ABSTRACT
OBJECTIVE: To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice. DATA SOURCES: Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information. STUDY DESIGN: 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. PRINCIPAL FINDINGS: 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. CONCLUSIONS: This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.
Subject(s)
Delivery of Health Care, Integrated , Efficiency , Group Practice, Prepaid/organization & administration , Health Maintenance Organizations/organization & administration , Health Services Accessibility/organization & administration , Patient-Centered Care , Physicians, Family/statistics & numerical data , Primary Health Care/organization & administration , Ambulatory Care Information Systems , Diagnosis-Related Groups , Female , Group Practice, Prepaid/statistics & numerical data , Health Maintenance Organizations/statistics & numerical data , Health Services Research , Humans , Idaho , Internet/statistics & numerical data , Male , Models, Organizational , Motivation , Office Visits , Primary Health Care/statistics & numerical data , Program Evaluation , Regression Analysis , Relative Value Scales , WashingtonABSTRACT
Prepaid medical groups like Grand Valley Health Plan, Grand Rapids, MI, are facing declining membership as employers shift to lower-priced PPOs. But some employers are starting to look more closely again at the value of managed care networks.
Subject(s)
Group Practice, Prepaid/organization & administration , Health Benefit Plans, Employee/trends , Marketing of Health Services/methods , Primary Prevention , Group Practice, Prepaid/statistics & numerical data , Humans , Michigan , Preferred Provider Organizations/statistics & numerical dataSubject(s)
Group Practice, Prepaid/standards , Independent Practice Associations/standards , Physician Incentive Plans , Quality Assurance, Health Care/economics , California , Capitation Fee , Data Collection , Group Practice, Prepaid/statistics & numerical data , Humans , Independent Practice Associations/statistics & numerical data , Patient Satisfaction , Physician-Patient Relations , Quality Indicators, Health CareSubject(s)
Disease Management , Group Practice, Prepaid/organization & administration , Health Maintenance Organizations/organization & administration , Capitation Fee , Coronary Artery Disease/therapy , Cost Control , Diabetes Mellitus/therapy , Group Practice, Prepaid/economics , Group Practice, Prepaid/statistics & numerical data , Health Maintenance Organizations/economics , Health Maintenance Organizations/statistics & numerical data , Heart Failure/therapy , Humans , Massachusetts , Pulmonary Disease, Chronic Obstructive/therapy , Risk AdjustmentABSTRACT
Despite widespread concern about denials of coverage by managed care organizations, little empirical information exists on the profile and outcomes of utilization review decisions. This study examines the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review. We found much higher denial rates than those previously reported. Denials were particularly common for emergency care and durable medical equipment. Retrospective requests were nearly four times more likely than prospective requests were to be denied, and when prospective requests were denied, it was more likely because the service fell outside the scope of covered benefits than because it was not medically necessary.
Subject(s)
Group Practice, Prepaid/statistics & numerical data , Insurance Claim Review/statistics & numerical data , Managed Care Programs/statistics & numerical data , Utilization Review , California , Group Practice, Prepaid/economics , Humans , Insurance, Health, Reimbursement/statistics & numerical data , Managed Care Programs/economics , United StatesABSTRACT
The 1990s witnessed various health provider efforts to integrate health care delivery with financing functions. Physician and hospital-led organizations developed their own insurance products and also contracted on a capitated or shared-risk basis with health maintenance organizations (HMOs). Several studies exist on the efforts of physician-led health organizations in these areas, but few studies exist on hospital-led organizations. We examined unique data on hospital-led health networks and systems for 1999 and found that about 60% had provider-owned insurance products and 50% held capitated contracts for their affiliates. In addition, these hospital-led organizations--especially health systems--had comparable levels of capitated contracting when compared to physician-led organizations. Although interest in capitation has waned, current economic realities may reignite interest in these arrangements given their potential for containing health expenditures without increasing consumer risk. In light of this, it is now a good time for physicians and medical group managers to reflect on their experiences in the 1990s and to assess the merits and shortcomings of different intermediary organizations with which they may align.
Subject(s)
Capitation Fee , Delivery of Health Care, Integrated/organization & administration , Hospital Restructuring/organization & administration , Provider-Sponsored Organizations/organization & administration , Risk Sharing, Financial/statistics & numerical data , American Hospital Association , Contract Services , Delivery of Health Care, Integrated/economics , Group Practice, Prepaid/statistics & numerical data , Health Maintenance Organizations/statistics & numerical data , Health Services Research , Hospital Restructuring/economics , Humans , Insurance Carriers , Ownership , Preferred Provider Organizations/statistics & numerical data , Provider-Sponsored Organizations/economics , United StatesSubject(s)
Capitation Fee/statistics & numerical data , Economics, Medical , Group Practice, Prepaid/economics , Specialization , Accounts Payable and Receivable , Data Collection , Efficiency, Organizational , Group Practice, Prepaid/statistics & numerical data , Humans , Income/statistics & numerical data , Risk Sharing, Financial , United StatesSubject(s)
Capitation Fee , Group Practice, Prepaid/organization & administration , Health Services Needs and Demand/organization & administration , Utilization Review/organization & administration , Group Practice, Prepaid/economics , Group Practice, Prepaid/statistics & numerical data , United StatesSubject(s)
Capitation Fee , Health Maintenance Organizations/statistics & numerical data , Independent Practice Associations/statistics & numerical data , Risk Sharing, Financial/statistics & numerical data , Capitation Fee/statistics & numerical data , Group Practice, Prepaid/economics , Group Practice, Prepaid/statistics & numerical data , Health Care Sector , Health Maintenance Organizations/economics , Independent Practice Associations/economics , United StatesABSTRACT
This paper uses 1996-97 Community Tracking Study data to analyze the effects of different insurance product designs on service use, access, and consumer assessments of care for nonelderly people with employer-sponsored insurance. Product types are defined by features including use of networks, gatekeeping, capitation, and group/staff model delivery systems. We found no evidence of differences across product types in unmet need or delayed care or use of hospitals, surgery, or emergency rooms. At the same time, different product designs present purchasers with a clear trade-off between paying more out of pocket and encountering more administrative barriers to care. In addition, an increasing proportion of consumers report dissatisfaction with choice of physicians and low trust in physicians as one moves along the managed care continuum from unmanaged to heavily managed products. Our findings have implications for efforts to regulate managed care. The existence of a trade-off between out-of-pocket costs and administrative barriers to care means that some forms of regulation run the risk of reducing choices available to consumers. This is particularly true of regulations that would change the nature of managed care products by prohibiting the use of specific care management tools. To the extent that the backlash against managed care targets restrictions on choice and administrative hassles among consumers who nonetheless choose more heavily managed products because of their lower cost, eliminating heavily managed products would leave those consumers worse off.
Subject(s)
Consumer Behavior/statistics & numerical data , Health Benefit Plans, Employee/classification , Health Services Accessibility/statistics & numerical data , Managed Care Programs/classification , Managed Care Programs/organization & administration , Product Line Management/organization & administration , Adult , Capitation Fee/statistics & numerical data , Cost Sharing/statistics & numerical data , Family Characteristics , Fee-for-Service Plans/statistics & numerical data , Gatekeeping/statistics & numerical data , Group Practice, Prepaid/statistics & numerical data , Health Benefit Plans, Employee/organization & administration , Health Care Surveys , Health Maintenance Organizations/statistics & numerical data , Humans , Managed Care Programs/statistics & numerical data , Middle Aged , Models, Organizational , Multivariate Analysis , Preferred Provider Organizations/statistics & numerical data , United StatesABSTRACT
Findings from the Fifth Annual Managed Care Indicator by Evergreen Re, a national health care consulting and reinsurance brokerage company, confirm other signs that the presence of capitation is waning slightly in the health care marketplace. Nevertheless, the number of multispecialty groups involved in capitation is still surprisingly high.
Subject(s)
Capitation Fee/statistics & numerical data , Group Practice, Prepaid/economics , Risk Sharing, Financial/statistics & numerical data , Economics, Medical , Group Practice, Prepaid/statistics & numerical data , Health Care Surveys , Income , Specialization , United StatesSubject(s)
Capitation Fee , Group Practice, Prepaid/economics , Managed Care Programs/economics , Risk Sharing, Financial/organization & administration , Bankruptcy , Contract Services/economics , Database Management Systems , Group Practice, Prepaid/organization & administration , Group Practice, Prepaid/statistics & numerical data , Information Management , Managed Care Programs/organization & administration , Managed Care Programs/statistics & numerical data , United States , Utilization ReviewABSTRACT
OBJECTIVES: The timing of cesarean sections is studied to examine how physician convenience and financial incentives play a role in the decision to perform a cesarean section. METHODS: Using birth certificate and hospital financial data from California, the likelihood of cesarean sections being performed at particular times of day was examined, controlling for maternal characteristics and the mother's insurance coverage. Two diagnoses associated with cesarean sections are examined separately: fetal distress and prolonged/dysfunctional labor. The hypotheses are that cesarean sections performed for physician convenience are more likely to occur in the evening hours and that type of insurance will affect the incentive to perform cesarean sections to obtain leisure. RESULTS: The probability of cesarean sections for patients insured by a group-model HMO is more stable during the course of a day than that for patients insured by all other insurance plans. Group-model HMO patients with previous cesarean sections are less likely to have cesarean sections in the evening hours and are less likely to be diagnosed with fetal distress or prolonged/dysfunctional labor. CONCLUSIONS: The differences in cesarean sections and diagnosis rates between group-model HMO patients and other patients could arise from several mechanisms: group-model HMOs provide consistent financial incentives to their staff, they may be better able to guide physician practice, and they might provide staff support to physicians so there is less leisure-based incentive to perform cesarean sections. In contrast, nongroup-model HMOs do not appear to reduce the incentive of physicians to maximize leisure relative to traditional insurance.
Subject(s)
Cesarean Section/statistics & numerical data , Group Practice, Prepaid/statistics & numerical data , Health Maintenance Organizations/statistics & numerical data , Motivation , Practice Patterns, Physicians'/economics , California/epidemiology , Decision Making , Dystocia/diagnosis , Evidence-Based Medicine , Female , Fetal Distress/diagnosis , Group Practice, Prepaid/organization & administration , Health Maintenance Organizations/organization & administration , Health Services Research , Humans , Leisure Activities , Practice Patterns, Physicians'/statistics & numerical data , Pregnancy , Probability , Time Factors , Time and Motion StudiesSubject(s)
Capitation Fee/statistics & numerical data , Group Practice, Prepaid/statistics & numerical data , Managed Care Programs/statistics & numerical data , Contract Services/statistics & numerical data , Data Collection , Group Practice, Prepaid/economics , Managed Care Programs/economics , Risk Sharing, Financial/statistics & numerical data , United StatesABSTRACT
OBJECTIVE: To examine the implications of serious and chronic health problems on the willingness of enrollees to switch health plans if they are dissatisfied with their current arrangements. DATA SOURCE: A large (20,283 respondents) survey of employees of three national corporations committed to the model of managed competition, with substantial enrollment in four types of health plans: fee-for-service, prepaid group practice, independent practice associations, and point-of-service plans. STUDY DESIGN: A set of logistic regression models are estimated to determine the probability of disenrollment, if dissatisfied, controlling for the influence on satisfaction and disenrollment of age, race, education, family income and size, gender, marital status, mental health status, pregnancy, duration of employment and enrollment in the plan, number of alternative plans, and HMO penetration in the local market. Separate coefficients are estimated for enrollees with and without significant physical health problems. Additional models are estimated to test for the influence of selection effects as well as alternative measures of dissatisfaction and health problems. DATA COLLECTION: Data were collected through a mailed survey with a response rate of 63.5 percent; comparisons to a subsample administered by telephone showed few differences. PRINCIPAL FINDINGS: In group/staff model HMOs and point-of-service plans, only 12-17 percent of the chronically ill enrollees who were so dissatisfied when surveyed that they intended to disenroll actually left their plan in the next open enrollment period. This compared to 25-29 percent of the healthy enrollees in these same plans, who reported this level of dissatisfaction and 58-63 percent of the enrollees under fee-for-service insurance. CONCLUSIONS: Switching plans appears to be significantly limited for enrollees with serious health problems, the very enrollees who will be best informed about the ability of their health plan to provide adequate medical care. These effects are most pronounced in plans that have exclusive contracts with providers. We conclude that disenrollment provides only weak safeguards on quality for the sickest enrollees and that reported levels of dissatisfaction and disenrollment represent inaccurate signals of plan performance.
Subject(s)
Health Benefit Plans, Employee/statistics & numerical data , Health Status , Managed Competition/statistics & numerical data , Patient Satisfaction/statistics & numerical data , Adult , Fee-for-Service Plans/statistics & numerical data , Female , Group Practice, Prepaid/statistics & numerical data , Humans , Independent Practice Associations/statistics & numerical data , Insurance Selection Bias , Logistic Models , Male , Preferred Provider Organizations/statistics & numerical data , Surveys and Questionnaires , United StatesABSTRACT
The current study compares treatment use and long-term survival in colorectal cancer patients between Medicare beneficiaries enrolled in two large prepaid group/staff health maintenance organizations (HMOs) and the fee-for-service (FFS) setting. The study is based on 15,352 colorectal cancer cases diagnosed between 1985 and 1992 and followed through 1995. Survival differences between the HMO and FFS cases were assessed using Cox regression. Treatment differences were evaluated using logistic regression. HMO cases had a lower overall mortality than did FFS cases but not a significantly lower colorectal cancer-specific mortality. Use of surgical resection was similar between HMO and FFS cases. However, rectal cancer cases in the HMOs were more likely to receive postsurgical radiation therapy than FFS cases. Superior overall survival in the HMOs may be the result of increased colorectal cancer screening, greater use of adjuvant therapies, and selection of healthier individuals.