Structural change in Medicare funding: Impact on the dietetics workforce

Aim:  To review the dietetic workforce profile and share of Enhanced Primary Care claims in the context of the Strengthening Medicare support for allied health services.
Methods:  Dietitians Association of Australia membership data from 2004 to 2007 were analysed to assess changes in the number and work hours of private practice dietitians. Medicare data for 2004–2005 to 2006–2007 were reviewed regarding uptake and distribution of allied health consultations.
Results:  The number of allied health Enhanced Primary Care consultations doubled between 2004–2005 and 2005–2006, with similar increases in 2006–2007. Physiotherapists claimed most, followed by podiatrists, then dietitians. Dietitians claimed most consultations per provider in 2004–2005 and 2005–2006, surpassed by podiatrists and diabetes educators in 2006–2007. The number and full-time equivalents of private practice dietitians increased since 2004. Almost one-third of members were engaged in private practice work by 2007. Approximately half of these worked eight hours or fewer per week in this setting over the period surveyed (45.9–50.8%).
Conclusions:  Medicare funding for allied health has provided structural change and presents an opportunity for growth in the private sector of dietetics. While the number and full-time equivalents of private practice dietitians increased since 2004, the anticipated sharp increase relative to other work areas was not seen. Dietetics had a high uptake of Medicare consultations per provider and consultations increased each year; however, the declining share of total consultations demonstrates that dietitians are not using the opportunity presented by Medicare to the same degree as some allied health professions.     

Melbourne dietitians' experience of Medicare policy on allied health services (strengthening Medicare; Enhanced Primary Care) in the first 12 months

Objective: To describe Victorian private practitioner dietitians’ experience of the Enhanced Primary Care (EPC) program funded under national heath insurance. Design: Dietitians’ experience of the EPC program was investigated between August 2004 and July 2005. A purposive sample of 10% (n = 15) of Victorian dietitians in private practice was interviewed via semi‐structured interviews or focus groups. Focus group/interview data were audio‐taped, transcribed verbatim and thematically analysed using NVIVO software to manage data. Subjects: Victorian dietitians. Setting: Dietetic private practice. Main outcome measures: Issues identified from narrative themes. Results: Thirteen (86%) participants were registered with the Medicare Australia and managed EPC‐referred patients. Two chose not to. All those using the program supported it but voiced frustrations experienced in the first year. Five themes emerged from narrative analysis involving difficulties with implementation in the following areas: referral issues, client preparedness, annual number of consultations limit, impact of financial cost on client and non‐reimbursed administration costs. Conclusion: For clients with chronic illness, access to dietitians in private practice under Medicare EPC is an important service. As increasing numbers of dietitians nationally work with EPC patients with chronic illness or complex care needs, there is a need for information sharing between professional groups about billing procedures and chronic care management. More dietitians need to structure practice to initiate bulk‐billing. Rigorous evaluation is needed to understand which diagnosis types can benefit from the program and to implement an evidence‐based model of chronic care improvement for dietetics consultations.     

Multiple payers,commonality and free-riding in health care: Medicare and private payers

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.     

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.     

An economic history of Medicare part C

Context: Twenty‐five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee‐for‐service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer‐sponsored health insurance with managed care over the same time period. Findings: Beneficiaries’ access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high‐quality care, and to save Medicare money.     

Referrals to dietitians/nutritionists: A cross‐sectional analysis of Australian GP registrars’ clinical practice

Aim

The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals.

Methods

This was a cross‐sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six‐month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010–2015). Independent variables were related to registrar, patient, practice and consultation.

Results

A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23–0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement.

Conclusions

Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients’ complex care needs.     

Feasibility and acceptability of a physical activity promotion programme in general practice

BACKGROUND: Physical activity promotion in general practice is advocated though not incorporated into daily practice. Several barriers must be overcome to develop a feasible and acceptable programme. OBJECTIVE: The aim of this study was to conduct a process evaluation of a physical activity promotion programme in general practice (PACE), in which patients visited their provider (GP or practice nurse) twice. METHODS: Process evaluation was conducted by means of telephone-administered, semi-structured interviews with providers and practice assistants. The main topics of the interviews were overall impression of PACE, PACE training, content and usability of the intervention materials, counselling, implementation of the intervention, and opportunities for future use. RESULTS: In the 15 participating general practices, a total of 17 providers and 12 practice assistants were interviewed. The overall impression of the PACE programme was positive. Most providers experienced the provided material and training as helpful. Some problems concerning the number of forms used and patients having difficulties completing the forms were mentioned. Most providers (70.6%) spend 10 min or more discussing PACE during the first consultation. The second consultation mostly was completed within 10 min. Patients overestimating their level of physical activity was mentioned as the main barrier in providing the counselling. PACE was evaluated as suitable for implementation in Dutch general practice, and 60% of the providers actually intended using PACE in the future. CONCLUSION: The PACE programme was evaluated as being both acceptable and feasible in a selection of Dutch general practices. Positive adaptations will be made in order to implement PACE successfully in general practice at a wider scale.     

Differences in Referral Rates from General Practice

There are many unexplained differences in the rates at whichgeneral practitioners make referrals to other medical specialists.This study investigated 17 586 referrals from 141 general practitionersto specialists in seven specialties in Ringkjøbing countyin Denmark. As an expression of the referral rate, a referralindex was estimated for every general practitioner. The referralindex was the number of referrals to the specialist per 1000patients per year, including children, standardized for ageand sex to the average population in Ringkjøbing county.The following six variables were evaluated in relation to thereferral index: specialists in the local area, doctors per practice,consultations per general practitioner per year, patients registered,consultations per 1000 patients per year standardized for ageand sex, and supplementary procedures per consultation. Stepwisemultiple regression analysis was used. The study showed thatthe referral index rose both with a better access to specialistand with an increasing number of consultations per practitionerper year. The referral index fell with increased numbers ofpatients registered. No correlation was found between the referralindex and number of supplementary procedures per consultation,number of doctors per practice and number of consultations per1000 patients per year.     

Outreach clinics in Israel: a common but unregulated phenomenon.

BACKGROUND: Specialist outreach consultations in the primary care setting have long been controversial with regard to both their effectiveness in treating patients and their potential in improving the interaction between family physicians and specialists. OBJECTIVE: The aim of this study was to establish the prevalence and nature of outreach consultations in primary care clinics in Israel. METHODS: Questionnaires were sent to the heads of all public family practices of the General Sick Fund in our district (38 practices with about 180,000 patients). All 38 practice managers returned completed questionnaires. RESULTS: Twenty-eight of the 38 practices (74%) have some type of specialist consultation available within their clinics. The most common specialties providing outreach clinics are cardiology (47%), nephrology (45%) and internal medicine (39%), where the consultation was performed with the family physician and the patient present. Psychiatry consultations (42%), however, were generally performed without the patient being present. Most of the practice heads felt that in essence outreach clinics could be a positive way of treating their patients. CONCLUSIONS: Head physicians of primary care clinics tend to see outreach clinics as being a very positive tool with which to treat patients. Although many family physicians have some form of specialist consultation available, it is provided and performed mainly on an ad hoc basis. At present no data are available on how best to structure these consultations, or on which specialties outreach clinics are most suitable.     

The value of case studies

Background: Studies describing GP consultation have identified duration of consultation as an important marker of patient satisfaction. Duration of consultation differs between countries. Objective: The aim of this study was to measure the duration of consultations and the different segments of the consultation in a representative sample of GPs in the Nantes district (France).

Material and methods: 150 GPs in the Nantes district were randomly selected from the telephone directory. A letter of explanation was sent, followed up by a telephone call asking the GPs to receive an observer into their surgery. The observer timed consultations and the different segments of the consultation. Results: 30 out of 150 GPs contacted agreed to participate. 329 consultations were observed. Average duration of consultation was 14 min and 24 s; it was 15 min in non-computerised practices and 12 min and 50 s in computerised practices. Consultations for psychological problems or with many reasons for consulting took longer. Doctors usually talked more than patients, except during long consultations. Patients were not examined in only 2% of consultations. Trainers in general practice had longer consultations. Discussion: Many GPs refused to receive the observer; the ratio of trainers within the group of respondents (40%) was higher than in the general GP population (7–10%). As in other studies, female GPs were overre-presented as active participants. In our sample, the average duration of consultation was longer than in other studies. The finding regarding the duration of consultation in computerised practices may need validation in other studies. EurJ Gen Pract 2000;6:88–92.     

Teledermatology Consultations Provide Specialty Care for Farmworkers in Rural Clinics

ABSTRACT:  Context: Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care. Purpose: This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics. Methods: Dermatologists provided 79 consultations, using store-and-forward teledermatology, to farmworkers who presented with a skin disease to rural North Carolina clinics. Clinic providers rated the value of the consultation. Findings: Most requests for consultations (94%) came from family nurse practitioners or physician assistants. Twelve percent of consultations were rated somewhat helpful, and the remainder helpful or very helpful. After receiving the consultation, providers changed the diagnosis in 13% of cases. The consultation led providers to contact or attempt to contact 21% of patients to change treatment recommendations. Conclusions: Access to expert dermatologic services is needed by rural health care providers. Teledermatology consultations may be a helpful tool to meet this need.     

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND: Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs. OBJECTIVES: Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice. METHOD: A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices. RESULTS: The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice. CONCLUSION: The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.     

Study protocol: The registrar clinical encounters in training (ReCEnT) study

ABSTRACT: BACKGROUND: Patient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars. Methods/design This is an ongoing prospective multi-site cohort study of general practice registrars' consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program. CONCLUSIONS: The study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap - the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars' patterns of practice (for example, prescribing practice) over the course of their training.     

A Random Effects Multinomial Logit Analysis of Using Medicare and VA Healthcare Among Veterans With Dementia

This study aimed to examine longitudinal patterns of VA-only use, dual VA and Medicare use, or Medicare-only use among veterans with dementia. Data on VA and Medicare use (1998–2001) were obtained from VA administrative datasets and Medicare claims for 2,137 male veterans with a formal diagnosis of Alzheimer's disease or vascular dementia enrolled in the National Longitudinal Caregiver Study. A random effects multinomial logit model accounting for unobserved individual heterogeneity was used to estimate the effects of patient and caregiver characteristics on use group over time. Compared to VA-only use, dual VA and Medicare use was associated with being white, married, higher education, having private insurance, Medicaid, low VA priority level, more functional limitations, and having lived in a nursing home or died in that year. Medicare-only use was associated with older age, being married, higher education, having private insurance, low VA priority level, living further from a VA Medical Center, having more comorbidities, functional limitations, and having lived in a nursing home or died. Veterans whose caregivers reported better health were more likely to be dual users, but those whose caregivers reported more comorbidities were more likely to use Medicare only. Different aspects of veterans' needs and caregiver characteristics have differential effect on where veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care.     

Current approaches to obesity management in UK Primary Care: the Counterweight Programme

Background/Aims Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care. Method A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self‐reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) ≥30 kg m^?2, n = 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti‐obesity medication. Computerized medical records for the total practice population (n = 206 341, 18–75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded. Results Eighty‐three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight‐related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice‐based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti‐obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected. Conclusion Obesity is under‐recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice‐based counselling being the most common intervention.