The emergency services physician assistant: results of two years' experience

The physician assistant (PA) has become an integral part of urban health care. The roles chosen are diverse and often meet the particular needs of physicians or hospitals. We have developed a unique program in emergency services that allows for training and development of PAs in two distinctly different hospital settings. These PAs perform medical-surgical liaison work bridging what, at times, can be a complex cultural gap. It is our premise that these individuals can significantly improve the quality and quantity of care rendered.     

PAs--consumer advocates or adversaries?

Changes in America's health care delivery system require patients to participate more actively in decisions that affect their well-being. PAs should not discourage this trend; instead, they should help the health care consumer to become a partner in the health care decision-making process, and use their mid-level practitioner status to become consumer advocates within the system. This position requires a commitment to educate patients about the risks, benefits, and costs of care, as well as the available alternatives. In addition, PAs should strive to become information sources about the cost and distribution of services.     

A comprehensive plan for managed care of patients infected with human immunodeficiency virus.

Medicaid is rapidly moving toward managed care throughout the United States and will have a major impact on care programs for those infected with human immunodeficiency virus (HIV). The experience at the Johns Hopkins HIV Care Service is an example of the transition from fee-for-service to managed care. The Maryland Medicaid program, which has required enrollment of all Medicaid recipients since June 1997, uses an adjusted payment rate and separately funds protease inhibitors. Elements that made the transition to a managed care organization possible included the early development of a comprehensive network of services and a database showing that historical Medicaid payments were low compared with the statewide experience. Our Medicaid managed care program promotes unlimited access to specialists, rejects the "gatekeeper" concept for any service, and includes an open formulary. Nevertheless, it is uncertain that the services now provided can be sustained with anticipated reductions in payments that seem inevitable with Medicaid policies here and nationally.     

Exchange of perspectives with other health care professionals.

The time has come for the PA profession to reach out and communicate with other health care providers--with physicians, nurses, health care administrators, and other allied health professionals. In addition, PAs must encourage these providers to share their vision of tomorrow's health care delivery system and the roles that they will play with PAs. A PA educator outlines a plan for starting the process.     

The Cleveland Alzheimer's managed care demonstration: outcomes after 12 months of implementation

PURPOSE: This demonstration evaluates the effects of integrating Alzheimer's Association care consultation service with health care services offered by a large managed care system. The primary hypothesis is that Association care consultation will decrease service utilization, increase satisfaction with managed care, and decrease caregiver depression and care-related strain. Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis, patients have more severe memory problems, caregivers use other Association services in tandem with care consultation, and caregivers are not patients' spouses. DESIGN AND METHODS: The demonstration is a randomized trial that examines outcomes after a 12-month study period. Interview data from 157 primary family caregivers are combined with data abstracted from medical/administrative records. RESULTS: Support for the primary hypothesis is found for selected, but not all, service utilization outcomes and for caregiver depression. Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes. IMPLICATIONS: Care consultation delivered within a partnership between a managed care health system and an Alzheimer's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers.     

Managed long-term care: limits and lessons

In the mid-1990s, states began to reduce their reliance on commercial health plans in the primary and acute care markets. At the same time, however, many states are for the first time encouraging these plans to participate in long-term care programs. The evidence suggests, however, that commercial health plans will not provide a quick cure to the long-term care system. At the same time, several states have managed long-term care initiatives that do not rely on commercial health plans but that do an excellent job of case management and that also seem to be among the national leaders in offering home and community-based services. Oregon provides one example, but so does the traditional managed long-term care system in Arizona and the Community Options Program in Wisconsin. The current efforts in Arizona and Wisconsin to abandon these models and to embrace competition may therefore be a mistake.     

Good managed care needs universal health insurance

Although the increase of corporate managed care has helped to reduce excesses and costs, continued gains in cost-effectiveness depend on good clinically managed care. Benefits of clinically managed care depend on stable contracts and universal coverage. Instead, employers are decreasing coverage and creating a market of "lemons" in which low-cost plans are rewarded for cost-cutting tactics. These tactics have spawned movements that demand rights for patients and providers. Choosing to shore up those rights, however, will increase the number of uninsured persons. This tragic choice, which no other industrialized nation has permitted, will not be resolved until some form of universal health insurance is implemented.     

Quality and Accountability: Children’s Emergency Services in a Managed Care Environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program’s Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children’s emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers. [Moody-Williams JD, Dawson D, Miller DR, Schafermeyer RW, Wright J, Athey J: Quality and accountability: Children’s emergency services in a managed care environment. Ann Emerg Med December 1999;34:753-760.]     

An evaluation of the impact of a community-based adherence support programme on ART outcomes in selected government HIV treatment sites in South Africa

This study assessed the impact of a community-based adherence support service on the outcomes of patients on antiretroviral therapy (ART). The evaluation was a retrospective study based on patient clinical records. This study noted that a significantly higher proportion of patients with a community-based adherence supporter (also known as a patient advocate, PA) had viral load (VL) of less than 400 copies/ml at six months of treatment (70%, p=0.001); a significantly higher proportion of patients with PAs (89%) attained a treatment pickup rate of over 95% (67%; p=0.021). Patients at health facilities with PA services maintained a suppressed VL for a longer period as opposed to patients at health facilities without PA services (p=0.001), also patients at health facilities with PA services remained in care for longer periods (p=0.001). Therefore, the study concludes that integrated community-based adherence support is crucial in ensuring that patients remain in care, regularly pickup their treatment from ART clinics and are virologically suppressed. The study also underscores the importance of access to health services and the presence of an enabling environment in the treatment of AIDS.     

The economic burden associated with prior authorizations in an allergist office.

Costs for managed care organizations to process prior authorizations (PAs) for nonformulary medications have been estimated to be dollars 20-25 per request. Costs for physicians to process these requests have not been studied extensively. A data collection tool was developed and used by physicians and nurses to document time spent on processing PAs. Data were collected over 8 weeks and 117 requests were processed. Nurses averaged 5.6 +/- 6.5 calls per day per nurse and spent an average of 17 minutes per call. Physicians averaged 1.9 +/- 1.2 calls per day averaging 5.8 +/- 5.0 minutes per call. During the study period nurses spent >40 hours on 231 calls and physicians spent >8 hours on 154 calls. Based on the hourly rate of the nurses and physicians, the total cost in this specialty practice was dollars 17.77 per PA. Of the 117 PA requests, 98.7% were approved the first time they were processed. There are substantial costs with processing PAs for nonformulary drugs on the physician office side of managed care as well as on the insurance side of the process. Specialty physicians should have a different process for obtaining notformulary medications because almost 100% of their requests are granted.     

Emergency Medical Services for Children managed care white paper series: introduction

The introduction of managed care principles profoundly changed the delivery of health care in the United States. The Emergency Medical Services for Children (EMSC) program has developed a series of white papers to address the impact of managed care on the emergency care system for children and adolescents. We hope that these white papers will focus discussions among managed care organizations, health care providers, and the public in ways that will lead to improvement in the system of care available to children and adolescents.     

Shop around before enrolling in managed care plans

Managed care programs have a significant impact on AIDS patients, 60 percent of whom receive Medicaid. Information on Medicaid managed care programs is limited. It is important for patients to investigate whether a specialist with experience in HIV care is available, or if their plan will readily provide patients access to a physician who has experience. Patients also should determine whether the managed care plan uses current treatment standards and whether it has a limited drug formulary. Managed care plans should have a grievance procedure set up to resolve disputes, and provide services such as nutritional and substance abuse counseling. A glossary of health care terms is provided.     

Health care, treatment patterns and cost of services for patients infected with chronic hepatitis C virus in a large insured New England population

The purpose of this study was to describe the cost of health care and the patterns of treatment of young patients (under 65 years of age) identified in health insurance claims as having received services for chronic hepatitis C virus (HCV) infection. We screened computerized claims from a US indemnity and managed care organization for out-patient and in-patient diagnoses related to HCV. Treatment patterns and costs of services were evaluated in the following sites of care: in-patient care, emergency room, hospital out-patient care, ambulatory office care and pharmaceuticals. There were 191 patients with chronic HCV-related claims in this study population (25 per 100 000), during 1995–97. Medical services and pharmaceutical costs in total (US$ 7.1 million) constituted a considerable cost in patients with chronic HCV-related claims during 1995–97. A subset of 98 patients were prescribed interferon-α with substantial variability in treatment regimens. Claims data provides a unique opportunity to estimate dollars paid for treatment patterns and health services in a 'real world' insured population and contributes to the understanding of health services for chronic HCV.     

The employment of nurse practitioners and physician assistants in U.S. nursing homes

PURPOSE: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. DESIGN AND METHODS: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. RESULTS: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). IMPLICATIONS: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.     

Psychological distress and engagement in HIV-related services among individuals seeking mental health care

In the US, HIV-related mental health care has been funded for its ability to help engage and retain individuals living with HIV into other components of HIV-related care and treatment. However, little is known empirically about the types of HIV prevention and care with which they are, or need to be, connected. To explore this, data were collected from 617 individuals upon their self-enrollment in HIV-related mental health care in a large US city with high rates of HIV infection. Nearly a third of the participants (n=195) were "minimally engaged" in care services, 53% were "moderately engaged" and 15.6% were "highly engaged". There were significant differences between level of care engagement according to one's ethnicity, X(2)(4, n=617)=38.05; p<.001; Cramer's V=.18, with African-Americans and Latinos more likely to be highly engaged in care services compared to their Caucasian counterparts. Furthermore, individuals who were highly engaged in services had significantly lower levels of depression than their less engaged peers, F(2, 614)=8.18; p<.001; eta(2)=.03. Results suggest that while ethnic minorities were engaged in a higher number of care services, they were enrolling in mental health care following enrollment in other care services. Given the numerous benefits of engaging in HIV-related mental health early in the course of infection, it is important that case managers and primary care physicians educate African-Americans and Latinos on the benefits of mental health care in order to facilitate earlier engagement in HIV-related mental health services.     

Prioritization of health care services. A progress report by the Oregon Health Services Commission

The Oregon Health Services Commission is composed of a group of 11 consumers and health care professionals. It was appointed by the governor as required by the "Oregon Basic Health Services Act" to produce a prioritized list of health services ranked on the basis of their relative importance to populations served. Following actuarial analysis, the legislature will determine the extent to which the "list" of services can be funded to provide health care access for Medicaid recipients earning up to the 100th percentile of the federal poverty level. Prioritization will be based on a cost-benefit formula applied to each treatment/condition unit and assignment of each of these to a general category, which itself has been ranked on the basis of "public value."     

The impact of Medicare coverage on the PA profession.

Federal legislation that took effect on January 1 provides for Medicare part B reimbursement for physician assistant services in several clinical settings. Besides recognizing PAs' contribution to health care delivery, the law may greatly increase demand for PAs (especially in geriatric medicine), allow them to branch out to more nontraditional forms of practice, and prompt a need for a larger pool of graduates from PA education programs. This legislative victory does not diminish--but heightens--the profession's responsibility to show that PA services are cost-effective.     

Quality and accountability: Children's emergency services in a managed care environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.     

Physician assistants in emergency medicine

Physician assistants (PAs) specially trained in emergency medicine can be used effectively to work with emergency medicine physicians to provide efficient and expedient high-quality patient care. The concept of using PAs in the emergency department is reviewed, and items of concern to professionals who are reluctant to use PAs are discussed. Financial issues and malpractice risk are examined, and our experience with patient perceptions is summarized. The PA program at Beth Israel Medical Center is used as a case study to demonstrate the use and integration of the PA within the division of emergency services. Although a well-trained emergency physician is the gold standard for quality patient care, cost-effective quality care for certain patient complaints can be rendered acceptably by others.