The future of capitation: the physician role in managing change in practice.

Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.

Educating residents about managed care: a partnership between an academic medical center and a managed care organization.

Physicians are taught to think in terms of individual patients rather than in terms of the health of a population, a view typically reinforced by residency training. Managers of managed care organizations estimate that it takes between one and two years of additional post-residency experience to prepare graduates of U.S. residency programs to practice in managed care settings. The authors describe a two-week block rotation in managed care and health system change that is required of all third-year medical residents at New York-Presbyterian Hospital/ Weill Cornell Medical Center. The program was developed through a partnership between the Joan and Sanford I. Weill Medical College of Cornell University, the New York-Presbyterian Hospital, and Empire BlueCross BlueShield. The authors discuss the rationale, curriculum content, teaching methods, and evaluation of the program, which is designed not only to educate residents about managed care but also to enable them to think critically about the changing health care system. The results of the program have exceeded expectations. Residents' knowledge of health economics, managed care concepts, and health system change, as measured by pre- and post-rotation tests, has shown a steep learning curve. Further, the residents have consistently given the rotation the highest ratings, and some residents have changed their career plans as a result of their participation. The program, which continues to expand, has demonstrated the potential of collaboration between traditional adversaries, an academic medical center and a managed care insurance company, and provides a replicable model for similar partnerships.

Poverty and ill health: physicians can, and should, make a difference.

A growing body of research confirms the existence of a powerful connection between socioeconomic status and health. This research has implications for both clinical practice and public policy and deserves to be more widely understood by physicians. Absolute poverty, which implies a lack of resources deemed necessary for survival, is self-evidently associated with poor health, particularly in less developed countries. Over the past two decades, economic decline or stagnation has reduced the incomes of 1.6 billion people. Strong evidence now indicates that relative poverty, which is defined in relation to the average resources available in a society, is also a major determinant of health in industrialized countries. For example, persons in U.S. states with income distributions that are more equitable have longer life expectancies than persons in less egalitarian states. There are numerous possible approaches to improving the health of poor populations. The most essential task is to ensure the satisfaction of basic human needs: shelter, clean air, safe drinking water, and adequate nutrition. Other approaches include reducing barriers to the adoption of healthier modes of living and improving access to appropriate and effective health and social services. Physicians as clinicians, educators, research scientists, and advocates for policy change can contribute to all of these approaches. Physicians and other health professionals should understand poverty and its effects on health and should endeavor to influence policymakers nationally and internationally to reduce the burden of ill health that is a consequence of poverty.

Hispanic patients in an academic group practice: measurement issues and comparisons with non-Hispanics.

Health services researchers face a challenge when analyzing populations that include patients of Hispanic cultural heritage. Definitions of Hispanic have changed over the past 25 years. Methods of ascertaining race and ethnicity are flawed, particularly within health care institutions. This study was designed to address these problems by applying a new and unique methodology for identifying Hispanics in a clinical practice. Physicians in a hospital-based academic group practice were asked to identify all Hispanics in their patient panels. A random sample of patients identified as Hispanics were then surveyed by telephone to establish country of origin, length of time in the United States, and bilinguality. This demonstrated a great diversity of country of origin among Hispanics. The 2630 Hispanic patients identified by these methods were compared with non-Hispanics in terms of demographics, case mix, and health care utilization. Health services researchers should consider identification by physicians as a useful method for identifying Hispanics in clinical practice settings.

Measuring the use of the population perspective on internal medicine attending rounds.

BACKGROUND: The population perspective (risk-factor assessment, prevention, epidemiology, and the social aspects of illness) is increasingly important in medical school and residency curricula. The authors designed an observational study to assess the population-perspective content of internal medicine teaching rounds led by attending physicians at the Columbia-Presbyterian Medical Center. METHOD: During eight months in 1992 a trained research assistant used a structured observation form in observing attending rounds. Population scores were calculated by totaling the number of times population-perspective topics were mentioned during each case presentation (one point was awarded per mention, with an additional point being added for discussions lasting 30 seconds or more). Chi-square tests and unpaired t-tests were used to compare scores between teams with one generalist and one subspecialist attending physician and teams with two subspecialists. RESULTS: Fifteen teams and 368 patient presentations were observed. The mean population scores were 24.5 for teams with generalist attending physicians and 17.9 for teams with subspecialists only (p < .0001). The population scores for individual case presentations ranged from 2 to 55. CONCLUSION: The population-perspective topics were raised more frequently on the internal medicine teaching rounds when a generalist attending physician was present than when there were only subspecialist attending physicians.

The influence of social class on health status: American and British research on health inequalities.

PURPOSE: To summarize recent and past American and British studies on the relationship of social class and health status. DATA SOURCES: A systematic review of the pertinent British and American literature, including references identified from bibliographies of books and recent articles. STUDY SELECTION: Published English-language studies that report original or summary data describing socioeconomic status and mortality/morbidity are emphasized. DATA SYNTHESIS: Social class, whether measured by occupation, income, or education, has a marked effect on mortality and morbidity. Use of British and American standardized mortality ratios (SMRs) shows that the gap between the advantaged upper socioeconomic classes and the disadvantaged lower classes has become wider from 1930 to 1980. Explanations for this inequality in health status by socioeconomic status point to four factors: artefact, social selection, culture/behavior, and material/structural conditions. A synthesis of existing literature suggests that material deprivation and social deprivation are the most important factors contributing to this association, although data from longitudinal studies implicate social hierarchy. CONCLUSION: The reviewed studies point to growing inequalities in health status between those of lower and those of higher socioeconomic status. Clinicians and teachers in internal medicine should incorporate this knowledge in assessing patients and adopt a perspective that takes account of socioeconomic factors in diagnostic and management decisions.

[Limitations of case-mix systems in primary care: comparison of the severity of patients in community hospitals and health care centers in the United States]. / Limitaciones de los sistemas case-mix en atencion primaria: comparación de la gravedad de los pacientes atendidos en un centro ubicado en el hospital y dos centros extrahospitalarios en EE.UU.

OBJECTIVE: The aim was to show the limitations of the case-mix "based on attendance", which take into account neither the seriousness of the diagnoses nor the comorbidity. DESIGN: A crossover descriptive study of a retrospective nature. SETTING: In New York, in two centres located in the Hispanic community of Upper Manhattan and a third in the Presbyterian Hospital. PARTICIPANTS: During 1991, 225 patients were studied: 150 attended in the hospital PCC and 75 in the non-hospital PCCs. A simple random sampling of the list of patients attended was performed. INTERVENTIONS: The seriousness of the conditions of the patients attended in the two different types of PCC was compared through the Duke Severity of Illness Scale (DUSOI), a patient-based case-mix which assesses the level of seriousness of each individual diagnosis and the comorbidity linked to the diagnoses grouped together. MEASUREMENTS AND MAIN RESULTS: Significant differences between the seriousness of the conditions of the patients in the two sub-samples were found when comparison by means of bivariant analysis was performed. Scoring on the Severity Scale was significantly higher for those attending hospital (65.5 and 55.1 respectively). CONCLUSIONS: Patient classification systems based on the reasons for attendance underestimate the seriousness of the condition. A case-mix in which the patient is the unit of analysis needs to be developed.

Health of the public. The academic response. Health of the Public Mission Statement Working Group.

Aging of the population, increasing prevalence of chronic and disabling illnesses with multiple social and behavioral risk factors, concern about quality of care, and escalating costs of medical care require fundamental changes in the way that academic health centers discharge their mission. This article describes a newly developed "Mission Statement" for academic health centers that wish to contribute positively to the health of the populations that they serve. A shift toward addressing the needs of the public may produce increasing institutional strength, long-run stability, and enhanced productivity, as well as higher quality, more cost-effective care for patients. Seventeen centers in the Health of the Public Program are currently conducting activities that implement the described mission elements. The goals and objectives described herein create a foundation for change, with more balanced institutional goals, and could turn an emerging confrontation between academe and its public into an opportunity for both.

Impact of physicians' part-time status on inpatients' use of medical care and their satisfaction with physicians in an academic group practice.

Inpatients' use of medical care and their satisfaction with their physicians were examined comparing the patients of three part-time physicians and five full-time physicians in an internal medicine group practice at the Columbia-Presbyterian Medical Center. In one study, by chart review over a seven-month period in 1988, each patient's length of stay and severity of illness were measured. A total of 58 cases were reviewed: 34 from full-time physicians and 24 from part-time physicians. When matched for severity of illness, there was no difference in lengths of stay between the patients of the part-time and those of the full-time physicians. In a second study, on interviewer-administered questionnaires completed over a ten-month period in 1986-1987, 60 patients gave satisfaction ratings of their primary physicians: 36 with full-time physicians and 24 with part-time physicians. Patients' satisfaction was equally high for both groups of physicians. The authors suggest that since more women physicians in internal medicine are demanding part-time work, and since part-time arrangements have been criticized as having adverse effects on patient care, their findings may contribute to more enlightened attitudes towards physicians who choose part-time status.

Looking at the patient in the mix: is case mix methodology unfair to the hospital outpatient department?

The diagnoses of 431 general internal medicine patients from an urban outpatient department (OPD) were analyzed using two methods of case mix description: 1) a visit-based method which captures a single diagnosis for each visit; 2) a patient-based method which captures multiple diagnoses for a patient over one year. Nine of the top ten diagnoses were the same using either method, but the prevalence of diagnoses was two- to twelvefold higher with the patient-based method. Next the OPD was compared by the visit-based method with a national survey of doctors' private offices. Although the visit-based case mix in the OPD appeared to be the same as that in doctors' private offices, the analysis suggested that differences may be hidden by the method of describing case mix. The authors conclude that a visit-based approach to case mix description makes urban OPDs resemble doctors' private offices because the visit-based method undercounts those patients with chronic diagnoses, co-morbid conditions, and psychosocial problems, so common in the urban OPD. These findings have major implications for ambulatory reimbursement schemes, most of which capture only one diagnosis for each visit.

Divisions of general medicine: ambulatory care activities and responses to cost containment.

To evaluate caring for the poor and uninsured in divisions of general medicine (DGMs), and to document the impact of recent reimbursement changes on division ambulatory care activity, the authors conducted a survey of DGM directors. Questionnaires mailed to directors of 214 divisions or residency programs yielded 120 responses. DGMs staffed, on average, three ambulatory sites, with a median of 17,000 visits per site. Overall, 66% of visits were by poor, underinsured, and uninsured patients. The majority of directors (75%) considered care of the poor a goal of their divisions. The most commonly reported response to the cost containment environment was implementation of revenue-generating measures (66%); 19% reported reductions in care to the poor; and 20% reported increased service to this group. It is concluded that DGMs care for large numbers of poor and uninsured patients and therefore must carefully evaluate the impacts of current policy proposals on their future ambulatory care activities.

Hospital-based group practice: does it change clinic patterns of care?

Initiation of a hospital-based faculty group practice to replace part of a general medical clinic was evaluated in a quasi-experimental design. Practice setting (where patients received their primary care) was the independent variable. The group practice, unlike the traditional clinic, emphasized primary care by providing 24-hour, seven day/week access by telephone; continuity between inpatient and ambulatory care (all patients admitted as private patients of group practice attending physicians) and coordination of care. Resource use, including visits to the primary care site, the emergency room and specialty clinics, and tests ordered at each site were tracked for one year by chart review. Multivariate analysis showed that, contrary to expectations, group practice patients had no fewer emergency room or specialty clinic visits, although they did make more visits to the practice. With respect to tests, practice patients had almost two more tests ordered in the primary care site than clinic patients, although there was no concomitant reduction in tests ordered at other sites. The authors conclude that ambulatory care resource use is an insufficient measure of the effect of a change in practice setting.