Group practice strategies to manage pharmaceutical cost in an HMO network.

OBJECTIVE: To evaluate the prevalence of various pharmaceutical cost management strategies used by group practices within a managed care network and their relationship to drug costs among enrollees. STRATEGIES STUDIED: Care management (gatekeeping, practice profiling, practice guidelines, case management), techniques for maintaining clinic medication records, and policies regulating physician interaction with pharmaceutical sales representatives (PSRs). STUDY DESIGN: Cross-sectional survey of primary care group practice organizations (n = 103) affiliated with Blue Cross Blue Shield of Minnesota in early 1996. METHODS: Multivariate linear regression analysis was performed on corresponding claims data for members continuously enrolled in these practices from January 1 to December 31, 1995 (n = 76,387), using the patient as the unit of analysis. RESULTS: Substantial variation in strategy prevalence was observed; this variation was thought to influence pharmaceutical costs. Seventy-six percent of practices had medication lists in outpatient medical records, 53% had policies limiting pharmaceutical detailing, and 44% had patients assigned to primary care gatekeepers; however, only 10% used outpatient nurse case managers. Use of outpatient nurse case managers (P < .010), primary care physician gatekeeping (P < .002), policies to control pharmaceutical detailing (P < .001), and medication lists and outpatient charts (P < .001) was found to be independently associated with lower pharmaceutical expenditures. Significant colinearity was found between group size and the strategies studied. CONCLUSIONS: Significantly lower pharmaceutical costs per member per year were observed in the groups reporting primary care gatekeeping, outpatient medication records, outpatient case managers, and policies regarding physician interactions with PSRs.

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.

The effects of medical group practice and physician payment methods on costs of care.

OBJECTIVE: To assess the effects of payment methods on the costs of care in medical group practices. DATA SOURCES: Eighty-six clinics providing services for a Blue Cross managed care program during 1995. The clinics were analyzed to determine the relationship between payment methods and cost of care. Cost and patient data were obtained from Blue Cross records, and medical group practice clinic data were obtained by a survey of those organizations. STUDY DESIGN: The effects of clinic and physician payment methods on per member per year (PMPY) adjusted patient costs are evaluated using a two-stage regression model. Patient costs are adjusted for differences in payment schedules; patient age, gender, and ACG; clinic organizational variables are included as explanatory variables. DATA COLLECTION: Patient cost data were extracted from Blue Cross claims files, and patient and physician data from their enrollee and provider data banks. Medical group practice data were obtained by a mailed survey with telephone follow-up. PRINCIPAL FINDINGS: Capitation payment is correlated with lower patient care costs. When combined with fee-for-service with withhold provisions, this effect is smaller indicating that these two clinic payment methods are not interchangeable. Clinics with more physician compensation based on measures of resource use or based on some share of the net revenue of the clinic have lower patient care costs than those with more compensation related to productivity or based on salary. Salary compensation is strongly associated with higher costs. The use of physician profiles and clinical guidelines is associated with lower costs, but referral management systems have no such effect. The lower cost clinics are the smaller, multispecialty clinics. CONCLUSIONS: This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care. However, the methods by which that influence is manifest is not clear. Although the organizational structure of clinics and their use of managed care programs appear to play a role, this influence is less than expected.

Primary care physician incentives in medical group practices.

CONTEXT: Although medical groups are adapting to changes in financing health care, little is known about individual physician incentives in this environment. OBJECTIVES: To describe methods group practices use to compensate primary care physicians in a managed care environment and to examine the association of revenue sources for the group practice from all patients and primary care physician incentives. DESIGN: We surveyed by mail group practice administrators for practices that had at least 200 members continuously enrolled in 1995. SETTING: Group practices that had contractual arrangements with Blue Cross/Blue Shield of Minnesota. PARTICIPANTS: One hundred of 129 group practices returned usable surveys. RESULTS: Most groups had some portion of primary care physicians' compensation at risk, although 17 groups compensated them through fully guaranteed annual salary. Seventy-one groups used productivity, 4 groups used quality of care, 1 group used utilization, and 30 used group financial performance. Factors reported to significantly influence primary care physician compensation included billings or charges, overall group practice performance, and net revenue or profit. Groups that had a higher proportion of income from various types of fee-for-service arrangements used lower proportions of base salary for primary care physician compensation and were more likely to relate physician income to measures of productivity. CONCLUSIONS: Substantial variation exists in the types of primary care physician incentives implemented by medical groups. Base salary, individual productivity, and group financial performance were most frequently used to determine compensation. Physician personal financial risk was higher overall in group practices that derived more revenue from fee-for-service contracts.

Housestaff workload and procedure frequency in the neonatal intensive care unit.

OBJECTIVE: To investigate the association of clinical workload and the decision to perform procedures on infants in the neonatal intensive care unit (NICU). DESIGN: Prospective cohort study over one academic year, observing infants exposed to housestaff working under various levels of clinical workload. SUBJECTS: All 31 housestaff rotating on the NICU service during the academic year 1993 to 1994 were observed. A total of 785 infants were admitted to these housestaff. SETTING: One academic Level III intensive care nursery. MEASUREMENTS AND MAIN RESULTS: Clinical workload was operationalized as number of NICU infants cared for by the individual houseofficer on-call each night. The procedures of interest were number of umbilical artery catheters (UACs), intubations, lumbar punctures (LPs), and peripheral phlebotomy performed by the houseofficer on-call. Using multiple linear regression approaches, controlling for the average severity-of-illness of each of the NICU infants, the experience and residency program of the houseofficer on-call, and the individual attending, we found that increased clinical workload (number of NICU infants) resulted in a significantly greater probability that an admitted infant received an umbilical artery catheter (p = .02), but resulted in less probability that any NICU infant received a lumbar puncture (p = .0001) or peripheral phlebotomy (p = .0002). The decision to intubate an infant was not affected by the workload in the NICU. CONCLUSIONS: The clinical workload of housestaff in the NICU can affect decisions to perform procedures on infants in the NICU. For equivalently severely ill infants, there is a greater chance of receiving a UAC and less chance of being phlebotomized or receiving an LP when workload is high. Attending neonatologists need to be sensitive to possible effects of workload on patient care in the NICU.

Variations in the management of primary care: effect on cost in an HMO network.

OBJECTIVE: To determine the relation to cost of different aspects of the management of primary care among group practices within a health maintenance organization network. MEASURES: A cross-sectional survey study of medical practices conducted with Blue Cross Blue Shield of Minnesota, St Paul. The subjects were group practices accepting financial and administrative responsibility for primary care services in the managed care plans of Blue Cross Blue Shield of Minnesota. One hundred twelve primary care practices and 153397 enrollees were included in this analysis. The principal resource use measure in this study was nonhospital cost per member per year estimated from payments to providers plus subscriber-eligible liability. RESULTS: The medical directors' responses revealed considerable variability in the management of primary care in these 112 practices. Group practice characteristics consistently associated with lower nonhospital cost were patient identification of a primary care physician, cost of care profiling, more frequent physician profiling, more patients per hour in the clinic, a higher proportion of primary care physicians in the specialty of family or general practice, and a greater number of physicians in the group practice. CONCLUSIONS: Results of this study demonstrate substantial variation in the management of primary care among group practices participating in a health maintenance organization network. These differences are associated with significant variation in the nonhospital cost of care for enrollees.

The organizational structure of medical group practices in a managed care environment.

This article analyzes the organizational structures of 155 medical group practices providing services in the highly competitive managed care environment in the upper midwest. The structure of the group practices and the methods of physicians' payment are analyzed in terms of the proportion of revenue obtained from financial risk-sharing managed care payment systems and the length of time involved with those systems.

The effect at one teaching hospital of interns' workloads on the satisfaction of their patients.

PURPOSE: To explore whether the amount of workload of first-year residents (interns) affects the satisfaction of their patients. METHOD: The authors collected data from January through May 1995 for 145 patients admitted to Lexinton Veterans Affairs Medical Center with the primary diagnosis of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Workload was measured as the number of other patients for whom the intern had primary responsibility on the day of the studied patient's admission. A questionnaire measured the patients' satisfaction on the day of discharge. The authors analyzed the data using Pearson correlation and multiple linear regression. RESULTS: For the 89 patients with COPD (controlling for patient age, severity of illness, and sex of intern), greater workloads for their interns was a significant predictor of decreased patients' satisfaction (p = .001). No association was found for the 56 patients with CHF. CONCLUSION: Interns' workloads on the day their patients are admitted can influence their patients' subsequent satisfaction.

House staff supervision, workload, and experience in the neonatal intensive care unit: results of a national survey.

One hundred fifty-nine pediatric chief residents were surveyed regarding characteristics of the neonatal intensive care unit rotation for house staff at their institution. We documented substantial interinstitution variability in house staff NICU rotations in terms of number of rotations, and the workload and supervision of house staff.

A randomized trial of providing house staff with patient social history information. Effect on patient outcomes.

The purpose of this project was to assess if providing physicians (house staff) with routine comprehensive social history information on their patients will improve patient outcomes. Comprehensive social history information was gathered over a 5-month period on 134 consecutive patients. Patients were randomized to have social history information provided or not provided to the resident physician caring for them. Outcomes of interest were: patient satisfaction, length of stay, and early unplanned readmission. Analysis was with analysis of covariance, controlling for patient severity of illness and amount of social history information documented by the house officer. Outcomes were the same for patients for whom house staff were provided social history information versus those for whom the information was not provided. The authors conclude that providing house staff with routine comprehensive social history information did not influence patient outcomes.

Surveillance of handwashing episodes in adult intensive-care units by measuring an index of soap and paper towel consumption.

OBJECTIVE: To determine whether handwashing surveillance could be conducted by measurements of soap and towel consumption. DESIGN AND PARTICIPANTS: In the medical intensive-care unit (MICU) of the Omaha Veterans' Affairs Medical Center, 10 4-hour day-time observation periods encompassing 409 handwashing episodes were scheduled in a 51-day period. In the surgical intensive-care unit (SICU), 7 4-hour periods encompassing 350 episodes were scheduled in a 49-day period. An observer measured paper towel height, towel weight, and soap weight at each sink. The observer also counted handwashing episodes and bed occupancy. Using handwashing episodes as a dependent variable, stepwise linear regression was performed with changes in towel height, towel weight, and soap weight as independent variables. RESULTS: Mean handwashing episodes per hour per occupied bed were 2.39 +/- 0.80 (standard deviation) in the MICU and 2.83 +/- 0.72 in the SICU. Correlation r with handwashing episodes for MICU changes was 0.891 for towel height, 0.950 for towel weight, and 0.882 for soap weight. Corresponding correlations for the SICU were 0.881, 0.918, and 0.904. For both units, stepwise regression retained changes in the weight of towels and soap as independent variables (P < .0001), with R2 0.965 (MICU) and 0.981 (SICU). CONCLUSION: Because soap and towel consumption measurements are closely related to handwashing frequency and because these measurements are easy to obtain, they offer a means of handwashing surveillance that can be sustained indefinitely. This can facilitate feedback-based interventions to improve handwashing frequency.

Internal medicine residency training and outcomes.

OBJECTIVE: To review the impact of the clinical education of internal medicine residents on patients' outcomes. DATA SOURCES AND STUDY SELECTION: English-language studies of the relation between internal medicine housestaff training and patients' outcomes were systematically identified by a MEDLINE search and from bibliographies and reference lists of recently published articles. MAIN RESULTS: We hypothesized that the primary impact of internal medicine residency training on patients' outcomes would be the result of: (1) the inexperience of the residents; (2) the heavy workload these inexperienced residents are expected to manage: or (3) some structural feature of the internal medicine teaching services, such as the discontinuity of patient care inherent in night float systems and the fact that residents rotate to different services each month. We also hypothesized that residents may in may ways provide superior care, and many actually improve certain patient outcomes. Housestaff inexperience, workload, and structural features that promote discontinuity have been shown to affect especially outcomes of resource utilization, length of stay, and patient satisfaction. No study has demonstrated that internal medicine residents contribute to excess patient morbidity or mortality. However, the published studies in this area are for the most part retrospective and were conducted 10 to 15 years ago. The full extent of the untoward (or the beneficial) effects of internal medicine residency training on patients' outcomes is unknown. CONCLUSIONS: Multisite, prospective studies would remedy the deficiencies in the published research in this area and would yield the most valid insight into the range and extent of the effects of housestaff training on patients' outcomes. In the absence of such studies and in a rapidly changing managed care environment, academic medical centers and departments of medicine need to be aware of those aspects of the clinical education of residents that are most likely to affect patients' outcomes.

Intern call structure and patient satisfaction.

Our institution has instituted "short-call" and "nightfloat" systems to reduce the number of admissions to the traditional "long-call" housestaff. However, the nightfloat system introduces increased discontinuity to patient care, and interns may spend less time with short-call patients because they are nor required to spend the night on-call. Discontinuity and less time spent with patients may result in decreased patient satisfaction. Over a 6-month period, data were collected on 145 consecutive patients admitted to a teaching Veterans Affairs Medical Center with the primary diagnoses of congestive heart failure and chronic obstructive pulmonary disease. We found that patients admitted to either short-call or nightfloat interns were significantly less satisfied with their care than patients admitted to long-call housestaff, controlling for intern gender, patient age, and patient severity of illness (p = 0.02). Residency program directors need to realize that changes in the structure of teaching environment may have an impact on patient satisfaction.

Does pediatric housestaff experience influence tests ordered for infants in the neonatal intensive care unit?

OBJECTIVE: To assess the relationship between the experience of pediatric housestaff and tests ordered on infants in the neonatal intensive care unit (ICU). DESIGN: Prospective, cohort study over one full academic year. SETTING: One academic Level III neonatal intensive care nursery. PATIENTS: Data were collected prospectively on all 785 infants admitted to the neonatal ICU from July 1993 to June 1994. These infants were cared for by 14 different categorical pediatric housestaff. MEASUREMENTS AND MAIN RESULTS: Our neonatal ICU has either a resident or an intern on-call by himself/herself at night, affording us a natural setting to compare intern vs. resident test ordering. The outcomes of interest were number of arterial blood gases, radiographs, and electrolytes ordered per infant by the on-call pediatric houseofficer, as tabulated the morning after the call night. Control variables included the severity-of-illness of the individual infant (using the Neonatal Therapeutic Intervention Scoring System), the workload of the houseofficer (number of patients, number of admissions), and supervision (rounding frequency and on-call attending). Controlling for the severity-of-illness of the infant, the workload on the call night, and supervision with multiple linear regression, we found that interns ordered significantly (p = .02) greater numbers of arterial blood gases per infant than residents, amounting to some 0.33 blood gases per infant per call night (3.22 vs. 2.89 arterial blood gases per infant per night). This increase of 0.33 blood gases per infant amounts to interns ordering $169 more arterial blood gases per call night at our institution. There was no difference between interns and residents in ordering radiographs or electrolytes. CONCLUSION: Interns order significantly more arterial blood gases per infant than junior and senior residents on-call in the neonatal ICU. Additional study is required to see if the experience of housestaff is associated with a broader array of neonatal outcomes, such as morbidity and mortality.