Medical school attended as a predictor of medical malpractice claims.

OBJECTIVES: Following earlier research which showed that certain types of physicians are more likely to be sued for malpractice, this study explored (1). whether graduates of certain medical schools have consistently higher rates of lawsuits against them, (2). if the rates of lawsuits against physicians are associated with their school of graduation, and (3). whether the characteristics of the medical school explain any differences found. DESIGN: Retrospective analysis of malpractice claims data from three states merged with physician data from the AMA Masterfile (n=30288). STUDY SUBJECTS: All US medical schools with at least 5% of graduates practising in three study states (n=89). MAIN OUTCOME MEASURES: Proportion of graduates from a medical school for a particular decade sued for medical malpractice between 1990 and 1997 and odds ratio for lawsuits against physicians from high and low outlier schools; correlations between the lawsuit rates of successive cohorts of graduates of specific medical schools. RESULTS: Medical schools that are outliers for malpractice lawsuits against their graduates in one decade are likely to retain their outlier status in the subsequent decade. In addition, outlier status of a physician's medical school in the decade before his or her graduation is predictive of that physician's malpractice claims experience (p<0.01). All correlations of cohorts were relatively high and all were statistically significant at p<0.001. Comparison of outlier and non-outlier schools showed that some differences exist in school ownership (p<0.05), years since established (p<0.05), and mean number of residents and fellows (p<0.01). CONCLUSIONS: Consistent differences in malpractice experience exist among medical schools. Further research exploring alternative explanations for these differences needs to be conducted.

Physician-system alignment: introductory overview.

The papers in this Special Supplement are based on research funded by the participating members of the joint Center for Health Management Research (CHMR) and Center for Organized Delivery Systems (CODS), and supported by the National Science Foundation under its Industry-University Cooperative Research Center Program. This 3-year research initiative from 1996 through 1999 involved 69 physician organizations (primarily organized medical groups as opposed to IPAs) associated with 14 organized delivery systems. The groups ranged in size from three to 958 with an average size of 76.4 and a median size of 25.0. Comparisons of the study groups with United States physician groups overall are shown in Table 1. The study groups are larger and more likely to be multispecialty than all groups in the United States. The organized delivery systems range in size from one hospital to 80 hospitals with an average of 21 hospitals per system and a median of 11 hospitals per system. They average 4.6 affiliated medical groups with a range from one to 23. The organized delivery systems range in total revenues in 1998 from $340 million to $6.2 billion with an average of $2.1 billion. All the study systems are not-for-profit. Most are located in single market areas, but several are located in multiple markets. For the most part, they represent some of the larger most experienced organized delivery systems in the country. Among the primary objectives of the study was to identify the factors most strongly associated with physician alignment with the health care system and the consequences for the implementation of evidence-based care management practices. The study was also designed to identify the barriers and facilitators to achieving such alignment and its consequences.

The ties that bind: interorganizational linkages and physician-system alignment.

OBJECTIVES: To examine the association between the degree of alignment between physicians and health care systems, and interorganizational linkages between physician groups and health care systems. METHODS: The study used a cross sectional, comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians. Measures of interorganizational linkages were specified at the institutional, administrative, and technical core levels of the physician group and were developed from surveys sent to the administrator of each of the 61 physician groups in the sample. Two stage Heckman models with fixed effects adjustments in the second stage were used to correct for sample selection and clustering respectively. RESULTS: After accounting for sample selection, fixed effects, and group and individual controls, physicians in groups with more valued practice service linkages display consistently higher alignment with systems than physicians in groups that have fewer such linkages. Results also suggest that centralized administrative control lowers physician-system alignment for selected measures of alignment. Governance interlocks exhibited only weak associations with alignment. CONCLUSIONS: Our findings suggest that alignment generally follows resource exchanges that promote value-added contributions to physicians and physician groups while preserving control and authority within the group.

Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture in physician organizations.

OBJECTIVES: To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations. METHODS: Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole. Data are from two sources: (1) surveys of physicians assessing the culture of the medical groups in which they work, and (2) surveys of medical directors and other managerial key informants pertaining to care management practices, compensation methods, and the management and governance of the medical groups. Physician-level data were aggregated to the group level to attain measures of group culture and then merged with the data regarding care management, incentives, and management and governance. Stepwise multiple regression was used to examine the study hypotheses. RESULTS: As hypothesized, the number of different types of compensation incentives used (cost containment, productivity, quality) was positively associated with the comprehensiveness of care management practices. The degree of salary control (ie, market-based salary grades and ranges versus the use of bookings or fees and individual negotiation) was also positively associated with the deployment of care management practices. As hypothesized, market pressures in the form of percentages of health maintenance and preferred provider organization patients seen were generally positively associated with the use of care management practices. Organizational culture had no association except that a patient-centered culture in combination with a greater number of different types of compensation incentives used was positively associated with greater use of care management practices. CONCLUSIONS: Both compensation incentives and managed care market pressures were significantly associated with the use of evidence-based care management practices. The lack of association for culture may be due to the relatively amorphous nature of most physician organizations at this point.

Factors associated with physician involvement in care management.

BACKGROUND: Enthusiasm for the concept of care management (CM) has led to unprecedented growth in the number of guidelines and protocols, but provider organizations have struggled to enlist the active support and participation of physicians in CM activities. OBJECTIVES: To empirically examine the factors influencing physician participation in and attitudes toward CM activities. METHODS: Data on 1,514 physicians were used to predict physician attitudes toward CM and their perceptions of group CM behaviors. Dependent variables were modeled using two-stage Heckman selection bias models with fixed effects corrections. Independent predictors included physician- and group-level controls as well as six potential CM participation and attitude facilitators. RESULTS: Physician participation in the implementation phase of CM activities was positively related to participation and attitude. However, physician participation in the development phase may be negatively related to later participation in CM activities. Management involvement in development phase has mixed effects (positive or no effect), but their involvement in the implementation phase was somewhat negatively related to CM participation and attitude. Financial incentives for participation in CM activities and presence of a useful management information system also appeared to be positively related to attitude and participation. CONCLUSIONS: Appropriate physician and management involvement, as well as financial incentives and useful management information systems may facilitate physician participation in CM activities. Physician involvement in implementation of CM practices appears to be important, whereas their involvement in the development phase may be negatively related to later attitudes and participation. The findings call for a more in-depth understanding of the timing of physician input in CM activities.

Physician commitment to organized delivery systems.

BACKGROUND: Health care systems have developed many types of contracting vehicles with physicians. The immediate aim of these vehicles has been to foster physician commitment and alignment to the system. The ultimate aim of these vehicles has been to garner managed care contracts, reduce costs, and improve quality. To date, most of these vehicles have failed to improve physician commitment. This may be one reason why the ultimate outcomes have not been observed. Consequently, systems are experimenting with new methods to partner with physicians. One new method is to segment physicians into tightly linked and loosely linked strategic alliances and devote different levels of resources and attention to each. OBJECTIVES: This study evaluates whether the segmentation of physicians into tightly linked versus loosely linked strategic alliances improves the commitment of physicians to the system. The study then investigates which constituent elements of the tightly linked strategic alliances exhibit the greatest association with commitment. DESIGNS AND SUBJECTS: The study uses a cross-sectional design and survey data drawn from 1,965 physicians affiliated with 14 health care systems around the country. Tightly linked physicians typically practiced in hospital-sponsored group practices, whereas loosely linked physicians typically used the system's hospitals as their primary site of inpatient practice. MEASURES: Commitment is measured by seven different scales drawn from the literature on organizational commitment, loyalty, and identification. Some of the scales refer to physician attitudes, whereas others describe physician behaviors. The literature suggests that commitment is associated with both instrumental/utilitarian considerations (eg, older age, tenure with system, admissions to system, receipt of a stipend, etc.) as well as administrative involvement/participation considerations (eg, decision-making roles). A series of physician background and practice characteristics are used here to model these two types of factors. RESULTS: The study finds small but significant differences in commitment between physicians in tightly linked versus loosely linked alliances. Multivariate analyses suggest that instrumental/utilitarian factors (eg, age, receipt of stipend, percent of admissions to the system) may exhibit stronger associations with commitment than the physician's administrative involvement in the organization. CONCLUSIONS: To the degree that physician commitment is possible, systems should appeal to physicians' calculative motivations using extrinsic rewards rather than normative involvement in the organization.

Risk assumption and physician alignment with health care organizations.

OBJECTIVES: To examine the association between risk assumption by individual physicians and physician groups and the degree of alignment between physicians and health care systems. METHODS: A cross sectional comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians. Measures of risk assumption were developed from surveys sent to the administrator of each of the 61 physician groups in the sample and to physicians affiliated with these groups. Two stage Heckman models with fixed effects adjustments in the second stage were used to correct for sample selection and clustering respectively. RESULTS: After accounting for selection, fixed effects, and group and individual controls, physicians in groups with larger proportional revenue from managed care displayed greater normative commitment and system loyalty than physicians in groups with lower proportional managed care revenue. Individual-level managed care risk was also positively related to both normative commitment and group behavioral commitment to the system. Physicians in groups with larger physician equity positions expressed lower levels of normative commitment to the system. Physician productivity compensation was negatively related to all measures of alignment. Finally, group emphasis on individually-based incentives for staff physicians was negatively related to system identification. CONCLUSIONS: Our findings suggest that organizations must balance individually-based risk schemes with those that emphasize the performance of the group and the system to achieve long-term goals of loyalty, identification, and commitment to the system.

Physician-system relationships: stumbling blocks and promising practices.

OBJECTIVES: To identify the barriers, facilitators, and potential better practices to achieving physician-system alignment. METHODS: Interviews using a semi-structured, open-ended protocol were conducted during a total of 18 site visits, each usually 2 days in length, covering multiple topics of physician group-system alignment. Interviews were conducted with members of the target physician group, key leaders of the health care system, and representatives of physicians not in the target group. The summary of the interviews for each of the site visits was analyzed to determine barriers, facilitators, and better practices for achieving more effective relationships between physician groups and health care systems. RESULTS: A number of barriers to more effective relationships between physician groups and health systems were identified. Barriers related to environment, culture, and information systems were most prevalent. Other major general areas of barriers encountered were physician leadership, group-system relationship, compensation and productivity, care management practices, group strategy, and accountability. Examples of practices that may help to resolve some of these issues were also identified. CONCLUSIONS: Physician-system relationships can and do cause problems for improving health care. The evidence from the conducted site visits suggests that specific strategies may help improve these relationships but more research is needed in order assess the actual impact of these strategies.

Understanding costs of home and community based services.

With detailed cost information, home and community-based services (HCBS) providers can make intelligent choices that reduce costs without compromising quality and outcomes. Using cost and utilization data from a large HCBS program, monthly costs are estimated and related to demographic and clinical variables. HCBS costs are positively related to disability and cognitive impairment, but not to available social support. Costs vary significantly across the nursing home-eligible population, indicating that caution is warranted when seeking to capitate HCBS services. Per capita costs are strongly related to program volume and experience, falling from $508 to $423 (16.7 percent) over the course of the program.

Economic analyses of bone marrow and blood stem cell transplantation for leukemias and lymphoma: what do we know?

The use of blood and/or bone marrow stem cell transplantation (SCT) grew extensively in the last decade as technological advances led to improved outcomes and wider availability. The first study of SCT costs, however, was not published until 1989. This paper summarizes current knowledge about costs and cost-effectiveness of allogeneic and autologous SCT for leukemias and lymphoma. Methodological issues in cost studies such as types of costs, methods of data collection, and time horizons are discussed, and studies are evaluated with regard to these issues. Considerations specific to economic analyses of SCT are considered, including the potential impact of technological changes, learning curve effects, and inter-institutional differences.

Economic analyses of phase III cooperative cancer group clinical trials: are they feasible?

Both economic and clinical evaluations of new pharmaceutical agents are important to physicians who practice in the current health care environment. While cooperative cancer groups carry out large-scale phase III clinical evaluations of these agents, few cooperative group studies incorporate economic analyses because of concerns over overburdening of data management, investigators, and statistical center personnel. In this study, we describe the results and operational considerations of one of the first completed economic analyses of a phase III cooperative group trial of the Eastern Cooperative Oncology Group (ECOG). We developed an economic model estimating economic benefits of yeast-derived granulocyte-macrophage colony-stimulating factor (GM-CSF) as adjunct therapy for adult patients (56-70 years) with acute myelogenous leukemia. Clinical data were based on prospectively collected information from a recently reported double-blind phase III multi-institutional study carried out by ECOG. Retrospective economic data were obtained from financial information systems at our hospital, one of the study sites. The cost-minimization analyses were based on the perspective of a third-party payer. Indirect costs related to loss of earnings by patients and caregivers as well as quality-of-life adjustments were not incorporated into the model. Clinical trial results indicated that patients treated with GM-CSF had shorter times to recovery of absolute neutrophil count of 500 cells/mm3 and 1000 cells/mm3 and fewer serious infections than patients who received placebo following induction chemotherapy, while no significant differences were noted in red blood cell and platelet transfusion dependency, toxicities, and duration of hospitalization. The economic model estimated that the group treated with GM-CSF was estimated to have lower costs of care, associated with lower frequencies of serious infections and lower overall infection-related costs. Sensitivity analyses indicated that these results held true over a wide range of estimates of costs and infection rates. Prospective economic analyses of phase III cooperative cancer group clinical trials have not been completed to date. Strategies that are not likely to overburden data managers and statistical center personnel are possible to devise. However, these studies require careful planning and coordination between clinical trialists, economists, and health services researchers.

Economic analyses in clinical trials for cooperative groups: operational considerations.

Clinical trials have served as valuable tools for evaluating new therapeutic strategies in the treatment of cancer. Traditionally, new pharmaceuticals and procedures have been appraised on the basis of effectiveness, efficacy, and safety. Recently, economic concerns have become increasingly important when considering treatment strategies for cancer patients. The national emphasis on assessing the costs of health care has focused primarily on the cost-effectiveness of resource allocation. Policy makers are exhibiting greater interest in economic data to supplement clinical data of new procedures and pharmaceutical agents before the approval and widespread application of such methodologies. Clinical trials have increasingly become viewed as a proper setting for such economic analyses. In this paper, we review operational details for carrying out economic analyses of clinical trials being conducted in the cancer cooperative group setting.

Ethnicity and access to care in systemic lupus erythematosus.

OBJECTIVE: To define access to care and to examine the relationship between ethnicity and access to care in systemic lupus erythematosus (SLE). METHODS: A review of published literature was supplemented with preliminary data from a pilot study. Data from patient interviews, chart reviews, and insurer surveys were collected at 2 sites and used to develop several measures of access. The relationship between ethnicity and access was examined through chi-square analyses, difference of means testing, and multivariate regression. RESULTS: Although African-American SLE patients appear less likely to be privately insured and more likely to be uninsured, no significant differences in utilization rates were detected between ethnic groups. Uninsured patients, however, had significantly fewer physician visits than both the Medicaid and the privately insured patients. Multivariate regression confirm a strong and negative relationship between physician visits and patient coinsurance rates. CONCLUSION: Careful examination of multiple dimensions of access may highlight differences between ethnic groups. Further research is necessary to document these differences and explore their relationships to outcomes.

The impact of managed care on dermatology.

The goal of managed care is to find the most effective mix of the factors of production to provide quality care to its members. The aforementioned information on the impact of managed care on dermatology suggests that the future of dermatology need not be bleak. The supply of dermatologists in the nation is far more consistent with the demand of classic MCOs for dermatologists than for almost all other specialties. In addition, any form of health care reform that increases access to health care for the uninsured and underinsured will increase the demand for dermatologic care. Similarly, a well-functioning managed care plan will move to establish the boundary line between skin care by PCPs and dermatologists in a consensual, objective, and mutually respectful process. The attempt to define this boundary will give added impetus to the development of outcomes measurement and management in managed care and serve to advance the interests of all parties concerned, including the patient. A well-defined boundary line between care appropriately rendered by PCPs and that provided by dermatologists will result in dermatologists treating a higher severity of illness--the cases for which dermatologists were trained to treat. The higher level of severity of illness could be associated with a higher level of professional satisfaction. Similarly, capitated arrangements between dermatologists and PCPs create incentives for cooperative education and communication initiatives between both parties to define appropriate ranges of care and referral timing. Where capitated arrangements do not exist, it is also important to define such appropriate ranges of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Competitive bidding for Medicare services.

One of the key issues in implementing prospective Medicare fee schedules is how to set prices that accurately reflect competitive market forces. Competitive bidding has long been used in government procurement efforts for nonhealth services. In this paper, we evaluate how provider behavior will be affected if Medicare uses competitive bidding to set Medicare fee schedules. Our model provides several important insights about competitive bidding for health care services. First, the model shows that competitive bidding will lead to 2-stage competition between providers. In the bidding stage, providers will compete to submit winning bids. In the following stage, winning providers will compete for business through marketing efforts that may enhance quality. Second, the model shows how the design of the bidding mechanism affects bidding strategies and the importance of individual provisions within the design, such as penalties for losing bidders. Third, the model demonstrates how competitive bidding will affect quality. It shows how quality may deteriorate if the bidding mechanism chooses an exclusive winner and why naming multiple winners can keep quality at acceptable levels. Finally, we identify criteria for determining whether a particular type of Medicare service is well-suited for competitive bidding.