Demand management: enabling patients to use medical care appropriately.

A rationale is presented for considering demand management as well as supply management (managed care) in the current debate on health care reform. Demand management is the support of individuals so that they may make rational health and medical decisions based on a consideration of benefits and risks. The concept of demand for medical services is examined within a theoretical framework of four components: morbidity, perceived need, patient preference, and nonhealth motives. Two components, perceived need and patient preference, are suggested to offer considerable potential for making utilization more appropriate and reducing costs. Current demand services and potential hazards related to their continued expansion are discussed.

Impact of a facility-based corporate fitness program on the number of absences from work due to illness.

This study examined the relationship between participation in a facility-based fitness program and the number of reported absences from work due to illness. Employees who became members had a history of fewer absences before the program began in 1987 than employees who did not become members. Comparing 1988 with 1986, members experienced a significant decrease in absences, whereas nonmembers did not. Male and female members experienced 0.42 and 1.0 fewer days absent in 1988 than in 1986, respectively. Controlling for gender and previous absences, members could be expected to have 1.2 fewer absences in 1988 than nonmembers. On average, those who participated most frequently experienced the greatest improvement in attendance. A significant interaction between participation and 1986 absences indicated that a member's decrease in absences depended both on how many absences the member had to begin with, and how much he or she participated. Members having a high number of absences in 1986 could expect the greatest benefit from frequent participation.

A preliminary study on the timeliness of ambulatory care utilization following medical self-care interventions.

A sub-sample, from a large prospective study examining the effects on utilization from the introduction of medical self-care materials, was followed to determine the timeliness of that utilization. Judgments on early, on time, or late visits, by patients, providers, and algorithms showed agreement for experimentals (n = 203) but not controls (n = 56). Comparisons on the rates of judged early, on time, and late visits differed between groups (by the physician and algorithm comparison), and further differed when comparing late only visits (by the algorithm comparison). The experimentals demonstrated a trend to delay care seeking though no adverse effect on health was identified when comparing subsequent illness days and hospitalizations. Medical self-care can reduce utilization and improve patients' ability to judge visit timeliness. Apparent trends to increase late visits may be an artifact of conservative judgments rendered by medical opinion.

Characteristics of self-selected responders to a health risk appraisal: generalizability of corporate health assessments.

Selected characteristics and total medical claims of health risk appraisal (HRA) responders and non-responders were compared in a sample of employees having a three-year employment and claims history. HRA responders were younger and more likely to file medical claims than non-responders. Although mean medical claims were greater for HRA responders than non-responders, when adjusted for age and sex this difference reflected the proportion of employees reporting claims, not a difference in the claims amount.

The relationship between retrospective health insurance claims and a health risk appraisal-generated measure of health status.

This research examined the relationship between a measure of health status (defined as the health index--the difference between actual and appraised ages) derived from a health risk appraisal and retrospective health insurance claims taken from one cooperating work organization. A model was defined consisting of 3-year retrospective medical claims as the criterion and age and the health index as predictors. Using a cube-root transformation of medical claims, a significant inverse relationship for age and the health index was identified for men. No relationships were found for women. It was concluded that, for men when age is held constant, a negative relationship exists between retrospective medical claims and a health risk appraisal-generated health status indicator, the health index.

The effect of self-care interventions on the use of medical service within a Medicare population.

To determine the effect of a self-care communication-based health education program on ambulatory care utilization, a prospective, randomized, controlled trial was conducted with a Medicare population within a health maintenance organization. A statistically significant decrease of 15% in total medical visits was found in the experimental group as compared with a control. Although not evident in the control, a statistically significant decrease in the ratio of follow-up visits from pre-entry to postentry was realized in the experimental group. Medical-visit decreases resulted in a savings of $36.65 per household in the experimental group for a benefit-cost ratio of 2.19 saved for every dollar spent on intervention. These results demonstrate that a health education program can reduce utilization while having no known negative impact on the quality of health.

Life-style and organizational health insurance costs.

Most health professionals accept life-style as being causally related to morbidity and mortality, but many managers question this relationship, particularly in relation to corporate health care costs. This research compared responses from a lifestyle questionnaire (HealthScore), age, and organizational size, with Blue Cross/Blue Shield rates for eight work sites in Ohio. HealthScore was demonstrated to be the best predictor of health insurance rates. This relationship held for a secondary analysis involving Blue Shield rates adjusted for company size and coverage.

Effect of a self-care education program on medical visits.

A prospective, randomized, controlled trial of self-care educational interventions was conducted in a health maintenance organization to determine their effect on ambulatory care utilization. Statistically significant decreases in total medical visits and minor illness visits were found in each of three experimental groups as compared with a control group. These decreases averaged 17% and 35%, respectively. These results were most clearly linked to a system of written communications emphasizing personal decision making about the use of medical care. The addition of a nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent ona nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent on the educational interventions. Self-care education systems may have important effects on medical care costs, physician satisfaction, and patient confidence.

Is it a change for the better? Health promotion.

The public's expectations of hospitals are changing in that they want to know more about taking care of themselves. It is therefore inevitable that hospitals will change.

Health promotion--keeping people out of the hospital.

Health promotion is finding a place in the community hospital. This article discusses the need for commitment to health promotion as an ongoing program and not a publicity campaign. Examples of successful programs, principles of good practice, and the benefits of providing the community with information are presented.

Physician extenders in walk-in clinics: a prospective evaluation of the AMOSIST program.

The Automated Military Outpatient System (AMOS) Project was developed to improve the ambulatory care of patients with episodic and chronic illnesses. During the development of its episodic care component, the relative frequency of problems treated by the walk-in clinic staff was analyzed and showed a high volume of acute minor illnesses. A simple, conservative triage system run by non-professionals was developed to screen patients to a clinic for benign, self-limited illnesses run by physician-extenders. This group, the equivalent of civilian licensed practical nurses and nurses' aides, was trained in a task-oriented fashion to treat 44 common minor illnesses. Clinical algorithms for these illnesses were developed and used as training tools, memory aids, and auditing instruments. This program is now operating in 26 US Army hospitals and caring for some 44,000 patients a month in the continetal United States. We report the results of a prospective audit of the corpsmen and a study of the patient attitude and acceptance of the program.