The five‐year (2010–2014) age‐standardised rate of KC in SA was 1,466.6 (95%CI 1,458.3‐1,474.8) per 100,000. Forty per cent of people had more than one KC removed. Men accounted for more incident cases (59.2%). Age‐specific rates showed least variability over time in the youngest age group (15–44 years). For 26 geographical areas, higher age‐standardised ratios of KC were seen in coastal and agricultural areas. There was a 59% increase in services for KC from 2000 to 2015. Conclusions: Age‐standardised rates for KC are relatively stable in SA, but regional variations are evident. Services for KC continue to rise. Implications for public health: This is the first systematic report of KC in SA. We demonstrate the utility of using validated Medicare data for assessing KC incidence and trends.     

The Influence of Insurance Status and Income on Health Care Use Among the Nonmetropolitan Elderly

The objective of this research is to examine the influence of income and type of insurance coverage on the use of health services among the nonmetropolitan elderly. A model of health services utilization is used as the foundation for examining this issue with data from a telephone survey of a randomly selected sample of residents from four nonmetropolitan counties in Pennsylvania. Results indicated that those elders with Medicaid coverage were less likely to visit a doctor than respondents with private insurance or Medicare only, even after controlling for income and other relevant factors. Further, lower income respondents with Medicare were less likely to visit the dentist than those with private insurance (Medicare does not cover dental care). In contrast, neither income nor insurance predicted hospital use. As such, the health and dental care needs of many lower income nonmetropolitan elders may potentially be going unmet. In general, findings highlight the continued relevance of economic barriers to the use of such services among the nonmetropolitan elderly.     

Horizontal inequities in Australia's mixed public/private health care system

Recent comparative evidence from OECD countries suggests that Australia's mixed public-private health system does a good job in ensuring high and fairly equal access to doctor, hospital and dental care services. This paper provides some further analysis of the same data from the Australian National Health Survey for 2001 to examine whether the general finding of horizontal equity remains when the full potential of the data is realized. We extend the common core cross-country comparative analysis by expanding the set of indicators used in the procedure of standardizing for health care need differences, by providing a separate analysis for the use for general practitioner and specialist care and by differentiating between admissions as public and private patients. Overall, our analysis confirms that in 2001 Medicare largely did seem to be attaining an equitable distribution of health care access: Australians in need of care did get to see a doctor and to be admitted to a hospital. However, they were not equally likely to see the same doctor and to end up in the same hospital bed. As in other OECD countries, higher income Australians are more likely to consult a specialist, all else equal, while lower income patients are more likely to consult a general practitioner. The unequal distribution of private health insurance coverage by income contributes to the phenomenon that the better-off and the less well-off do not receive the same mix of services. There is a risk that - as in some other OECD countries - the principle of equal access for equal need may be further compromised by the future expansion of the private sector in secondary care services. To the extent that such inequalities in use may translate in inequalities in health outcomes, there may be some reason for concern.     

History of domestic violence and health service use among mid-aged Australian women

OBJECTIVES: To examine associations between history of domestic violence and health service use among mid-aged Australian women, adjusting for physical and psychological health status and demographic factors. METHODS: Population-based cross-sectional postal survey (1996) of the Australian Longitudinal Study on Women's Health. Of 28,000 women randomly selected, 14,100 (53.5%) aged 45-50 years participated. Logistic regressions were used to assess associations between domestic violence and health service use. RESULTS: After adjusting for demographic variables, multivariate analysis revealed associations between ever having experienced domestic violence and three or more consultations in the previous 12 months with a family doctor (OR 2.07, 95% CI 1.68-2.55), hospital doctor (OR 1.77, 95% CI 1.44-2.I7), or specialist doctor (OR 1.54, 95% CI 1.35-1.75), or being hospitalised (OR 1.36, 95% CI 1.20-1.54). After adjusting for demographic variables and physical and psychological health status, these associations were attenuated: three or more consultations with family doctor (OR 1.36, 95% CI 1.09-1.70), hospital doctor (OR 1.16, 95% CI 0.92-1.45), or specialist doctor (OR 1.14, 95% CI 0.98-1.32), and being hospitalised (OR 1.10, 95% CI 0.96-1.26). CONCLUSIONS: Physical and psychological status accounted for the associations between domestic violence and higher health service use, with the exception of GP consultations, which remained associated with domestic violence. IMPLICATIONS: Physical health status only partially explains the increased health service use associated with domestic violence, while both physical and psychological health status explained higher usage of specialist and hospital services. It seems likely that women who have experienced domestic violence may be seeking consultations from GPs for reasons additional to health status.     

Pilot study comparing patients’ valuation of health‐care services with Medicare’s relative value units

Background and aims Physician reimbursement for services and thus income are largely determined by the Medicare Resource‐Based Relative Value Scale. Patients’ assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients’ valuation of health‐care services to Medicare’s relative value unit (RVU) assessments and to discover patients’ perceptions about the relative differences in incomes across physician specialties. Design Cross‐sectional survey. Participants and setting Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Methods Data collection included the use of a visual analog ‘value scale’ wherein participants assigned value to 10 specific physician‐dependent health‐care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the abovementioned services. Comparisons of (i) the ‘patient valuation RVUs’ with actual Medicare RVUs, and (ii) patients’ estimations of physician income with actual income were explored using t‐tests. Outcomes Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P < 0.001) and the range in values assigned by participants was much smaller than Medicare’s (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P < 0.001) and the differential across specialties was thought to be much smaller (estimate: $88 225, actual: $146 769). Conclusion In this pilot study, patients’ estimations of the value health‐care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients’ valuation of services rendered by physicians may be warranted.     

The effects of predetermined payment rates for Medicare home healthcare.

OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.     

Trends in health attitudes and self-perceptions among school-age South Australians between 1985 and 2004

OBJECTIVE: To describe trends in health attitudes and self-perceptions among school-age South Australians between 1985 and 2004. METHODS: The questionnaire from the 1985 Australian Schools Health and Fitness Survey was administered during 2004 in those South Australian schools that participated in the 1985 survey. Using chi square, responses were compared for 10-15 year-olds (1985, n=398; 2004, n=467) on attitudes to: visiting the doctor and dentist, smoking, sleep, diet, exercise, stress, having friends, and knowledge about fitness and health. Additionally, self-perceptions of health and fitness were compared. RESULTS: Among boys and girls between 1985 and 2004, there were significant declines in the perceived importance of regularly visiting the dentist and doctor, but improved attitudes to being a non-smoker. Among boys, the perceived importance of sleep and diet declined between surveys. A smaller percentage of boys and girls in the latter survey perceived their current health status as 'good'. In the lower SES sample, the percentage of girls rating healthy diet as 'very important' was lower in 2004. CONCLUSIONS: There have been general declines in perceived importance of many health-related behaviours among South Australian youth between 1985-2004. In contrast, the perceived importance of not smoking was higher in 2004 than 1985. Implications: The relative success of anti-smoking campaigns targeting youth suggests that health education must be accompanied by broader environmental support in order to effect positive behavioural change.     

Country of birth, country of residence, and menopausal transitions and symptoms: British birth cohort and Australian Longitudinal Study on Women's Health

OBJECTIVE: To explore endocrine-related and general symptoms among three groups of middle-aged women defined by country of birth and country of residence, in the context of debates about biological, cultural and other factors in menopause. METHODS: British-born women participating in a British birth cohort study (n=1,362) and age-matched Australian-born (n=1,724) and British-born (n=233) Australian women selected from the Australian Longitudinal Study on Women's Health (ALSWH) responded to two waves of surveys at ages 48 and 50. RESULTS: Australian-Australian and British-Australian women report reaching menopause later than British-British women, even after accounting for smoking status and parity. Hormone replacement therapy (HRT) use was lower and hysterectomy was more common among both Australian groups, probably reflecting differences in health services between Britain and Australia. The Australian-Australian and British-Australian groups were more likely to report endocrine-related symptoms than the British-British group, even after adjusting for menopausal status. British-British women were more likely to report some general symptoms. CONCLUSIONS: Symptom reporting is high among Australian and British midlife women and varies by country of residence, country of birth and menopausal status. IMPLICATIONS: The data do not support either a simple cultural or a simple biological explanation for differences in menopause experience.     

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.     

Australian women seeking counseling have higher use of health services

PURPOSE: Despite a high prevalence of psychological distress and poor mental health in the Australian community, use of counseling services is very low. There has been only limited research examining the profile of those who do access counseling services, mainly in terms of demographic and health behavior variables. To extend our understanding of those who currently access counseling services, this study aimed to examine the broader pattern of health service utilization by women who consulted counselors, psychologists, or social workers in the past year compared with those who did not among a population-based sample of middle-aged Australian women, and to determine whether health service utilization was independently associated with use of counseling services, controlling for other known predictors. METHODS: The cross-sectional population-based mail survey data for this study came from the third survey of the mid-aged cohort of the Australian Longitudinal Study on Women's Health, conducted in 2001. The sample comprised 11,201 women aged 50-55. The main study variable was a question asking whether they had consulted a counselor/psychologist/social worker in the past year. FINDINGS: Only 6.9% of women had consulted a counselor/psychologist/social worker in the past year. After controlling for self-reported mental health status, health behaviors and demographic variables in multivariate analysis, consulting a counselor/psychologist/social worker in the past year was significantly and positively associated with consultations with general practitioners (>/=5 consultations; odds ratio [OR], 4.14; 95% confidence interval [CI], 2.35-7.27; p < .0001), specialist (>/=3 consultations; OR, 2.09; 95% CI, 1.66-2.63; p < .0001), and hospital doctor (OR, 1.35; 95% CI, 1.10-1.66; p = .004). Use of counseling services was not associated with use of other allied and complementary health services in multivariate analyses. CONCLUSIONS: Further research is needed to determine whether the strong independent link between self-reported use of counseling and other medical and health services among middle-aged women is best explained by general practice referral patterns, availability of services, economic factors, or different help-seeking patterns among women.     

Age and Gender Differences in Medicare Expenditures and Service Utilization at the End of Life for Lung Cancer Decedents

PURPOSE: Gender and age differences in medical care are well documented. We examined age and gender differences in Medicare expenditures for lung cancer decedents in the last year of life (LYOL) through a cross-sectional study of Medicare administrative and claims data. METHODS: Participants were aged Medicare beneficiaries (>or=68) with lung cancer, who were covered by Parts A and B for 36 months before death (1996-1999; n = 13,120). Regression techniques were used to estimate age and gender differences in mean Medicare utilization and expenditures in the LYOL overall and by type of service, conditional on use: inpatient, outpatient, physician, skilled nursing facility (SNF), home health, and hospice, controlling for demographic, clinical, geographic, and supply characteristics. RESULTS: Women were more likely than men to use inpatient, SNF, home health, and hospice services. Women's average expenditures were approximately dollars 1,900 greater than men's, with differences attributed to higher average expenditures for SNF, home health, and hospice. Older cohorts used fewer inpatient and outpatient services and used more SNF and hospice services in their LYOL. Average Medicare expenditures were significantly lower in older cohorts (dollars 8,487 less for those age >or=85 at death than for those 68-74). Adjusting for age explains most of the gender differences in average Medicare expenditures. Remaining gender differences vary across age cohorts, with larger gender differences in social-supportive service expenditures among those 68-74 and 75-84 and outpatient and physician services among those 75-84 and >or=85. DISCUSSION AND CONCLUSIONS: Our findings suggest that gender disparities in expenditures are generally small at the end of life for lung cancer decedents, particularly among the older cohorts. As expected, the bigger observed differences are by age although the direction of the association is not consistent across types of service. Higher expenditures for women on social-supportive services may reflect fewer informal supports for older women compared with men.     

Determinants of general practitioner use among women in Australia

This study investigates the use of general practitioner services by women in Australia. Although there is a universal health insurance system (Medicare) in Australia, there are variations in access to services and out of pocket costs for services. Survey data from 2350 mid-age (45-50 years) and 2102 older (70-75 years) women participating in the Australian Longitudinal Study on Women's Health were linked with Medicare data to provide a range of individual and contextual variables hypothesised to explain general practitioner use. Structural equation modelling showed that physical health was the most powerful explanatory factor of general practitioner use. However, after adjusting for self-reported health, out of pocket cost per consultation was inversely associated with use of services. The out of pocket cost was generally lower for women with low socioeconomic status but cost was also directly related to geographical remoteness. Women living in more remote areas had higher out of pocket costs and poorer access to services. Women who reported better access to care were more likely to be satisfied with their most recent general practice consultation and less likely to be sceptical of the value of medical care. These results show the need for health policies that improve the equitable use of general practitioner services in Australia.     

Risk differential between Medicare beneficiaries enrolled and not enrolled in an HMO.

Medicare provides incentive reimbursements to health maintenance organizations (HMOs) which enroll Medicare beneficiaries on a risk option and provide care at a lower cost than expected. The incentive reimbursements are tied to an actuarial calculation of Medicare Adjusted Average Per Capita Cost (AAPCC). The AAPCC adjusts for a number of variables which affect Medicare reimbursements and for which data are available: place of residence, age, sex, welfare status, and institutional status of beneficiaries. These factors account for much of the expected difference in health care reimbursements. They do not, however, account for differences in health status. Because of this, AAPCC calculations of expected costs may be too high if a selected group of beneficiaries is healthier than average, or too low if the selected group has a poorer health status than average. This case study examines the utilization behavior and reimbursement experience of a group of Medicare beneficiaries prior to their joining an HMO (during an open enrollment period) under a risk-sharing option. Their use was compared with a comparable Medicare population (the comparison group) to determine if their usage rates were greater, equal, or less than average. Results show that beneficiaries who joined during open enrollment had a rate of hospital inpatient use over 50 percent below the comparison group and a reimbursement rate for inpatient services 47 percent below the comparison group. These beneficiaries' use of Part B services also appears to be lower than the comparison group. These results must be interpreted with care. The information came from a single case study. Specific aspects of the open enrollment process, described in the paper, further limit the general liability of the findings. Also, while some studies of the same subject support the results, many others do not.     

The Australian Health Care Agreement 1998–2003: Implications and strategic directions for occupational therapists

Funding for public health services in Australia is provided to the States and Territories from the Commonwealth. Contractual obligations for how these monies are allocated are detailed in the Australian Health Care Agreement 1998 –2003, which has replaced the Medicare Agreement 1993–1998. Key issues identified in the new Agreement, which will impact on occupational therapy services, include arrangements for mental health services, palliative care initiatives, casemix, health system reform, and private health insurance. Particular implications stem from the proposed reforms to the health system. These include the quality agenda, outcome-based funding and evidence-based practice. Other themes identified include future opportunities for occupational therapists working in health services and the imperative to form collaborative partnerships with consumers and other health care providers. The Australian Health Care Agreement is analysed and suggestions given for strategic directions for occupational therapists to consider.     

Preventive services for the elderly: would coverage affect utilization and costs under Medicare?

OBJECTIVES. This study was undertaken to determine whether adding a benefit for preventive services to older Medicare beneficiaries would affect utilization and costs under Medicare. METHODS. The demonstration used an experimental design, enrolling 4195 older, community-dwelling Medicare recipients. Medicare claims data for the 2 years in which the preventive visits occurred were compared for the intervention (n = 2105) and control (n = 2090) groups. Monthly allowable charges for Part A and Part B services and number of hospital discharges and ambulatory visits were compared. RESULTS. There were no significant differences in the charges between the groups owing to the intervention, although total charges were somewhat lower for the intervention group even when the cost of the intervention was included. Charges for both groups rose significantly as would be expected for an aging population. A companion paper describes a modest health benefit. CONCLUSIONS. There appears to be a modest health benefit with no negative cost impact. This finding gives an early quantitative basis for the discussion of whether to extend Medicare benefits to include a general preventive visit from a primary care clinician.