Voluntary partial capitation: the Community Nursing Organization Medicare demonstration

In a recently concluded Medicare demonstration, Community Nursing Organizations (CNOs) received capitated payment to provide a subset of Medicare services through a nursing case management delivery system. Demonstration participation was voluntary, both for CNOs and recruited beneficiaries, raising several challenging issues associated with selection. We investigate provider and beneficiary selection, as well as Medicare costs, using multiple evaluation methodologies. We find that CNO enrollment is associated with increased payment by Medicare for CNO-covered services. Results showing CNO enrollees to be more costly to Medicare for non-CNO services are consistent with cost shifting, but could also be accounted for by biased provider selection into the demonstration.     

THE DYNAMICS OF MEDICAL CARE USE IN THE BRITISH HOUSEHOLD PANEL SURVEY

We explore whether medical care use is persistent over a long panel using 18 waves of the British Household Panel Survey. Of particular interest is high medical care use because a few high users account for a disproportionate amount of use while many individuals use no medical care in a given year. If health is a primary driver of medical care demand, and we control for health, then past medical care use should be uninformative for future use. However, we find that conditional on health, other covariates and unobservable heterogeneity, medical care use remains significantly persistent. “No use” and “high use” are more strongly persistent, and persistence is generally stronger for women, those in poor health, and at older ages. We find that unobservable heterogeneity explains between 10% and 25% of the variation in medical care use. This heterogeneity is significantly correlated with both medical care use and health over our long panel. These findings have implications for the econometric modeling of medical care demand and suggest that policies aimed to reduce aggregate medical care spending by improving health, particularly the health of seniors, may be less effective than projected using static models. Copyright © 2012 John Wiley & Sons, Ltd.     

Out-of-pocket costs,primary care frequent attendance and sample selection: Estimates from a longitudinal cohort design

This paper examines the effect of out-of-pocket costs on subsequent frequent attendance in primary care using data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study from Canberra, Australia. The analysis sample comprised 1197 respondents with two or more GP consultations, and uses survey data linked to administrative health service use (Medicare) data which provides data on the number of consultations and out-of-pocket costs. Respondents identified in the highest decile of GP use in a year were defined as Frequent Attenders (FAs). Logistic regression models that did not account for potential selection effects showed that out-of-pocket costs incurred during respondents’ prior two consultations were significantly associated with subsequent FA status. Respondents who incurred higher costs ($15–$35; or >$35) were less likely to become FAs than those who incurred no or low (<AUS$15 per consultation) costs, with no difference evident between the no and low-cost groups. However, a counterfactual model that adjusted for factors associated with the selection into payment levels did not find an influence of payment, with only a non-significant gradient in the expected direction. Hence these findings raise doubts that price drives FA behaviour, suggesting that co-payments are unlikely to affect the number of GP consultations amongst frequent attenders.     

THE HEALTH EFFECTS OF THE INTERNATIONAL TRANSFER OF MEDICAL TECHNOLOGY

The rapid international transfer of medical technologies to the developing countries is in progress, promoting a “high technology” model of medicine mat is reflected in the structure of hospitals and university faculties, and medical education and practice. The resulting growth of specialties and sub-specialties in hospitals may inhibit the development of appropriate, village-based primary care services. Postgraduate medical education programs donated by the United States, Australia or Europe may disregard the vital issues of provision of universal primary care and local control of health services, and train doctors to devote resources to high technology urban models of care. Medical graduates emigrate to industrial countries because they find no “market” for their services in villages, where needs are the greatest. Bilateral foreign aid programs, WHO sponsored projects, multinational corporate transactions and medical missions and education have been important sources of technology transfer. While a national pharmacopoeia requires only 200 drugs, with 17 basic drugs in village clinics, most patients are denied suitable drug therapy because of inadequate primary care and the inappropriate transfer and promotion of over 4000 drugs that are expensive, incompletely tested in local conditions, or toxic. The deficiency in basic health services means only about 4 million of the 80 million children born each year in Africa, most of Latin America and South East Asia are effectively immunised with available vaccines. There are some apparently successful examples of appropriate health systems, based on the principles of universal access to primary care by health workers, and a national referral system to secondary and tertiary care. Effective monitoring of technology transfer and the development of appropriate health services involves important roles for the WHO and greater international co-operation among community health workers.     

THE WEIGHT OF KNOWLEDGE: TEACHERS AND STUDENTS AND DOCTORS AND PATIENTS

This paper examines one particular problem in medical education: the rapid accumulation of technical medical knowledge. It is suggested that this development contributes significantly to several major deficiencies in training for clinical practice: it encourages a passive learning model, it helps to undervalue consultation skills and it inappropriately increases the student's anxiety in “not knowing all the facts.” In addition, the emphasis on technical knowledge helps to narrow the focus of attention to technical details at the expense of essential information on the patient's relationships and environment. Knowledge will continue to accumulate; a number of suggestions are made to ameliorate some of the harmful effects of this accumulation on teaching and learning in medical school. They include more emphasis on the process of the consultation and on problem-solving skills learned experientially rather than mastery of facts. A further recommendation is made to re-evaluate what is the essential knowledge base so that greater weight is given to information about the patient's relationships, attitudes and beliefs. The paper concludes with an assessment of the major institutional constraints standing in the way of the educational reforms outlined and suggests some ways these could be overcome.     

DOES BULK BILLING CAUSE ABUSE OF MEDICARE?

Medicare data are examined to determine whether there is an association between bulk billing and the ‘abuse’ of Medicare. It is found that, with the exception of one group — ‘GP-Specialist’, there is no systematic relationship between bulk billing and increased medical incomes. Neither GP gross income nor total fees per patient vary significantly with the proportion of items bulk billed. By contrast, there is a significant and systematic increase in total fees per patient as medical incomes increase.     

Long-Term Care in San Mateo

This California county coordinates the “fourth stage of medicine” through a Medical Evaluation and Placement Team that includes medical social workers and public health nurses. As a result, says Dr. Salmon, it is well prepared to meet the demand for long-term services expected under Medicare and Medicaid.     

Do preset per visit payment rates affect home health agency behavior?

This article reports on preliminary impacts during the first year of a demonstration in which home health agencies (HHAs) were paid a prospectively set rate for each Medicare home health visit rendered, rather than being reimbursed for costs. Forty-seven agencies in five States participated. The evaluation compared the experiences of randomly assigned treatment agencies and their patients with those of control agencies and their patients and found no compelling evidence of any demonstration impact on agency cost per visit, the volume of home health services, agency revenue and profit, patient selection and retention, quality of care, or use and cost of Medicare services.     

Controlled evaluation of management of schizophrenia in one general practice: a pilot study.

The study reports on a controlled evaluation of services offered to patients with a diagnosis of schizophrenia in comparison to diabetic patients and matched attenders with no chronic illness. Data were collected from one inner city London group practice, by a retrospective analysis of patients' notes over a period of 6 years. Although patients with schizophrenia attended significantly more often than other patients, clinical assessments in the surgery were rarely undertaken. Communications with hospital consultant services were rare for both chronic groups of patients but in the case of those with schizophrenia the doctor received on average only one letter every 2 years. The findings support other recommendations for a more structured approach to the care of schizophrenia in general practice with regular attention to mental state assessment and monitoring of drug treatment.     

病案管理的现状与改进措施

病案管理是医院管理工作中的重要组成部份,不断的开发和构建新型病案管理模式,为医疗、教学、科研服务,为患者、保险机构服务是病案管理工作中的重要工作内容,文章就目前的病案管理现状进行了描述并对今后的发展提出了几点改进措施。     

陕西省宁强县地震灾后医疗救助及其政策建议

“5·12”汶川大地震影响范围广,造成的人民生命财产损失特别严重。地震发生后,全国上下同心协力,抗震救灾。在国家民政部的组织下,“汶川地震灾后紧急医疗救助评估基线调查”调查组迅速成立,深入灾区,对灾区居民的受灾情况、医疗卫生需求,以及政府相关的医疗救助工作进行了详细了解。旨在探索更有效的医疗救助机制,并提出科学有效的政策建议。本文首先对宁强基本概况和受灾情况作了全面的介绍,而后对政府的救援工作进行概述,最后对宁强的灾后医疗救助情况进行重点分析,探讨存在的问题并提出政策建议。     

Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to $250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. Findings: The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. Conclusions: This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.     

Use and cost of home health agency services under Medicare.

Presented are 1986 data and trend data (1974-86) on the use and cost of home health agency services rendered to aged and disabled Medicare beneficiaries. Since 1974, reimbursements for these services have grown more rapidly than overall Medicare expenditures. From 1974 to 1986, Medicare expenditures for these services increased from $141 million to $1.8 billion, an average annual rate of 24 percent. HHA reimbursements, however, continue to represent only a small proportion (3.6 percent in 1986) of all Medicare expenditures.     

现金或服务:长期照护保险的给付制度分析

给付方式是影响长期照护保险制度实施效果的重要因素。作者通过分析现金、服务和混合给付等三种给付模式的实施过程,揭示了三种给付模式的特点,提出了"政府"、"经办机构"、"评估机构"、"护理机构"以及"失能者及其家庭"五个主体对于给付模式选择的影响机制。在此基础上,针对主要的OECD国家以及我国不同的长期护理保险试点地区,分析了这些国家和地区给付模式的演变过程、设计初衷以及优、劣势。最后提出了未来我国长期护理保险制度中给付模式的设计思路。     

Differences in U.S. hospital service utilization between traditional Medicare and Medicare HMO patients

This study examines the differences between traditional U.S. Medicare and Medicare HMO Florida inpatient hospital utilization during the years 1992-1998, using nine high volume Diagnosis Related Groups. Utilization was measured by the number of ancillary services consumed, as well as the charges for those services. The analyses controlled for differences in utilization due to patient age, race, hospital size, year and market differences in hospital costs. Patient data were severity-adjusted and the analysis focused on the patients at the highest severity level. The study found that Medicare HMO patients with chronic diseases at the highest severity of illness level consumed significantly more services than traditional Medicare patients with the same chronic diseases. It was concluded that these Medicare HMO patients were either sicker (despite the severity adjustment) than the traditional Medicare patients and/or Medicare HMOs used different production processes than traditional Medicare, perhaps in order to minimize length of stay. Medicare HMO patients with acute illnesses at the highest severity level did not, in general, consume significantly more services than traditional Medicare patients at the same level of severity for the same diagnoses. The results imply that Medicare policy with regard to HMO expansion may not result in cost savings, and may, instead, result in higher costs if the proportion of the Medicare population hospitalized with chronic illnesses increases.     

Associations of trust and healthcare provider advice with HPV vaccine acceptance among African American parents

ObjectiveHealthcare providers (HCPs) are advised to give all parents a strong recommendation for HPV vaccination. However, it is possible that strong recommendations could be less effective at promoting vaccination among African Americans who on average have greater mistrust in the healthcare system. This study examines the associations of parental trust in HCPs and strength of HCP vaccination recommendation on HPV vaccine acceptance among African American parents.MethodsParticipants were recruited from an urban, academic medical center between July 2012 and July 2014. We surveyed 400 African American parents of children ages 10–12 years who were offered HPV vaccine by their HCPs to assess sociodemographic factors, vaccine beliefs, trust in HCPs, and the HPV vaccine recommendation received. Medical records were reviewed to determine vaccination receipt.ResultsIn multivariable analysis, children whose parents were “very strongly” recommended the HPV vaccine had over four times higher odds of vaccine receipt compared with those whose parents were “not very strongly” recommended the vaccine. Having a parent with “a lot of” versus “none” or only “some” trust in HCPs was associated with over twice the odds of receiving HPV vaccine. Very strong HCP recommendations were associated with higher odds of vaccination among all subgroups, including those with more negative baseline attitudes toward HPV vaccine and those with lower levels of trust. Adding the variables strength of HCP recommendation and parental trust in HCPs to a multivariable model already adjusted for sociodemographic factors and parental vaccine beliefs improved the pseudo R² from 0.52 to 0.55.ConclusionsAmong participants, receiving a strong vaccine recommendation and having a higher level of trust in HCPs were associated with higher odds of HPV vaccination, but did not add much to the predictive value of a model that already adjusted for baseline personal beliefs and sociodemographic factors.     

Australian General Practice

Background

While the number of GP services provided in Australia increased steadily from the inception of Medicare in 1984 until the mid 1990s, it declined by 6.6% from 1997–8 to 2003–4. This reflects a decline in average number of services provided per GP of 8.0%. In Australia, as in the US and Canada, there has been a change in the composition of the GP workforce in recent years, in particular an increased feminisation and aging of the GP workforce. We explore whether the decline in average level of services per GP is an inevitable outcome of changes in the composition of the GP workforce, or due to changes in the behaviour of individual GPs driven by attitudinal or economic factors.

Method

Using 8 years of data on the levels of GP activity within the Medicare system, we apply standardisation techniques to examine the expected impact of changes in the composition of the GP workforce. We show that the increasing feminisation of the GP workforce over this period would lead to a reduction in overall GP activity levels, everything else being equal, but that the effect is small (1.9%). Aging of workforce would have led to an increase in overall activity levels (7.5%), as would increases in levels of vocational registration (4.2%) and increases in the proportion of overseas-trained GPs (0.6%).

Results

Overall, if GPs of a given age-sex-education/training category had continued to provide services at the same average level in 2003 as in 1996, the change in composition from 1996 to 2003 would have led to increases in the levels of services per GP of 3.9%. This is 11.4% above the level of services per GP actually observed. We have examined changes in the number of services per GP within ‘pseudo cohorts’ of GPs, and observe that young cohorts of GPs provide fewer services on average than previous young cohorts. Middle-aged GPs, particularly middle-aged male GPs, have reduced the number of services they individually provide. While this reduced level of activity of individual GPs could be due to changes in the underlying need for services, it is more likely to be as a result of reduced demand due to higher prices being charged (consistent with the observed increases in charging levels), or to changing attitudes of GPs seeking more family time.

Conclusion

In planning for the future GP workforce, policy makers need to consider many factors. These include not only the demographic factors that influence the volume of GP activity, but also the changing behaviour of GPs and the factors that influence this behaviour.     

Racial/Ethnic Differences in Those Accompanying Medicare Patients to the Doctor: Insights from the 2013 Medicare Current Beneficiary’s Survey

Surprisingly little current, population-level detail exists regarding companion accompaniment for health care among Medicare beneficiaries, particularly by race/ethnicity. For respondents in the 2013 Medicare Current Beneficiary’s Survey Access to Care public use data (N?=?12,253), multivariable models predicted accompaniment to the doctor by race/ethnicity, adjusting for confounders. Chi square analyses compared, by race/ethnicity, who was accompanying and why. Overall, 37.5% of beneficiaries had accompaniment. In multivariable analyses, non-Hispanic blacks (OR 1.18; 95% CI 1.03–1.36) and Hispanics (OR 1.47; 95% CI 1.25–1.74) were significantly more likely than non-Hispanic whites to have accompaniment. Over 35% of all three groups had someone to “take notes,” “ask questions,” and/or “explain things,” which did not vary by race/ethnicity; significant differences were seen for “explain instructions,” “translate,” and “moral support.” Hispanics had the highest percentages for all three. Many Medicare beneficiaries have accompaniment to doctors’ appointments, particularly in minority racial/ethnic groups, which should be considered in policy and practice.     

Physicians Who Treat the Elderly in Rural Florida: Trends Indicating Concerns Regarding Access to Care

CONTEXT: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population. PURPOSE: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients. METHODS: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined. RESULTS: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P =.001). Mental health services (47% vs 18%, P =.001), vaccine administration (39% vs 16%, P =.008), and Pap smears (41% vs 13%, P =.008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P =.012) with their practice. CONCLUSIONS: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.