The impact of team-based primary care on health care services utilization and costs: Quebec’s family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec’s Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients’ health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.     

Understanding recent trends in Swiss ambulatory care utilization when out-of-pocket payment is minimal

Summary. Objective: To examine trends in ambulatory care utilization when individuals face almost no financial barriers to health care. Methods: Observational study of insurance data. Adults with minimal deductible were included. Ambulatory care visits and costs were measured from 1997 to 2002. Results: Mean ambulatory care costs/insuree increased from 1 292.– to 1 790.– CHF, corresponding to higher increases in drug costs (+61.7%) than services costs (+24.3%). The proportion of visits to generalists decreased while those to hospital outpatient services increased. Conclusions: In a demographically stable population of insurees, increases in ambulatory care costs were due neither to growth in physicians’ visits nor to increasing physicians’ fees per act, but to what was included in or prescribed during the visits. Submitted: 20 September 2005 Accepted: 2 June 2006     

The Canadian health care system: A model for America to emulate?

The American health care system has the world's highest per capita costs and over 30 million citizens uninsured. The neighbouring Canadian system provides coverage for all basic medical and hospital services, at costs per capita that are about US$700 lower. Single-agency public funding allows tighter control of Canadian expenditures, and reduces administrative overheads. Hospitals are run as non-profit private corporations, funded primarily by a fixed annual allocation for operating costs. Most physicians are in private fee-for-service practice, but cannot charge more than the insured tariff negotiated between their provincial government and medical association. This approach, while attractive in its decentralization, tends to separate the funding and management of clinical services. Thus, hospital information systems lag a decade behind the USA, managed care initiatives are few, health maintenance organisations do not exist, and experimentation with alternative funding or delivery systems has been sporadic. Strengths of the system compared to the USA include: higher patient satisfaction, universal coverage, slightly better cost containment, higher hospital occupancy rates, and reduction in income-related rationing with more equitable distribution of services. Weaknesses in common with the United States are: cost escalation consistently outstripping the consumer price index with costs per capita second highest in the world, ever rising consumption of services per capita, inadequate manpower planning and physician maldistribution, poor regional co-ordination of services, inadequate quality assurance and provider frustration. Additional weaknesses include: an emerging funding crisis caused by the massive federal deficit, less innovation in management and delivery of care as compared to the USA, implicit rationing with long waiting lists for some services, and recurrent provider-government conflicts that have reduced goodwill among stakeholders. Thus, while the Canadian model has important advantages, it does not offer a panacea for American health care woes.     

Service quality and attrition: an examination of a pediatric obesity program.

OBJECTIVE: To examine the demographic, illness, and quality of care determinants of service attrition in a pediatric obesity program, and to elucidate factors that may promote families' return to care. DESIGN: Cross-sectional survey with semi-structured interviews. SETTING: A regional children's hospital in the United States. STUDY PARTICIPANTS: Caregivers of 163 patients, consecutively enrolled in a pediatric obesity treatment program between January 1998 and September 2000, were contacted by telephone and offered participation in a survey of clinical care experiences. A total of 120 (74%) families participated. MAIN OUTCOME MEASURES: Service attrition as defined as premature discontinuation of treatment before completing phase I of a multi-phase treatment program. RESULTS: Multivariate results indicated that service attrition was associated with both insurance status and perceived quality of care. Patients with government-subsidized insurance were more likely to defect from services than those with commercial insurance. Perceived quality of care was highly associated with attrition after controlling for demographic and health parameters. Caregiver-reported reasons for service attrition included difficulty with adequate insurance coverage (53%), the child's desire to leave the program (50%), and the program taking too much time (32%). The most frequent suggestions to facilitate families' return to the program were: (i) assistance with insurance coverage; (ii) following up with families; and (iii) increasing engagement with the child. CONCLUSIONS: This study found few demographic differences between patients completing the program and those defecting from services. Both families completing the program and those discontinuing prematurely rated the overall quality of the program as high. However, lower quality of care was related to increased service attrition even after controlling for the effects of demographic and health parameters. Although a considerable number of patients discontinued services, very few reported that they would not return to the program. The results provide further support for ongoing audit and examination of families' care perceptions in preventing attrition and promoting service recovery.     

Technology and managed care: patient benefits of telemedicine in a rural health care network

Rural health providers have looked to telemedicine as a technology to reduce costs. However, virtual access to physicians and specialists may alter patients' demand for face-to-face physician access. We develop a model of service demand under managed care, and apply the model to a telemedicine application in rural Alaska. Provider-imposed delays and patient costs were highly significant predictors of patient contingent choices in a survey of ENT clinic patients. The results suggest that telemedicine increased estimated patient benefits by about $40 per visit, and reduced patients' loss from rationing of access to physicians by about 20%.     

影响农村妇女孕产期保健的社会因素分析

目的:探讨影响农村妇女孕产期保健的社会因素。方法:采用定性研究方法,根据目的抽样的原则,抽取孕产期保健服务的提供者、利用者以及地方级别的关键知情人士进行焦点小组访谈、个人深入访谈和关键人物访谈。结果:家庭经济贫困的妇女相对经济好的妇女更不容易利用保健服务;新型农村合作医疗可以吸引妇女到医院分娩,提高住院分娩率,降低母婴死亡率;交通对孕产妇利用保健服务有很大的影响;计划生育政策是计划外生育妇女利用孕产期服务最主要的障碍;流动妇女对孕产期保健服务的利用率低;当地农村仍奉行一些关于生孩子的传统习俗。结论:建议政府制定相关政策限制日益增长的医疗费用;加强流动人口和计划外生育妇女的管理;对农村妇女进行孕产期健康教育;扩大新型农村合作医疗的覆盖范围。     

The impact of financial incentives on health and health care: Evidence from a large wellness program

Workplace wellness programs have become increasingly common in the United States, although there is not yet consensus regarding the ability of such programs to improve employees' health and reduce health care costs. In this paper, we study a program offered by a large U.S. employer that provides substantial financial incentives directly tied to employees' health. The program has a high participation rate among eligible employees, around 80%, and we analyze the data on the first 4 years of the program, linked to health care claims. We document robust improvements in employee health and a correlation between certain health improvements and reductions in health care cost. Despite the latter association, we cannot find direct evidence causally linking program participation to reduced health care costs, although it seems plausible that such a relationship will arise over longer horizons.     

Differences in access to health care services among adults in rural America by rural classification categories and age

Objective: To study differences in excess to health care services between different population groups in rural areas of the United States. Design: Using data from the 1994 National Health Interview Survey and the 1991 Area Resource File, we examined the differences in excess with seven measures: having a regular source of care, having a usual place of care, having health insurance coverage, delaying medical care because of cost for all rural residents; number of doctor visits, number of hospital discharges and length of hospital stay per discharge for those who reported their health as being either poor or fair. Rural residents were classified by ages and grouped into four rural classification categories that were characterised along two dimensions: adjacent to a metropolitan statistical area (MSA) (yes/no) and inclusion of a city of at least 10 000 people (yes/no). Setting: Rural areas Subjects: Rural populations. Results: Residents aged 18–24 years had the worst access to services and the residents aged 65 years and over had the best access to services when measured by regular source of care, a usual place of care and health insurance status. Compared to those aged 50–64 years, residents aged 25–49 years were less likely to report having health insurance and more likely to report delaying seeking medical care because of costs. Rural residents who lived in a county adjacent to an MSA generally were less limited in access than those who lived in a county not adjacent to an MSA. Conclusions: Rural America is not a homogeneous entity in many aspects of the access to health care services.     

Determinants of expenditure variation in health care and care of the elderly among finnish municipalities

In Finland, municipal health care expenditure varies from FIM 3 800 per capita to FIM 7 800 per capita. The objective of this study was to estimate the impact of different economic, structural and demographic factors on the per capita costs of health services and care of the elderly. Using regression analysis we attempted to explain observed differences in expenditure by determining separately the effects of allocative and productive inefficiency and the effects of factors influencing the demand for services. We found income level of local population, generosity of central government matching grant, allocative efficiency (the mix of care between institutional and non-institutional care), productive efficiency of service providers, and factors associated with the need of services (age structure, morbidity) to be the most important determinants of health care expenditure. Our results reveal that municipalities have the means at their disposal (by shifting resources to outpatient care and increasing productivity) to significantly reduce expenditure on health services and care of the elderly.     

海南省基本医疗卫生服务均等化分析

目的：了解海南省市县际间基本医疗卫生服务均等化现状,为促进全省基本医疗卫生服务均等化建设提供参考。方法：利用海南省、我国及经合组织国家等卫生统计数据,对海南省市县际间基本医疗卫生服务均等化指标进行分析。结果：资源分布均等化方面,机构地理可及性相差较大,医护比为1∶1.2,资源分布的基尼系数大于0.3;筹资均等化方面,人均医疗保健支出低于全国,人均政府卫生支出额高的市县主要集中在各区域的中心,多数市县新农合住院实际补偿比在50%左右;服务提供均等化方面,多数市县床位使用率低于90%,药费占比在30%～40%,地区之间孕产妇及儿童健康管理差距较小,但管理率普遍低于全国。结论：基本医疗卫生服务资源分布与政治、经济等条件有关,筹资机制不健全、基本医疗和公共卫生服务提供能力低影响了基本医疗卫生服务的质量。建议合理布局基本医疗卫生服务资源,加大卫生筹资力度,提高基本医疗卫生服务提供能力。     

荷兰以人为本整合型卫生服务的实践与启示*

从服务提供、治理机制、组织管理和筹资支付四个维度,分析荷兰实现以人为本的整合型卫生服务的关键要素,包括以全科医生服务团队为核心的网络化医疗卫生服务体系、良性市场竞争机制和广泛的社会参与及多部门合作的治理网络,促进整合的医保支付制度,成熟的全科医生培养体系和互联互通的信息系统,并结合中国实际,提出我国现阶段应将基层医疗卫生服务体系作为建设重点和优先领域,以家庭医生签约服务为抓手,加强医保对服务提供者的激励和约束,破除市场竞争、人才培养和信息共享等方面的体制机制障碍,构建以家庭医生服务团队为核心的网络化服务体系。     

Cost–benefit analysis of the CoCare intervention to improve medical care in long-term care nursing homes: an analysis based on claims data

Background

Providing adequate medical care to nursing home residents is challenging. Transfers to emergency departments are frequent, although often avoidable. We conducted the complex CoCare intervention with the aim to optimize nursing staff–physician collaboration to reduce avoidable hospital admissions and ambulance transportations, thereby reducing costs.

Methods

This prospective, non-randomized study, based on German insurance data, includes residents in nursing homes. Health care cost from a payer perspective and cost–savings of such a complex intervention were investigated. The utilisation of services after implementation of the intervention was compared with services in previous quarters as well as services in the control group. To compensate for remaining differences in resident characteristics between intervention and control group, a propensity score was determined and adjusted for in the regression analyses.

Results

The study population included 1240 residents in the intervention and 7552 in the control group. Total costs of medical services utilisation were reduced by €468.56 (p < 0.001) per resident and quarter in the intervention group. Hospital stays were reduced by 0.08 (p = 0.001) and patient transports by 0.19 (p = 0.049). This led to 1.66 (p < 0.001) avoided hospital days or €621.37 (p < 0.001) in costs–savings of inpatient services. More services were billed by general practitioners in the intervention group, which led to additional costs of €97.89 (p < 0.001).

Conclusion

The benefits of our intervention clearly exceed its costs. In the intervention group, avoided hospital admissions led to additional outpatient billing. This indicates that such a multifactorial intervention program can be cost-saving and improve medical care in long-term care homes.

     

Incentives in a Medicaid carve-out: impact on children with special health care needs

Objective. To evaluate whether a specialty care payment "carve-out" from Medicaid managed care affects caseloads and expenditures for children with chronic conditions.
Data Source. Paid Medicaid claims in California with service dates between 1994 and 1997 that were authorized by the Title V Children with Special Health Needs program for children under age 21.
Study Design. A natural experiment design evaluated the impact of California's Medicaid managed care expansion during the 1990s, which preserved fee-for-service payment for certain complex medical diagnoses. Outcomes in time series regression include Title V program participation and expenditures. Multiple comparison groups include children in managed care counties who were not mandated to enroll, and children in nonmanaged care counties.
Data Collection/Extraction Methods. Data on the study population were obtained from the state health department claims files and from administrative files on enrollment and managed care participation.
Principal Findings. The carve-out policy increased the number of children receiving Title V-authorized services. Recipients and expenditures for some ambulatory services increased, although overall expenditures (driven by inpatient services) did not increase significantly. Cost intensity per Title V recipient generally declined.
Conclusions. The carve-out policy increased identification of children with special health care needs. The policy may have improved children's access to prevailing standards of care by motivating health plans and providers to identify and refer children to an important national program.     

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.     

艾滋病病毒感染者和艾滋病患者卫生服务利用及医疗费用的研究

目的 了解艾滋病病毒(HIV)感染者和艾滋病(AIDS)患者对卫生服务的利用及直接医疗费用。方法 于1999年12月对北京佑安医院收治的HIV感染者和AIDS患者进行回顾性研究。收集一般人口学特征、HIV感染及疾病进程的相关信息、过去一年内卫生服务利用情况及医疗费用资料。结果 共调查29例HIV感染者，其中17例(58．62％)为无症状期的HIV感染者，12例为AIDS患者。无症状期的HIV感染者平均每人年门诊6次，住院1．23次，每人年住院58．6天；AIDS患者平均每人年门诊7．8次，住院2．1次，住院200．2天。无症状期的HIV感染者平均每人年门诊费用为13729元，住院费用为4745元；AIDS患者平均每人年门诊及住院费用分别为15053元和22242元。既门诊又住院平均每人年的门诊及住院医疗费用，无症状期的HIV感染者为16248元，AIDS患者为36795元。结论 HIV感染者和AIDS患者医疗费用昂贵，对卫生服务的需求量大。需要进一步在更大范围内了解国内HIV感染者和AIDS患者对卫生服务利用的现状及需求。     

Cost shifting to jails after a change to managed mental health care

OBJECTIVE: To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. DATA SOURCES: Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. STUDY DESIGN: A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. DATA COLLECTION METHODS: Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. PRINCIPAL FINDINGS: There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. CONCLUSIONS: Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.     

Comparing and decomposing differences in preventive and hospital care: USA versus Taiwan

As the USA expands health insurance coverage, comparing utilization of healthcare services with countries like Taiwan that already have universal coverage can highlight problematic areas of each system. The universal coverage plan of Taiwan is the newest among developed countries, and it is known for readily providing access to care at low costs. However, Taiwan experiences problems on the supply side, such as inadequate compensation for providers, especially in the area of preventive care. We compare the use of preventive, hospital, and emergency care between the USA and Taiwan. The rate of preventive care use is much higher in the USA than in Taiwan, whereas the use of hospital and emergency care is about the same. Results of our decomposition analysis suggest that higher levels of education and income, along with inferior health status in the USA, are significant factors, each explaining between 7% and 15% of the gap in preventive care use. Our analysis suggests that, in addition to universal coverage, proper remuneration schemes, education levels, and cultural attitudes towards health care are important factors that influence the use of preventive care.     

Transportation brokerage services and Medicaid beneficiaries' access to care

Objective. To examine the effect of capitated transportation brokerage services on Medicaid beneficiaries' access to care and expenditures.
Data Sources/Study Setting. The study period from 1996 to 1999 corresponds to the period of a natural experiment during which Georgia and Kentucky implemented transportation brokerage services. Effects were estimated for asthmatic children and diabetic adults.
Study Design. We used difference-in-differences models to assess the effects of transportation brokerage services on access to care, measured by Medicaid expenditures and health services use. The study design is strengthened by the staggered implementation dates between states and within each state.
Principal Findings. For asthmatic children, transportation brokerage services increased nonemergency transportation expenditures and the likelihood of using any services; reductions in monthly expenditures more than offsetting the increased transportation costs. For diabetic adults, nonemergency transportation costs decreased despite increased monthly use of health services; average monthly medical expenditures and the likelihood of hospital admission for an ambulatory care-sensitive condition (ACSC) also decreased.
Conclusions. The shift to transportation brokerage services improved access to care among Medicaid beneficiaries and decreased the expenditures. The increase in access combined with reduced hospitalizations for asthmatic children and ACSC admissions for diabetic adults are suggestive of improvements in health outcomes.