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1.  Outcomes Among Chronically Ill Adults in a Medical Home Prototype 
The American journal of managed care  2013;19(10):e348-e358.
Objectives
To compare quality, utilization, and cost outcomes for patients with selected chronic illnesses at a patient-centered medical home (PCMH) prototype site with outcomes for patients with the same chronic illnesses at 19 nonintervention control sites.
Study Design
Nonequivalent pretest-posttest control group design.
Methods
PCMH redesign results were investigated for patients with preexisting diabetes, hypertension, and/or coronary heart disease. Data from automated databases were collected for eligible enrollees in an integrated healthcare delivery system. Multivariable regression models tested for adjusted differences between PCMH patients and controls during the baseline and follow-up periods. Dependent measures under study included clinical processes and, outcomes, monthly healthcare utilization, and costs.
Results
Compared with controls over 2 years, patients at the PCMH prototype clinic had slightly better clinical outcome control in coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol; P <.001). PCMH patients changed their patterns of primary care utilization, as reflected by 86% more secure electronic message contacts (P <.001), 10% more telephone contacts (P = .003), and 6% fewer in-person primary care visits (P <.001). PCMH patients had 21% fewer ambulatory care–sensitive hospitalizations (P <.001) and 7% fewer total inpatient admissions (P = .002) than controls. During the 2-year redesign, we observed 17% lower inpatient costs (P <.001) and 7% lower total healthcare costs (P <.001) among patients at the PCMH prototype clinic.
Conclusions
A clinic-level population-based PCMH redesign can decrease downstream utilization and reduce total healthcare costs in a subpopulation of patients with common chronic illnesses.
PMCID: PMC4074014  PMID: 24304182
2.  Children's Objective Physical Activity by Location: Why the Neighborhood Matters 
Pediatric exercise science  2013;25(3):468-486.
Knowledge of where children are active may lead to more informed policies about how and where to intervene and improve physical activity. This study examined where children aged 6–11 were physically active using time-stamped accelerometer data and parent-reported place logs and assessed the association of physical-activity location variation with demographic factors. Children spent most time and did most physical activity at home and school. Although neighborhood time was limited, this time was more proportionally active than time in other locations (e.g., active 42.1% of time in neighborhood vs. 18.1% of time at home). Children with any neighborhood-based physical activity had higher average total physical activity. Policies and environments that encourage children to spend time outdoors in their neighborhoods could result in higher overall physical activity.
PMCID: PMC4074079  PMID: 23877357
3.  Unmet dental need in community-dwelling adults with mental illness: Results from the 2007 Medical Expenditure Panel Survey 
Background
Mental illness (MI) affects approximately one in five US adults, and is associated with oral disease and poor dental treatment outcomes. Little is known about dental utilization or unmet dental need in this population.
Methods
This study examined dental visits and unmet dental need in community-dwelling adults with MI in 2007 Medical Expenditure Panel Survey (MEPS) data. Differences between adults with and without MI were tested using multivariate logistic regression.
Results
Eighteen percent of adults (N=19,368) had MI; 5.5 percent had unmet dental need. Although individuals with MI were not significantly more likely to have a dental visit (46.3 percent) than those without MI (42.2 percent; OR=1.09, 95 percent CI=.97–1.23), they were significantly more likely to report unmet need (11.0 versus 5.3 percent; OR=2.00, 95 percent CI=1.67–2.41). Those with mood or anxiety disorders were most likely to report unmet need (Ps<.001).
Conclusions
While individuals with MI did not visit the dentist significantly more than adults without MI, their higher level of unmet need suggests current dental service use is not addressing their needs adequately.
Clinical Implications
Dentists should be familiar with MI conditions as these patients may have greater unmet dental need.
PMCID: PMC3613122  PMID: 23449910
Mental illness; dental need; utilization
4.  Less counseling on Early Childhood Caries transmission by dentists 
Journal of public health dentistry  2012;73(2):10.1111/j.1752-7325.2012.00356.x.
Objective
High levels of Streptococcus mutans on teeth of young children are predictive of Early Childhood Caries (ECC). Transmission from mother-to-child is common and studies have demonstrated treatment of the mother results in less ECC. The objective of this study was to determine how dentists have adopted the practice of counseling about ECC.
Methods
In 2006 as part of a larger study on dental care for pregnant women, we surveyed 829 general dentists in Oregon. The questionnaire contained questions to capture the extent to which general dentists have adopted counseling pregnant women about ECC transmission, to describe personal and practice characteristics, and examine how dentists' views on the ease of adopting of new procedures related to ECC counseling. Multivariate logistic regression was used to identify separate and additive effects of demographic and practice characteristics, attitudes, and beliefs.
Results
The adjusted odds of a dentist who strongly believed in the link between mothers and babies and provided ECC counseling were 1.60 (95% CI 1.3-2.0, P<0.01). The odds of a dentist who reported discussing ECC with staff members and provided counseling were 2.7 (95% CI 1.7-4.3, P<0.01). Male dentists were less likely to counsel patients than female dentists (Adjusted OR = 0.5, 95% CI 0.3-1.0, p<0.05).
Conclusions
The strongest predictors of counseling patients about ECC were dentists' belief in the evidence of caries transmission and dentists' discussion of ECC during staff meetings.
doi:10.1111/j.1752-7325.2012.00356.x
PMCID: PMC3855324  PMID: 22970775
dental caries; prevention; infant; pregnant woman
5.  County-level characteristics as predictors of dentists’ ECC counseling in the USA: a survey study 
BMC Oral Health  2013;13:23.
Background
Transmission of Streptococcus mutans from mother-to-child can lead to Early Childhood Caries. A previous study identified characteristics and beliefs of general dentists about counseling pregnant women to reduce risk of infection and Early Childhood Caries. This study extends those findings with an analysis of county level factors.
Methods
In 2006, we surveyed 732 general dentists in Oregon, USA about dental care for pregnant women. Survey items asked about individual and practice characteristics. In the present study we matched those data to county level factors and used multinomial logistic regression to test the effects of the factors (i.e., dentist to population ratio, percentage of female dentists, percentage of females of childbearing age, and percentage of individuals living in poverty) on counseling behavior.
Results
County level factors were unrelated to counseling behavior when the models controlled for dentists' individual attitudes, beliefs, and practice level characteristics. The adjusted odds ratios for no counseling of pregnant patients (versus 100 percent counseling) were 1.1 (95% CI .8-1.7), 1.0 (1.0-1.1), 1.2 (.9-1.5), and 1.1 (1.0-1.2) for dentist/population ratio, percent female dentists, percent females of childbearing age, and percent in poverty, respectively Similar results were obtained when dentists who counseled some patients were compared to those counseling 100 percent of patients.
Conclusions
Community level factors do not appear to impact the individual counseling behavior of general dentists in Oregon, USA regarding the risk of maternal transmission of Early Childhood Caries.
doi:10.1186/1472-6831-13-23
PMCID: PMC3679951  PMID: 23688178
Early Childhood Caries; Prevention; Pregnant woman; County factors; Area Resource File
6.  Provider Factors and Patient-Reported Healthcare Discrimination in the Diabetes Study of California (DISTANCE) 
Patient education and counseling  2011;85(3):e216-e224.
Objective
We examined provider-level factors and reported discrimination in the healthcare setting.
Methods
With data from the Diabetes Study of Northern California (DISTANCE)—a race-stratified survey of diabetes patients in Kaiser Permanente Northern California—we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables including racial concordance.
Results
Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2% to 8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01–0.67), those rating their provider higher on communication (OR=0.70; 95% CI: 0.66–0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03–1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity.
Conclusions
Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.
Practice Implications
Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.
doi:10.1016/j.pec.2011.04.031
PMCID: PMC3178668  PMID: 21605956
Race/Ethnicity; Discrimination; Provider Factors; Diabetes Care; Managed Care
7.  Patient-Reported Racial/Ethnic Healthcare Provider Discrimination and Medication Intensification in the Diabetes Study of Northern California (DISTANCE) 
Journal of General Internal Medicine  2011;26(10):1138-1144.
Background
Racial/ethnic minority patients are more likely to report experiences with discrimination in the healthcare setting, potentially leading to reduced access to appropriate care; however, few studies evaluate reports of discrimination with objectively measured quality of care indicators.
Objective
To evaluate whether patient-reported racial/ethnic discrimination by healthcare providers was associated with evidence of poorer quality care measured by medication intensification.
Research Design and Participants
Baseline data from the Diabetes Study of Northern California (DISTANCE), a random, race-stratified sample from the Kaiser Permanente Diabetes Registry from 2005–2006, including both survey and medical record data.
Main Measures
Self-reported healthcare provider discrimination (from survey data) and medication intensification (from electronic prescription records) for poorly controlled diabetes patients (A1c ≥9.0%; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; low-density lipoprotein (LDL) ≥130 mg/dl).
Key Results
Of 10,409 eligible patients, 21% had hyperglycemia, 14% had hyperlipidemia, and 32% had hypertension. Of those with hyperglycemia, 59% had their medications intensified, along with 40% with hyperlipidemia, 33% with hypertension, and 47% in poor control of any risk factor. In adjusted log-binomial GEE models, discrimination was not associated with medication intensification [RR = 0.96 (95% CI: 0.74, 1.24) for hyperglycemia, RR = 1.23 (95% CI: 0.93, 1.63) for hyperlipidemia, RR = 1.06 (95% CI: 0.69, 1.61) for hypertension, and RR = 1.08 (95% CI: 0.88, 1.33) for the composite cohort].
Conclusions
We found no evidence that patient–reported healthcare discrimination was associated with less medication intensification. While not associated with this technical aspect of care, discrimination could still be associated with other aspects of care (e.g., patient-centeredness, communication).
doi:10.1007/s11606-011-1729-2
PMCID: PMC3181298  PMID: 21547610
diabetes; healthcare disparities; managed care; race/ethnicity; quality; discrimination
8.  Risk of Losing Insurance During the Transition into Adulthood Among Insured Youth with Disabilities 
To compare insured youth (age 15–25 years) with and without disabilities on risk of insurance loss. We conducted a cross-sectional study using data from the Survey of Income and Program Participation 2001. Descriptive statistics characterized insured youth who maintained and lost insurance for at least 3 months over a 3-year time frame. We conducted logistic regression to calculate the association between disability and insurance loss. Adjustment variables were gender, race, ethnicity, age, work or school status, poverty status, type of insurance at study onset, state generosity, and an interaction between disability and insurance type. This study includes 2,123 insured youth without disabilities, 320 insured youth with non-severe disabilities, and 295 insured youth with severe disabilities. Thirty-six percent of insured youth without disabilities lost insurance compared to 43% of insured youth with non-severe disabilities and 41% of insured youth with severe disabilities (P = .07). Youth with non-severe disabilities on public insurance have an estimated 61% lower odds of losing insurance (OR: 0.39; 95% CI: 0.16, 0.93; P = .03) compared to youth without disabilities on public insurance. Further, youth with severe disabilities on public insurance have an estimated 81% lower odds of losing insurance (OR: 0.19; 95% CI: 0.09, 0.40; P < .001) compared to youth without disabilities. When examining youth with private insurance, we find that youth with severe disabilities have 1.63 times higher odds (OR: 1.63; 95% CI: 1.03, 2.57; P = .04) of losing health insurance compared to youth without disabilities. Insurance type interacts with disability severity to affect odds of insurance loss among insured youth.
doi:10.1007/s10995-009-0470-5
PMCID: PMC3115452  PMID: 19517074
Disability; Youth with special health care needs; Insurance; Transition; Adolescent health
9.  Correlates of Patient-Reported Racial/Ethnic Health Care Discrimination in the Diabetes Study of Northern California (DISTANCE) 
Objectives
We examined possible determinants of self-reported health care discrimination.
Methods
We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates.
Results
Subjects (n=17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared to whites) and those with poorer health literacy (OR=1.10, 95% CI: 1.04-1.16), limited English proficiency (OR=1.91, 95% CI: 1.32-2.78), and depression (OR=1.53, 95% CI: 1.10-2.13).
Conclusions
In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.
doi:10.1353/hpu.2011.0033
PMCID: PMC3075840  PMID: 21317516
Race/ethnicity; discrimination; diabetes care; managed care
10.  Health insurance regain after a spell of uninsurance: a longitudinal comparison of youth with and without disabilities transitioning into adulthood 
Purpose
To examine insurance regain among youth with no, non-severe, and severe disabilities.
Methods
The data source for this study was the Survey of Income and Program Participation 2001–2004. We examined insurance regain among youth with no, non-severe, and severe disabilities between 15 and 25 using a longitudinal design. Kaplan-Meier survival functions provided estimates of uninsurance spell durations measured in waves, or 4-month intervals. We conducted a discrete time survival analysis adjusting for personal characteristics.
Results
This study includes 1310 youth who entered the SIPP with insurance and became uninsured. 985 youth (75%) regained insurance. Based on SIPP waves, median duration of uninsurance was 2 waves (between 5 and 8 months) for youth with severe disabilities and 3 waves (between 9 and 12 months) for youth with non-severe disability. Youth with non-severe disabilities had decreased odds of regaining health insurance compared to youth without disabilities (OR: .73; 95% CI: .57, .92; p=.01).
Conclusions
Youth with severe disabilities and youth without disabilities had similar odds of and durations to insurance regain. In contrast, youth with non-severe disabilities had lower odds of regaining insurance and experienced longer durations of uninsurance compared to peers without disabilities. We recommend additional research into the implications of Medicaid eligibility pathways and employment barriers for youth with non-severe disabilities.
doi:10.1016/j.jadohealth.2009.03.026
PMCID: PMC2808142  PMID: 19931827
11.  Access Intervention in an Integrated, Prepaid Group Practice: Effects on Primary Care Physician Productivity 
Health Services Research  2008;43(5 Pt 2):1888-1905.
Objective
To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice.
Data Sources
Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information.
Study Design
Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics.
Principal Findings
Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation.
Conclusions
This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.
doi:10.1111/j.1475-6773.2008.00880.x
PMCID: PMC2654163  PMID: 18662171
Access; productivity; cost; incentives; integrated group practice
12.  Physician Effects on Racial and Ethnic Disparities in Patients’ Experiences of Primary Care 
Journal of General Internal Medicine  2008;23(10):1666-1672.
Background
Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients.
Objective
To examine relative contribution of “between-” and “within-” physician effects on disparities in patients’ experiences of primary care.
Design
Regression models using physician fixed effects to account for patient clustering were specified to assess “between-” and “within-”physician effects on observed racial and ethnic disparities in patients’ experiences of primary care.
Participants
The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months.
Main Results
Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). “Between-physician” effects were mostly negative and larger than “within-physician” effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, “within-physician” effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05).
Conclusions
Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of “within-” and “between-” physician effects to racial and ethnic disparities in the technical quality of primary care.
doi:10.1007/s11606-008-0732-8
PMCID: PMC2533359  PMID: 18651194
physician effects; primary care; racial disparities; patients’ experiences of care; quality improvement
13.  Dissatisfaction With Dental Care Among Mothers Of Medicaid-Enrolled Children 
Objectives
This paper is part of a larger study examining the impact of mothers’ having a regular source of dental care (RSDC) on utilization of dental care and oral health of their preschool children. We describe levels of satisfaction with care among mothers whose preschool children were enrolled in Medicaid in Washington State. We report mothers’ satisfaction related to having a RSDC by type of dental setting/office.
Methods
Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode survey. Satisfaction with dental care was measured using the Dental Satisfaction Questionnaire (DSQ).
Results
Overall mean DSQ was 57.1±9.9 (range 18-89). A higher score indicates greater satisfaction. There was not evidence of a difference in dissatisfaction by race/ethnicity but Blacks and Hispanics were less satisfied with pain management than Whites. The majority of respondents agreed with the statement that “Dentists sometimes act rude to their patients.” Satisfaction is higher for mothers who have a regular private dentist they see consistently versus having a regular dentist through a public or non-profit clinic.
Conclusions
The satisfaction with dental care for this population is low, and considerably lower than found in other studies for primary medical care. Steps need to be taken to increase dental satisfaction and access to private dental clinics, and to increase perceived quality and pain management of dental care in both private clinics and public/non-profits serving low-income populations.
doi:10.1111/j.1600-0528.2007.00423.x
PMCID: PMC2574775  PMID: 18284431
Patient Satisfaction; Oral Health; Health Services Accessibility; Mothers
14.  Disparities in Regular Source of Dental Care among Mothers of Medicaid-Enrolled Preschool Children 
For mothers of Medicaid children aged 3 to 6 years, we examined whether mothers’ characteristics and local supply of dentists and public dental clinics are associated with having a regular source of dental care. Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington state. Mothers (N=4,373) completed a mixed-mode survey that was combined with dental supply measures. Results reveal 38% of mothers had a regular dental place and 27% had a regular dentist. Dental insurance, greater education, income, and length of residence and better mental health were associated with having a regular place or dentist for Black, Hispanic and White mothers, along with increased supply of private dentists and safety net clinics for White and Hispanic mothers. Mothers lacking a regular source of dental care may increase oral health disparities in their children.
doi:10.1353/hpu.2007.0096
PMCID: PMC2266968  PMID: 17982208
Access to dental care; regular source of dental care; dental insurance; Medicaid; mothers; oral health
15.  Use of Complementary and Alternative Medicine Providers by Fibromyalgia Patients Under Insurance Coverage 
Arthritis and rheumatism  2007;57(1):71-76.
Objective
To quantify how visits and expenditures differ between insured patients with fibromyalgia syndrome (FMS) who use complementary and alternative medicine (CAM) providers compared to FMS patients who do not. FMS patients were also compared to an age and gender matched comparison group without FMS.
Methods
Calendar year 2002 claims data from two large insurers in Washington State were analyzed for provider type (CAM vs. conventional), patient comorbid medical conditions, number of visits, and expenditures.
Results
Use of CAM providers by FMS patients was two and a half times higher than in a comparison group without FMS. (56% vs. 21%) FMS patients who used CAM had more health care visits than FMS patients not using CAM (34 vs. 23, p < .001); however, CAM users had similar expenditures to non-users among FMS patients ($4638 vs. $4728, n.s.), because expenditure per CAM visit is lower than expenditure per conventional visit. FMS patients who used CAM also had heavier overall disease burdens than those not using CAM.
Conclusion
With insurance coverage, a majority of FMS patients will use CAM providers. The sickest patients use more CAM and this leads to an increased number of health care visits. However, CAM use is not associated with higher overall expenditures. Until a cure for FMS is found, CAM providers may offer an economical alternative for FMS patients seeking symptomatic relief.
doi:10.1002/art.22471
PMCID: PMC1853385  PMID: 17266066
Fibromyalgia; Complementary and alternative medicine; Health services research
16.  The Effect of Complementary and Alternative Medicine Claims on Risk Adjustment 
Medical care  2006;44(12):1078-1084.
Objective
To assess how the inclusion of diagnoses from complementary and alternative medicine (CAM) providers affects measures of morbidity burden and expectations of health care resource use for insured patients.
Methods
Claims data from Washington State were used to create two versions of a case-mix index. One version included claims from all provider types; the second version omitted claims from CAM providers who are covered under commercial insurance. Expected resource use was also calculated. The distribution of expected and actual resource use was then compared for the two indices.
Results
Inclusion of CAM providers shifts many patients into higher morbidity categories; 54% of 61,914 CAM users had higher risk scores in the index which included CAM providers. When expected resource use categories were defined based on all providers, CAM users in the highest morbidity category had average (± s.d.) annual expenditures of $6661 (± $13,863). This was less than those in the highest morbidity category when CAM providers were not included in the index ($8562 ± $16,354), and was also lower than the highest morbidity patients who did not use any CAM services ($8419 ± $18,885).
Conclusions
Inclusion of services from CAM providers under third party payment increases risk scores for their patients but expectations of costs for this group are lower than expected had costs been estimated based only on services from traditional providers. Additional work is needed to validate risk adjustment indices when adding services from provider groups not included in the development of the index.
doi:10.1097/01.mlr.0000233695.65616.ed
PMCID: PMC1797614  PMID: 17122711
17.  Insurance Coverage and Subsequent Utilization of Complementary and Alternative Medical (CAM) Providers 
Objective
Since 1996, Washington State law has required private health insurance to cover licensed CAM providers. This study evaluated how insured people used CAM providers and what role this played in health care utilization and expenditures.
Study Design
Cross sectional analysis of calendar year 2002 insurance enrollees from Western Washington State.
Methods
Analysis of insurance demographic data, claims files, benefit information, diagnoses, CAM and conventional provider utilization, and health care expenditures for three large health insurance companies.
Results
Among over 600,000 enrollees, 13.7% made CAM claims. This included 1.6% of enrollees with claims for naturopathy, 1.3% acupuncture, 2.4% massage and 10.9% chiropractic. Patients enrolled in Preferred Provider Organizations and Point of Service products were significantly more likely to use CAM than those with Health Maintenance Organization coverage. CAM use was greater in women and people between 31 and 50 years of age. Chiropractic was more frequent in less populous counties. CAM provider visits usually focused on musculoskeletal complaints, except for naturopathic physicians who treated a broader array of problems. Median per visit expenditures for CAM care were $39.00 compared to $74.40 for conventional outpatient care. Total expenditures per enrollee were $2,589 of which $75 (2.9%) was spent on CAM.
Conclusions
The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest. Because the long term trajectory of CAM cost under third party payment is unknown, utilization of these services should be followed.
PMCID: PMC1513668  PMID: 16834526
Complementary Therapies; Health Care Costs; Insurance Claim Review; Utilization Review
18.  Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms 
Background
Managed care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.
Methods
A prospective cohort study design was conducted in the offices of 261 primary physicians in private practice in Seattle in 1997. Patients (N = 17,187) were screened in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms. Patients (n = 1,995) completed a 6-month follow-up survey. Of these, 691 patients received specialty care for pain, and 356 patients saw mental health specialists. For each patient, managed care was measured by the intensity of managed care controls in the patient's health plan and primary care office. Quality of specialty care at follow-up was measured by patient rating of care provided by the specialists. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days.
Results
The intensity of managed care controls in health plans and primary care offices was generally not associated with patient ratings of the quality of specialty care. However, pain patients in more-managed primary care offices had lower ratings of the quality of specialty care from physician specialists and ancillary providers.
Conclusion
For primary care patients with pain or depressive symptoms and who see specialists, managed care controls may influence ratings of specialty care for patients with pain but not patients with depressive symptoms.
doi:10.1186/1472-6963-7-22
PMCID: PMC1829159  PMID: 17306028
19.  Reducing Oral Health Disparities: A Focus on Social and Cultural Determinants 
BMC Oral Health  2006;6(Suppl 1):S4.
Oral health is essential to the general health and well-being of individuals and the population. Yet significant oral health disparities persist in the U.S. population because of a web of influences that include complex cultural and social processes that affect both oral health and access to effective dental health care.
This paper introduces an organizing framework for addressing oral health disparities. We present and discuss how the multiple influences on oral health and oral health disparities operate using this framework. Interventions targeted at different causal pathways bring new directions and implications for research and policy in reducing oral health disparities.
doi:10.1186/1472-6831-6-S1-S4
PMCID: PMC2147600  PMID: 16934121
20.  Randomized pilot study to disseminate caries-control services in dentist offices 
BMC Oral Health  2006;6:7.
Background
To determine whether education and financial incentives increased dentists' delivery of fluoride varnish and sealants to at risk children covered by capitation dental insurance in Washington state (U.S.).
Methods
In 1999, 53 dental offices in Washington Dental Service's capitation dental plan were invited to participate in the study, and consenting offices were randomized to intervention (n = 9) and control (n = 10) groups. Offices recruited 689 capitation children aged 6–14 and at risk for caries, who were followed for 2 years. Intervention offices received provider education and fee-for-service reimbursement for delivering fluoride varnish and sealants. Insurance records were used to calculate office service rates for fluoride, sealants, and restorations. Parents completed mail surveys after follow-up to measure their children's dental utilization, dental satisfaction, dental fear and oral health status. Regression models estimated differences in service rates between intervention and control offices, and compared survey measures between groups.
Results
Nineteen offices (34%) consented to participate in the study. Fluoride and sealant rates were greater in the intervention offices than the control offices, but the differences were not statistically significant. Restoration rates were lower in the intervention offices than the control offices. Parents in the intervention group reported their children had less dental fear than control group parents.
Conclusion
Due to low dentist participation the study lacked power to detect an intervention effect on dentists' delivery of caries-control services. The intervention may have reduced children's dental fear.
doi:10.1186/1472-6831-6-7
PMCID: PMC1513219  PMID: 16670027
21.  Managed Care, Physician Job Satisfaction, and the Quality of Primary Care 
OBJECTIVE
To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms.
DESIGN
Prospective cohort study.
SETTING
Offices of 261 primary physicians in private practice in Seattle.
PATIENTS
We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey.
MEASUREMENTS AND RESULTS
For each patient, managed care was measured by the intensity of managed care controls in the patient's primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes.
CONCLUSIONS
For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.
doi:10.1111/j.1525-1497.2005.32127.x
PMCID: PMC1490070  PMID: 15836532
managed care programs; pain; depression; quality; physician job satisfaction
22.  Managed Care, Access to Specialists, and Outcomes among Primary Care Patients with Pain 
Health Services Research  2003;38(1 Pt 1):1-19.
Objective
To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
Data Sources/Study Setting
Patient, physician, and office manager questionnaires collected in the Seattle area in 1996–1997, plus data abstracted from patient records and health plans.
Study Design
A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
Data Collection
Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
Principal Findings
A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
Conclusions
Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.
doi:10.1111/1475-6773.00102
PMCID: PMC1360871  PMID: 12650378
Managed care programs; pain, primary care; specialties (medical); referral; consultation; outcome assessment
23.  Managed Care, Access to Mental Health Specialists, and Outcomes Among Primary Care Patients with Depressive Symptoms 
OBJECTIVE
To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms.
DESIGN
Prospective cohort study.
SETTING
Offices of 261 primary physicians in private practice in Seattle.
PATIENTS
Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months.
MEASUREMENTS AND RESULTS
For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians.
CONCLUSIONS
The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.
doi:10.1046/j.1525-1497.2002.10321.x
PMCID: PMC1495032  PMID: 11972722
managed care programs; access; insurance; behavioral medicine; depression; primary care; mental health services; physician referral; outcome assessment; quality of care; internal medicine; family medicine; psychiatry; psychology

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