Optimal clinical management of eye problems: the role of optometrists in managed care plans.

BACKGROUND: Recent developments in the education and licensure of optometrists have created new opportunities for more-efficient provision of eye care. This study was conducted to determine the extent to which optometrists provided various kinds of eye care independently in managed care organizations. We compared optometric practices in health plans located in states in which the legal authority of optometrists was limited, to optometric practices in plans situated in states in which optometric licensure permitted broader prescribing authority. The volume and nature of referrals to ophthalmologists were assessed in relation to state law and organizational protocols. METHODS: A 15-item patient encounter form was developed and completed for all patients examined by the optometrists at each site during a 4-week period in 1998. Specific conditions were selected and criteria developed to help determine whether referrals to ophthalmologists were appropriate, or if they could have been managed by the optometrist These referrals were assessed by an independent panel of four optometrists. RESULTS: This study documented that optometrists provide a substantial range of eye care, and their individual scope of practice is influenced not only by legal boundaries, but also by financial and organizational factors found within managed care organizations. The pattern of referrals to ophthalmologists helped indicate the extent to which optometrists were underutilized or used appropriately in various settings. CONCLUSIONS: There is no single reliable predictor of whether optometrists will be used at the highest level of their abilities and scope of license. Although state licensure sets the overall parameters for care, optometric practice in managed care plans may be modified by internal protocols and organizational factors.

Germline BRCA1 alterations in a population-based series of ovarian cancer cases.

The objective of this study was to provide more accurate frequency estimates of breast cancer susceptibility gene 1 ( BRCA1 ) germline alterations in the ovarian cancer population. To achieve this, we determined the prevalence of BRCA1 alterations in a population-based series of consecutive ovarian cancer cases. This is the first population-based ovarian cancer study reporting BRCA1 alterations derived from a comprehensive screen of the entire coding region. One hundred and seven ovarian cancer cases were analyzed for BRCA1 alterations using the RNase mismatch cleavage assay followed by direct sequencing. Two truncating mutations, 962del4 and 3600del11, were identified. Both patients had a family history of breast or ovarian cancer. Several novel as well as previously reported uncharacterized variants were also identified, some of which were associated with a family history of cancer. The frequency distribution of common polymorphisms was determined in the 91 Caucasian cancer cases in this series and 24 sister controls using allele-specific amplification. The rare form of the Q356R polymorphism was significantly ( P = 0.03) associated with a family history of ovarian cancer, suggesting that this polymorphism may influence ovarian cancer risk. In summary, our data suggest a role for some uncharacterized variants and rare forms of polymorphisms in determining ovarian cancer risk, and highlight the necessity to screen for missense alterations as well as truncating mutations in this population.

Optometry as practiced in health plans within different state jurisdictions.

This study was conducted to determine how managed care plans use optometrists to provide vision and eye care. The study documents the variety of optometric practice patterns found within six health plans in several states, each having different organizational characteristics, professional staffing patterns, and payment arrangements, and each regulated by dissimilar state licensure laws. A 15-item patient encounter form was developed and completed for all patients examined by the optometrists at each site during a four-week period. The instrument included information on patient demographics, medical/ocular history, reason for the visit, procedures performed, diagnosis, therapy provided, ocular medications prescribed, prognosis, disposition, referrals, and duration of the visit. A variety of patterns were found, some of which did not necessarily closely follow the legal boundaries of optometric care. This study documented that optometrists provide a substantial volume and range of vision care, and their scope of practice is influenced by legal, financial, and organizational factors. In some plans, optometrists' skills were underutilized relative to their legal authority in certain situations; in others, creative, cooperative arrangements extended the benefits of optometry beyond the existent practice laws. Licensure is certainly a major influence on the scope of practice of health providers. This study revealed, however, that licensure alone does not appear to be the only determinant of use, delegation, and division of labor among health professionals, and that organizational factors seem to play a very significant role.

Current trends in the integration and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers.

OBJECTIVES: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services offered by hospitals. METHODS: A literature review and information search was conducted to determine which insurers had special policies for CAM and which hospitals were offering CAM. Telephone interviews were conducted with a definitive sample of 18 insurers and a representative subsample of seven hospitals. RESULTS: A majority of the insurers interviewed offered some coverage for the following: nutrition counseling, biofeedback, psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. Twelve insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness based on consumer interest, demonstrable clinical efficacy, and state mandates. Some hospitals are also responding to consumer interest in CAM, although hospitals can only offer CAM therapies for which local, licensed practitioners are available. Among the most common obstacles listed to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition and division, and lack of standards of practice. CONCLUSIONS: Consumer demand for CAM is motivating more insurers and hospitals to assess the benefits of incorporating CAM. Outcomes studies for both allopathic and CAM therapies are needed to help create a health care system based upon treatments that work, whether they are mainstream, complementary, or alternative.

In search of America's best hospitals. The promise and reality of quality assessment.

"America's Best Hospitals," by US News & World Report, is a sophisticated and influential appraisal of hospital care. Using measures of health care structure, process, and outcome, the report identifies outstanding hospitals in 16 medical specialties through an overall "index of hospital quality." This strong conceptual design, however, has not been adequately implemented because national data sources for all 3 components are severely limited. Most importantly, since there are no national data on process of care, a reputation survey has been used to measure this component of quality. One consequence of reliance on reputation is that a small group of prominent hospitals in each specialty receives such high scores that they automatically rise to the top of the rankings, regardless of structure or outcome score. "America's Best Hospitals" identifies America's best regarded hospitals, but provides limited additional insight into quality. Adequate surveillance and protection of quality in an era of managed care requires measurement systems beyond the scope of existing data and methods.

Caring for neighbors: an examination of nonresident use of New York City hospitals.

In 1989, almost 10 percent of all patients--or nearly 100,000 patients--hospitalized at facilities located in New York City were not city residents. Nonresidents are attracted to the city by the prestige and expertise of the city's hospitals; they are more likely than residents to require the hospitals' most sophisticated and specialized services, ranging from transplantation and coronary bypass surgery to treatment of malignant conditions. The largest numbers of nonresident patients, however, receive care for conditions that are relatively routine, care which would seem to be generally available at suburban hospitals. Although New York City hospitals continued to serve a substantial number of patients residing outside the city, the flow of nonresident patients seems to be slowly diminishing, particularly at the city's academic medical centers. (The specialty hospitals, on the other hand, seem to be attracting an increasing share of nonresident patients.) This decline occurred despite the one-third increase in population since 1960 in the New York State counties surrounding the city. To complicate matters, many New Yorkers are leaving the city for care. Almost 40,000 New York City residents were admitted to hospitals elsewhere in New York State, and perhaps another 20,000 to 40,000 may be receiving hospital care in other states. These trends have obvious implications for the city's hospital in their dual role as leaders in advanced and sophisticated medical care and as providers of vital patient care services to the city's population. The most highly specialized services can maintain clinical expertise and remain financially viable only if a sufficient number of patients can be attracted from throughout the metropolitan area and beyond. Likewise, the city's hospitals can be confident of fulfilling basic patient care needs only as long as New Yorkers do not look elsewhere for care. With the myriad pressures on our hospitals, the challenge of keeping them inviting and responsive will be formidable, but the construction of modern facilities, emphasis on patient-centered care, cultivation of strong relationships with communities and practitioners, and careful monitoring of patient flows and patient satisfaction should help the city's hospitals continue to attract patients, both from within the city and beyond the city limits.

Sentinel health events as indicators of unmet needs.

It is vitally important to be able to assess the impact of the health care system on the populations it serves. This paper explores whether sentinel health events--negative health states, such as death, disability, and disease, that might have been avoided given current medical and public health knowledge and technology--can be used as sociomedical indicators to assess levels of unmet needs and to evaluate health system performance. Using hospital discharge data, the occurrence of sentinel health events in New York State and differences among population subgroups are examined. Among hospitalized residents of New York State in 1983, more than 17,000 deaths occurred that were possibly avoidable. More than 336,000 instances of disease were found that were potentially preventable. Significantly higher rates and ratios for many sentinel events were found among blacks, Medicaid recipients, and users of public hospitals than were found for comparison groups. The sentinel events approach proved to be useful and practical. However, refinements and adaptations of the sentinel events method are needed, including the development of one or more smaller sets of indicators--tracer sentinel events--that can be used to profile aspects of health status and the health system.

Measuring avoidable deaths and diseases in New York State.

The measurement of sentinel health events--avoidable deaths and diseases--is a practical and valuable method for assessing the state of the community's health and the performance of the health system in meeting the needs of the population. A comprehensive framework for identification of sentinel health events has been defined by the Working Group on Preventable and Manageable Diseases. The Working Group developed lists that include more than 120 medical conditions for which death or disease is deemed to be potentially avoidable through primary prevention activities or timely and appropriate treatment. Hospital discharge abstract data offer a unique perspective for examining these potentially avoidable negative health outcomes. Such data, available in New York State through the Statewide Planning and Research Cooperative System (SPARCS), are a source of detailed and accessible information on a wide range of morbidity-producing conditions and associated deaths. Among the findings of this sentinel health events study, based on an analysis of SPARCS data, are the following: Among hospitalized residents of New York State in 1983, more than 19,000 deaths occurred that were potentially avoidable. More than one-third of these deaths occurred among persons under age 65. More than 336,000 instances of disease were found that were potentially preventable, amounting to 123 disease occurrences per 1,000 discharges. In the category of sentinel events where each event may be avoidable, only three conditions alone were associated with 75 percent of the deaths and 60 percent of the disease occurrences--malignant neoplasm of the trachea, bronchus, and lung; emphysema or chronic obstructive lung disease(s); and malignant neoplasm of the bladder. In the category of events where some proportion of events may be avoidable, one diagnosis--vascular complications associated with hypertensive disease(s)--was linked with 45 percent of the deaths. Significantly higher rates and ratios for many sentinel events were found among blacks, Medicaid recipients, and users of public hospitals than were found for comparison groups. For example, among patients hospitalized for colon and related neoplasms, black patients were more than twice as likely to die than white patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of hospital-based ambulatory care in New York City's Health Manpower Shortage Areas.

The development of a comprehensive data base for hospital-based ambulatory care has made possible the accurate determination of each community's use of hospitals in New York City and permits a reliable estimation of all ambulatory care received by residents of Health Manpower Shortage Areas (HMSAs). In spite of the city's abundant supply of private practitioners and widespread Medicaid coverage, residents of HMSAs in New York City are heavily dependent on hospital-based ambulatory care. Contrary to commonly held notions, however, HMSA residents do not appear to overuse hospital-based ambulatory care. Rather, that use appears to be quite modest, given their poorer health status.

New York's role as a center for health care: an analysis of nonresident patients served by New York City hospitals.

Patients who reside outside of New York City have long been an important segment of the patient population at New York City hospitals. Each year, as far back as systematic data are available, approximately 10 percent of all patients at New York City hospitals have been non residents. Increasing competition and changing reimbursement policies compel hospitals in New York City to assess their role in caring for these patients and its economic implications. This report provides a comprehensive assessment of the characteristics of nonresident patients and their significance to the city's hospitals. Using data from all New York City hospitals, the report analyzes the demographics, insurance coverage, and case-mix characteristics of nonresident and resident patients. And, using more detailed data from New York University Medical Center and Columbia-Presbyterian Medical Center, it addresses the financial and reimbursement policy questions posed by the care of nonresident patients. The key findings of the report are as follows: A total of 115,307 nonresidents were hospitalized in New York City in 1982; this figure represents 10.4 percent of all patients in city hospitals. Over 80 percent of nonresident patients come from 14 counties surrounding New York City. Nonresident patients are a crucial component of the patient population at six hospitals that are the principal affiliates of a medical school and the six specialty hospitals. At academic health centers, nonresidents represent 25 percent of all inpatients; at the specialty hospitals, they represent 36 percent. Manhattan hospitals account for 69 percent of all nonresident discharges in the city. Outside of Manhattan, only Montefiore Medical Center and Long Island Jewish Medical Center have substantial numbers of nonresident patients. Among nonresident patients, 75 percent of admissions are scheduled in advance and 72 percent of hospital stays are for surgical procedures. In contrast, among resident patients, only 50 percent of admissions ares scheduled and 52 percent are for surgical procedures. Almost two-thirds of nonresident patients are covered by private insurance, compared to one-third of residents. Nonresident patients require more hospital resources on average than residents do. The average Diagnosis Related Group (DRG) weight, a measure of expected resource intensity, is 22.5 percent higher for nonresidents than for residents. However, nonresidents also come to New York City hospitals for relatively routine care. For example, the most common diagnoses among nonresidents and residents are uncomplicated deliveries and abortions. At New York University Medical Center and Columbia-Presbyterian Medical Center, nonresidents have higher average charges than residents, but the charge differences are much smaller than the DRG weight differences. Thus, within a given DRG, nonresidents consume fewer resources than residents. Under Medicare's Prospective Payment System bases on DRGs, nonresidents appear to be financially attractive to New York hospitals, based on the experience of New York University Medical Center.

The financial condition of New York City voluntary hospitals: the first year of NYPHRM (New York Prospective Hospital Reimbursement Methodology).

HIGHLIGHTS OF THE STUDY. In 1983, for the first time since 1977, the average voluntary hospital in New York City did not incur a deficit. Nevertheless, voluntary hospitals in New York City continued to have a lower return on their assets than voluntary hospitals in the rest of the state, in the Mid-Atlantic region, and in the nation. New York City voluntary hospitals would need 85 percent of their total assets to repay their debt, while the comparison groups would use less than 60 percent. The annual rate of growth in hospital expenses among New York City voluntary hospitals declined from almost 12 percent between 1981 and 1982 to less than 9.5 percent between 1982 and 1983, which also was almost a full percentage point below the national rate of increase. Between 1982 and 1983, the value of uncompensated care provided by New York City voluntary hospitals increased from 3.4 percent to 3.7 percent of total operating expenses. Fourteen of the 49 New York City voluntary hospitals studied were financially stressed in 1983, compared to 18 in 1982. Without the additional revenues received from the NYPHRM pools, 10 more New York City voluntary hospitals would have had bottom-line deficits. More details on the financial condition of New York City voluntary hospitals in 1983, and first year of NYPHRM, follow. Definitions, data sources, and methods are described in an appendix to the report, which also includes a glossary of financial terms.