To help contain health care spending and improve the quality of care, practitioners and policy makers are trying to move away from fee-for-service toward value-based payment, which links providers’ reimbursement to the value, rather than the volume, of services delivered. With funding from the Robert Wood Johnson Foundation, eight grantees across the country are designing and implementing value-based payment reform projects. For example, in Salem, Oregon, the Physicians Choice Foundation is testing “Program Oriented Payments,” which include incentives for providers who follow a condition-specific program of care designed to meet goals set jointly by patient and provider. In this article we describe the funding rationale and the specific objectives, strategies, progress, and early stages of implementation of the eight projects. We also share some early lessons and identify prerequisites for success, such as ensuring that providers have broad and timely access to data so they can meet patients’ needs in cost-effective ways.
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.
Nonequivalent pretest-posttest control group design.
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.
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.
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.
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.
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.
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.
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).
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.
Dentists should be familiar with MI conditions as these patients may have greater unmet dental need.
Mental illness; dental need; utilization
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.
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.
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).
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.
dental caries; prevention; infant; pregnant woman
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.
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.
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.
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.
Early Childhood Caries; Prevention; Pregnant woman; County factors; Area Resource File
We examined provider-level factors and reported discrimination in the healthcare setting.
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.
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.
Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.
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.
Race/Ethnicity; Discrimination; Provider Factors; Diabetes Care; Managed Care
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.
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.
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).
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].
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).
diabetes; healthcare disparities; managed care; race/ethnicity; quality; discrimination
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.
Disability; Youth with special health care needs; Insurance; Transition; Adolescent health
We examined possible determinants of self-reported health care discrimination.
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.
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).
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.
Race/ethnicity; discrimination; diabetes care; managed care
To examine insurance regain among youth with no, non-severe, and severe disabilities.
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.
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).
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.
To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice.
Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information.
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.
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.
This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.
Access; productivity; cost; incentives; integrated group practice
Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients.
To examine relative contribution of “between-” and “within-” physician effects on disparities in patients’ experiences of primary care.
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.
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.
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).
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.
physician effects; primary care; racial disparities; patients’ experiences of care; quality improvement
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.
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).
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.
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.
Patient Satisfaction; Oral Health; Health Services Accessibility; Mothers
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.
Access to dental care; regular source of dental care; dental insurance; Medicaid; mothers; oral health
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.
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.
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.
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.
Fibromyalgia; Complementary and alternative medicine; Health services research
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.
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.
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).
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.
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.
Cross sectional analysis of calendar year 2002 insurance enrollees from Western Washington State.
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.
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.
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.
Complementary Therapies; Health Care Costs; Insurance Claim Review; Utilization Review
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.
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.
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.
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.
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.
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.).
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.
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.
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.
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.
Prospective cohort study.
Offices of 261 primary physicians in private practice in Seattle.
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.
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.
managed care programs; pain; depression; quality; physician job satisfaction
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.
A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
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.
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.
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.
Managed care programs; pain, primary care; specialties (medical); referral; consultation; outcome assessment
To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms.
Prospective cohort study.
Offices of 261 primary physicians in private practice in Seattle.
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.
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.
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
Medicare beneficiaries enrolled in a health maintenance organization (HMO) were randomized to a preventive services benefit package for 2 years or to usual care. At 24- and 48-month followups, the treatment group had completed more advance directives, participated in more exercise, and consumed less dietary fat than the control group. Unexpectedly, more deaths occurred in the treatment group. Surviving treatment-group enrollees reported higher satisfaction with health, less decline in self-rated health status, and fewer depressive symptoms than surviving control participants. Despite these changes, the intervention did not yield lower cost per quality-adjusted life year in this historically prevention-oriented HMO.