Physicians' Perceptions of the Changing Health Care System: Comparisons by Gender and Specialties

This study was designed to investigate physicians' perceptions of changes in the United States health care system impacting academic medicine, quality of care, patient referrals, cost, ethical and sociopolitical aspects of medicine. A survey was mailed in 1998 to 1,272 physicians (graduates of Jefferson Medical College between 1987 and 1992); 835 physicians (66%) responded. Results showed that a substantial majority (92%) believed that learning to work in a managed care environment should become an essential component of medical education. Physicians perceived that current changes impair physicians' autonomy (94%), and restrain physicians' freedom to provide optimal care (84%). A sizable majority (76%) endorsed patients' freedom to seek specialist care, and 55% believed that capitation reduces physicians' motivation for long-term monitoring of patients. The majority endorsed universal health coverage (80%), and agreed to support rather than resist the changes (62%). Only 18% hold a positive view of the changes in the future. The majority believed that medical education should prepare physicians to provide end-of-life care (92%), and that organized medicine should take a stand on social issues that can influence the well-being of society (79%). Only 34% endorsed the legalization of physician-assisted suicide. No gender differences were observed, but a few differences were found between generalists and specialists. Results can help in understanding physicians' perceptions of current changes in the United States health care system, and in providing guidelines for the development of educational programs to prepare physicians to face new challenges.     

Medical students' opinions concerning the health care system

The opinions of freshman and senior medical students on major health sytstem problems and policies were investigated in 1980–81. Responses of 214 freshmen and 203 seniors are reported in four major areas: (1) physician dominance of the health care system, (2) autonomy in patient care, (3) availability of services, and (4) preventive and social aspects of care. With respect to physician dominance, more seniors (63%) than freshman (44%) agree that physicians should determine health policy and that dominance of other health personnel is necessary (75%) and (61%). Professional review of patient care is generally acceptable to both classes, but more freshmen than seniors agree that evaluation should be a condition for relicensure. Less than a fifth of the students in either class believe that patients should be told as little as possible or that they should accept the authority of doctors without question. More freshmen than seniors consider the availability of medical care a major problem (76%) and (58%), and similar proportions believe it is the responsibility of government to assure access to all. Freshmen and seniors generally agree on the need for greater emphasis on prevention and social aspects of illness. Because of the important role played by physicians in the health care system, it is recommended that serious attention be devoted to education in this area, even though it may have a limited impact on professional attitudes.     

Liability for managed care decisions: the Employee Retirement Income Security Act (ERISA) and the uneven playing field.

As managed care organizations expand their programs of quality assurance and physician evaluation, more medical malpractice lawsuits may be brought against managed care organizations on the ground that, like hospitals, they are legally responsible for negligent corporate acts that injure patients. However, the federal Employee Retirement Income Security Act (ERISA) shields managed care organizations from liability when they are part of an employee group health plan governed by ERISA. Unlike patients with other types of insurance, patients in ERISA health plans do not have a malpractice remedy for a managed care organization's negligence. A few federal appeals courts recently recognized that ERISA plans can be vicariously liable for their physicians' medical malpractice, but only if the physician is the plan's employee or agent. Yet ERISA still prohibits negligence claims against ERISA health plans for injuries resulting from denial of plan benefits, failure to use qualified physicians, utilization review, or improper plan administration. Current managed care operations do not neatly distinguish between administering benefits and controlling quality of care. Neither should the law. ERISA should be amended to provide employees with the same remedies that patients in non-ERISA plans enjoy.     

The spillover effects of Medicare managed care: Medicare Advantage and hospital utilization

More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial – offsetting more than 10% of increased payments to Medicare Advantage plans.     

Wagging the dog: an analysis of year 2000 workforce and education outcomes from recommendations of the 1995 Pew Commission report

Over-production in the number of hospitals and health care workers has led to increased cost of medical care and inequities within the health care delivery system. An increase in managed care penetration within the market-place is believed to mandate dramatic changes in the way that health care is structured and delivered. The 1995 Pew Commission report projected major changes in health care organizations and health manpower through the effects of managed care and public regulation. This paper describes the outcomes to health delivery organizations and the health care workforce five years since the Pew Commission Report and discusses the belief that market forces are more effective mechanisms for addressing health care delivery and workforce requirements than public regulatory initiatives.     

Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing

BACKGROUND: Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services. OBJECTIVE: To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms. DESIGN: In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals. SETTING/ PARTICIPANTS: Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%).Results: The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial-60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law. CONCLUSIONS: Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.     

Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.Funds for this study were generously provided by the L.K. Whittier Foundation. Samuel A. Skootsky's salary was in part supported by Southern California Edison.     

Barriers to the diagnosis and treatment of depression in Jordan. A nationwide qualitative study

BACKGROUND: Depression is one of the most common causes of morbidity in developing countries. It is believed that there are many barriers to diagnosis and treatment in the primary care setting, but little research exists. METHODS: Five focus groups were conducted with the goal of exploring themes related to barriers to the diagnosis and treatment of depression, with a purposeful nationwide sample of 50 primary health care providers working in the public health clinics of the Jordanian Ministry of Health (MOH). Participant comments were transcribed and analyzed by the authors, who agreed on common themes. RESULTS: Lack of education about depression, lack of availability of appropriate therapies, competing clinical demands, social issues, and the lack of patient acceptance of the diagnosis were felt to be among the most important barriers to the identification, diagnosis, and treatment of patients with depression in this population. CONCLUSIONS: Continuing medical education for providers about depression, provision of counseling services and antidepressant medications at the primary care level, and efforts to destigmatize depression may result in increased rates of recognition and treatment of depression in this population. Systematizing traditional social support behaviors may be effective in reducing the numbers of patients referred for medical care.     

社区长期保健志愿者服务的技术支撑与组织协调

目的 发挥社区卫生服务中心在社区长期保健志愿者服务中的作用。方法 对上海市4家社区卫生服务中心的医务人员，就其以社区长期保健志愿者服务的认识及卫生服务中心所起的作用进行调查。结果 97．94％的医务人员认为社区志愿者能提供长期保健服务。志愿者提供的服务内容主要为：提供家庭医疗、护理咨询、对需要长期照顾的患者提供精神安慰、对照顾者提供健康咨询等。74．71％的医务人员认为志愿者服务可以收取少量费用，以奖励志愿者服务和补偿物质消耗。64．54％的医务人员认为社区长期保健志愿者队伍应由社区卫生服务中心负责组织。结论 社区长期保健志愿者服务有必要、也有可能，社区卫生服务中心应为长期保健志愿者服务提供技术支撑和组织协调。     

Identifying, assessing and managing high-risk patients under Medicare risk contracts

Physicians participating in Medicare managed care plans are increasingly sharing in the financial risks of providing care to enrollees. Although capitation payments are calculated to reflect the average costs for an entire patient panel, there is typically great variation among patients, from healthy individuals to patients requiring high volume and high-cost care. To be successful, physicians must identify high-risk seniors, develop care plans to maintain health and functioning, and monitor health status and ongoing care and treatment. Techniques for performing a comprehensive geriatric assessment include written questionnaires and interviews during office appointments. The goal is to evaluate each patient's health status, medical risk factors, psychosocial profile, cognitive capacities, and functional capabilities and limitations. After frail and at-risk seniors are identified, the physician must collaborate with the case manager, geriatric nurse practitioner, other caregivers, and the patient and family members to initiate and maintain effective care management.     

Results of the 2006 National Resident Matching Program: family medicine

The results of the 2006 National Resident Matching Program (NRMP) reflect a currently stable level of student interest in family medicine residency training in the United States. Compared with the 2005 Match, 26 more positions (with the same number of US seniors) were filled in family medicine residency programs through the NRMP in 2006, at the same time as four more (five fewer US seniors) in primary care internal medicine, one fewer in pediatrics-primary care (12 more US seniors), and four more (19 more US seniors) in internal medicine-pediatric programs. Many different forces, including student perspectives of the demands, rewards, and prestige of the specialty; the turbulence and uncertainty of the health care environment; lifestyle issues; and the impact of faculty role models continue to influence medical student career choices. Two more positions (nine more US seniors) were filled in categorical internal medicine. Two fewer positions (11 fewer US seniors) were filled in categorical pediatrics programs. The 2006 NRMP results suggest that interest in family medicine and primary care careers continues to be stable. With the needs of the nation calling for the roles and services of family physicians, family medicine matched too few graduates through the 2006 NRMP to meet the nation's needs for primary care physicians.     

Referrals from an emergency room to primary care practices at an urban hospital.

Three hundred ninety-eight patients treated in the emergency room for non-urgent complaints who stated that they had no regular source of primary medical care were referred to one of several medical care centers in the area. Overall, 34 per cent of such patients complied with the referral. Correlates of compliance were: age (very young and very old), patient-perceived health status, medically determined need for follow-up care, and having an appointment made by the emergency room provider. Another group of 500 successfully referred patients became excellent users of the primary care office, complying with requested health maintenance and follow-up visits. However, emergency room utilization by the successfully referred patients did not decrease more than among referred patients who did not enroll in the primary care source.     

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.     

Audit of management of arterial hypertension in primary health care in Sousse

A medical audit has been carried out on a representative sample of 456 hypertensive patients followed in the health care facilities of Sousse during 2002, to evaluate the quality of management of hypertension in primary health care. The study yielded the following results: the patients selected for a first line follow-up did not represent more than 79% of the studied population. The minimal recommended balance was achieved in 8% of cases only. Adequate drug therapy was prescribed in 64% of cases. 59% of patients were considered compliant. Controls of blood pressure was achieved in 5,5% of patients. The quality of management of hypertension in primary health care was considered satis factory in 28,7% of patents with a significant difference between urban and rural areas (24,9% versus 40,5%). These results indicate that increased attention should be paid by the national program of Struggle against the Chronic Diseases to the quality of management of hypertension in primary health care institutions.     

Results of the 2007 National Resident Matching Program: family medicine

The results of the 2007 National Resident Matching Program (NRMP) reflect a currently stable level of student interest in family medicine residency training in the United States. Compared with the 2006 Match, five fewer positions (with 25 fewer US seniors) were filled in family medicine residency programs through the NRMP in 2007, at the same time as 20 fewer (two more US seniors) in primary care internal medicine, the same number of pediatrics-primary care (four fewer US seniors), and one more (19 fewer US seniors) in internal medicine-pediatrics programs. Multiple forces, including student perspectives of the demands, rewards, and prestige of the specialty; the turbulence and uncertainty of the health care environment; lifestyle issues; and the impact of faculty role models continue to influence medical student career choices. Eighty-four more positions (12 more US seniors) were filled in categorical internal medicine. Fifty-four more positions (22 more US seniors) were filled in categorical pediatrics programs. The 2007 NRMP results suggest that interest in family medicine and primary care careers continues to decline. With the needs of the nation calling for the roles and services of family physicians, family medicine matched too few graduates through the 2007 NRMP to meet the nation's needs for primary care physicians.     

美国医改实施的进展、前景与启示

美国医改实施三年来,在扩大医保可及性、改革医疗服务市场、降低医疗费用和改进服务质量方面取得较大进展,但许多触及既得利益集团的核心改革政策如建立保险交易所、改革支付方式、削减部分福利项目、提高富人税率等开源节流措施尚未正式启动,这将成为奥巴马连任后面临的主要挑战。美国医改鼓励服务的整合、改革支付制度、重视预防保健服务等做法值得中国医改借鉴,同时以商业医疗保险为主导的保险体系暴露出的弊端也启示中国政府以更加审慎的态度发展商业医疗保险。     

Domestic violence and primary care. Attitudes, practices, and beliefs.

OBJECTIVE: To assess the attitudes and beliefs of the primary care provider team (physicians, physician assistants, nurses, and medical assistants) toward the identification and management of abused patients and perpetrators of domestic violence (DV). DESIGN: Survey of the health care team using a confidential questionnaire. SETTING AND SUBJECTS: Five primary care clinics with 240 providers at a large urban health maintenance organization. RESULTS: The response rate was 86% (206 respondents). Fifty percent of clinicians and 70% of nurses/assistants believed that the prevalence of DV in their practice was 1% or loss; 1 in 10 clinicians and nearly half of nurses/assistants had never identified an abused person; 45% of clinicians never or seldom asked about DV when examining injured patients; and all participants were much less confident in asking about DV than about smoking or consuming alcohol. Twenty-five percent believed the abused person's personality led to the violence; 28% believed they did not have strategies to help abused persons; and 20% were concerned for their personal safety in discussing DV. Only 10% believed they had management information, but 77% had not attended any educational programs on DV in the past year. CONCLUSIONS: This study provides important information about current knowledge, attitudes, and beliefs of health care providers toward the diagnosis and management of DV. This information should prove useful to all who attempt to design clinical strategies and educational programs to address this issue.     

国外三种区域医疗体系转型方式比较研究及启示

对瑞典延雪平县政府、美国山间医疗保健公司以及美国南中心基金会3种区域医疗体系的转型、改进过程方式进行比较研究,分析其在改进变革过程所运用的手段及方法的共同之处。结合我国医改现状,认为我国医改尚需在以下方面努力:质量和改进应作为一项核心战略;提升组织能力及技能;建立强大的初级卫生保健系统;让患者参与医疗服务及服务设计;将信息作为指导改进的依据等。     

Downsizing the physician workforce.

OBJECTIVE: To estimate the need for downsizing the physician workforce in a changing health care environment. METHODS: First assuming that 1993 physician-to-population ratios would be maintained, the authors derived downsizing estimates by determining the annual growth in the supply of specialists necessary to maintain these ratios (sum of losses from death and retirement plus increase necessary to parallel population growth) and compared them with an estimate of the number of new physicians being produced (average annual number of board certificates issued between 1990 and 1994). Then, assuming that workforce needs would change in a system increasingly dominated by managed care, the authors estimated specialty-specific downsizing needs for a managed care dominated environment using data from several sources. RESULTS: To maintain the 1993 199.6 active physicians per 100,000 population ratio, 14,644 new physicians would be needed each year. Given that an average of 20,655 physicians were certified each year between 1990 and 1994, at least 6011 fewer new physicians were needed annually to maintain 1993 levels. To maintain the 132.2 ratio of active non-primary care physicians per 100,000 population, the system needed to produce 9698 non-primary care physicians per year, because an average of 14,527 new non-primary care physicians entered the workforce between 1990 and 1994, downsizing by 4829, or 33%, was needed. To maintain the 66.8 active primary care physicians per 100,000 population ratio, 4946 new primary care physicians were needed per year, since primary care averaged 6128 new certifications per year, a downsizing of 1182, or 20% was indicated. Only family practice, neurosurgery, otolaryngology, and urology did not require downsizing. Seventeen medical and hospital-based specialties, including 7 of 10 internal medicine subspecialties, needed downsizing by at least 40%. Less downsizing in general was needed in the surgical specialties and in psychiatry. A managed care dominated-system would call for greater downsizing in most of the non-primary care specialties. CONCLUSION: These data support the need for downsizing the nation''s physician supply, especially in the internal medicine subspecialties and hospital support specialties and to a lesser extent among surgeons and primary care physicians.     

Results of the 2000 National Resident Matching Program: family practice

The results of the 2000 National Resident Matching Program (NRMP) reflect substantial volatility in the perceptions and career choices of physicians entering graduate medical education in the United States. Ninety-four fewer positions (191 fewer US seniors) were filled in family practice residency programs through the NRMP in 2000, compared with 1999, as well as 60 fewer (66 fewer US seniors) in primary care internal medicine, 12 fewer in pediatrics-primary care (6 fewer US seniors), and 10 fewer (9 fewer US seniors) in internal medicine-pediatric programs. In contrast, 37 more positions (36 more US seniors) were filled in anesthesiology and 4 more (13 more US seniors) in diagnostic radiology, two "marker" disciplines that have recently been market sensitive. Twelve fewer positions (63 fewer US seniors) were also filled in categorical internal medicine, while 35 fewer positions (104 fewer US seniors) were filled in categorical pediatrics programs, where trainees perceive options for practicing as generalists or entering subspecialty fellowships, depending on the market. While the needs of the nation, especially rural and underserved populations, continue to offer a market for family physicians, family practice experienced a third year of decline through the 2000 NRMP. Current forces, including media hype, market factors, lifestyle choices, debt, and the turbulence of the health care environment, appear to be influencing many students to choose subspecialty rather than primary care careers.