Self-referral in point-of-service health plans

Within-Physician Differences in Patient Sharing Between Primary Care Physicians and Cardiologists Who Treat White and Black Patients With Heart Disease

BACKGROUND

Black-White disparities in heart disease treatment may be attributable to differences in physician referral networks. We mapped physician networks for Medicare patients and examined within-physician Black-White differences in patient sharing between primary care physicians and cardiologists.

METHODS AND RESULTS

Using Medicare fee-for-service files for 2016 to 2017, we identified a cohort of Black and White patients with heart disease and the primary care physicians and cardiologists treating them. To ensure the robustness of within-physician comparisons, we restricted the sample to regional health care markets (ie, hospital referral regions) with at least 10 physicians sharing ≥3 Black and White patients. We used claims to construct 2 race-specific physician network measures: degree (number of cardiologists with whom a primary care physician shares patients) and transitivity (network tightness). Measures were adjusted for Black-White differences in physician panel size and calculated for all settings (hospital and office) and for office settings only. Of 306 US hospital referral regions, 226 and 145 met study criteria for all settings and office setting analyses, respectively. Black patients had more cardiology encounters overall (6.9 versus 6.6; P<0.001) and with unique cardiologists (3.0 versus 2.6; P<0.001), but fewer office encounters (31.7% versus 41.1%; P<0.001). Primary care physicians shared Black patients with more cardiologists than White patients (mean differential degree 23.4 for all settings and 3.6 for office analyses; P<0.001 for both). Black patient-sharing networks were less tightly connected in all but office settings (mean differential transitivity -0.2 for all settings [P<0.001] and near 0 for office analyses [P=0.74]).

CONCLUSIONS

Within-physician Black-White differences in patient sharing exist and may contribute to disparities in cardiac care.

Capturing What Matters with Patients' Bypass Behavior? Evidence from a Cross-Sectional Study in China

BACKGROUND

In China, bypassing is becoming increasingly prevalent. Such behavior, as going directly to upper-level health-care facilities without a primary care provider (PCP) referral when facing non-critical diseases, contrasts to "expanding the role of PCPs as the first-contact of care", may cause unneglectable damage to the healthcare system and people's physical health.

OBJECTIVE

To examine the relationship between patient experience in primary health-care clinics (PHCs) and their bypass behavior.

METHODS

A cross-sectional study was designed for data collection. From July 2021 to August 2021, we conducted a questionnaire survey nationally. Fifty-three investigators were dispatched to 212 pre-chosen PHCs, around which 1060 interviewees were selected to gather information, using a convenience sampling. The primary independent variable was scores measured by Chinese Primary Care Assessment Tool (PCAT-C) to quantify patients' experience at PHCs. The dependent variable was a binary variable measured by a self-developed instrument to identify whether participants actually practiced bypassing. Covariates were well-screened determinants of patients' bypass behavior including socio-demographic factors, policy factors, and health-care suppliers. Binary logistic regression analysis was employed to evaluate the association of patients' experience with their bypass behavior.

FINDINGS

A total of 928 qualified questionnaires were obtained. The first contact dimension (OR 0.961 [95% CI 0.934 to 0.988], P = 0.005) and continuity dimension (OR 1.034 [95% CI 1.000 to 1.068], P = 0.047) of patients' experience were significantly associated with patients' bypass behavior (P < 0.05). In addition, age (OR 1.072, [95% CI 1.015-1.132], P = 0.013) and gender (OR 2.044, [95% CI 1.139-3.670], P = 0.017) also made a statistically significant difference.

CONCLUSION

Enhancement in patient experience at PHCs may help reduce their bypass behavior. Specifically, efforts are needed to improve primary care accessibility and utilization. The positive correlation between bypassing rates and continuity scores may require more attention on strengthening PCPs' technical quality besides the quality of interpersonal interactions.

Healthcare Professionals’ Views of the Integrated County Healthcare Consortium in Zhejiang, China

Introduction:

The integrated county healthcare consortium (ICHC) is becoming an important measure to improve the capacity of primary-level medical services and to achieve grading diagnosis and treatment system in China. However, it is not clear whether health professionals are satisfied with this reform and what are the problems with it. This study aimed to understand the satisfaction of healthcare professionals to the ICHC in Zhejiang Province, China, and analyze the problems and improvement measures of the ICHC.

Methods:

A cross-sectional study was carried out in the 11 pilot counties (cities and districts) implementing the construction of the ICHC in Zhejiang in November 2019. Healthcare professionals from the leading county-level hospital, three township health centers (THCs) or community health centers (CHCs) in each ICHC were invited to participate in this survey.

Results:

A total of 3531 healthcare professionals were included, 85.92% of the participants agreed that the integration of the Centers for Disease Control and Prevention (CDC) and other professional public health institutions into the construction of ICHC could actively promote basic public health work. The most severe problem was the lack of financial guarantee fund input (severity score: 2.92 ± 1.76). The most crucial measure to promote the construction of the ICHC was to increase government financial input and improve the security mechanism (importance score: 4.81 ± 0.47). The satisfaction of the healthcare professionals to the ICHC was 89.41%. The satisfaction of healthcare professionals from county-level hospitals was 2.37 (95% CI: 1.760–3.238) times higher than that of healthcare professionals from the township health centers (THCs) or community health centers (CHCs). The satisfaction of health professionals with a college degree or below was 3.215 (95% CI: 1.413–6.786) times higher than that of health professionals with a master’s degree or above.

Conclusions:

Zhejiang Province has taken adequate measures to promote the construction of the ICHC. However, there are still some problems. Appropriate and effective policies should be implemented to enhance policy coordination and promote competition among ICHCs, as well as to strengthen medical service quality management and improve performance appraisal scheme.

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan

Background

A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system.

Methods

This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass.

Results

The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities.

Conclusions

Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05908-w.

Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study

Excess healthcare utilization is rapidly rising in rural China. This study focused on excess outpatient demand (EOD) and aimed to measure its performance and sociodemographic determinants among China’s rural residents. A total of 1290 residents from four counties in central China were enrolled via multistage cluster random sampling. EOD is the condition in which the level of hospital a patient chooses is higher than the indicated level in the governmental guide. A multilevel logistic regression was used to examine the sociodemographic determinants of EOD. Residents with EOD accounted for 85.83%. The risk of EOD was 51.17% and value was 5.69. The value of EOD in diseases was higher than that in symptoms (t = −21.498, p < 0.001). Age (OR = 0.489), educational level (OR = 1.986) and hospital distance difference (OR = 0.259) were the main sociodemographic determinants of EOD. Excess outpatient demand was evident in rural China, but extreme conditions were rare. Results revealed that age, educational level and hospital distance were the main sociodemographic determinants of EOD. The capacity of primary healthcare institutions, universality of common disease judgement and understanding of institution’s scope of disease curing capabilities of residents should be improved to reduce EOD.

Data-driven modeling of diabetes care teams using social network analysis

OBJECTIVE

We assess working relationships and collaborations within and between diabetes health care provider teams using social network analysis and a multi-scale community detection.

MATERIALS AND METHODS

Retrospective analysis of claims data from a large employer over 2 years was performed. The study cohort contained 827 patients diagnosed with diabetes. The cohort received care from 2567 and 2541 health care providers in the first and second year, respectively. Social network analysis was used to identify networks of health care providers involved in the care of patients with diabetes. A multi-scale community detection was applied to the network to identify groups of health care providers more densely connected. Social network analysis metrics identified influential providers for the overall network and for each community of providers.

RESULTS

Centrality measures identified medical laboratories and mail-order pharmacies as the central providers for the 2 years. Seventy-six percent of the detected communities included primary care physicians, and 97% of the communities included specialists. Pharmacists were detected as central providers in 24% of the communities.

DISCUSSION

Social network analysis measures identified the central providers in the network of diabetes health care providers. These providers could be considered as influencers in the network that could enhance the implication of promotion programs through their access to a large number of patients and providers.

CONCLUSION

The proposed framework provides multi-scale metrics for assessing care team relationships. These metrics can be used by implementation experts to identify influential providers for care interventions and by health service researchers to determine impact of team relationships on patient outcomes.

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria

AIM

To assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease.

METHODS

The cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients' experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied.

RESULTS

More than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care.

CONCLUSION

Visiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.

Left without being seen in a hybrid point of service collection model emergency department

OBJECTIVE

This study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses "point-of-service" (POS) collection for low acuity patients.

METHODS

This was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS.

RESULTS

133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year.

CONCLUSION

In an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care.

Prevalence and determinants of self referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: a cross sectional study

Introduction

Self-referrals to inappropriate levels of care result in an increased patient waiting time, overburdening of higher levels of care, reduced primary healthcare utilisation rate and increasing healthcare costs. Furthermore, self-referral places an additional encumbrance on various levels of care as allocation of resources and infrastructure cannot be accurately planned, based on the facility catchment population. The aim of this study was to determine the prevalence and determinants of patient self-referral at the out-patient department of Stanger Hospital, KwaZulu-Natal between January and June 2017.

Methods

A cross-sectional study was conducted at the out-patient department in Stanger Hospital, using interviewer administered questionnaires to collect information from 385 patients, through convenience sampling, between January and June 2017. Multivariable regression analysis was used to test for factors associated with self-referral.

Results

of the 385 patients interviewed 36% (n = 138) were self-referrals. Most of the self-referrals were male (51.5%) and of the African race (57.2%). Five institutional factors namely: care received from healthcare workers (91.3%); waiting times (88.4%); help offered (87%); treatment and attitude of healthcare workers (63%) and availability of medication (55.8%) were considered as the main drivers of self-referral. Multivariable regression analysis established a significant positive association between patient self-referral and age (40 years and below), attitude of healthcare workers, quality of care received form healthcare workers, waiting times and the availability of diagnostic tests.

Conclusion

This study indicates that most patients attending Stanger Hospital do comply with the prescribed referral pathway, however a significant proportion still bypass the referral system.

Understanding healthcare self-referral in Nigeria from the service users' perspective: a qualitative study of Niger state

BACKGROUND

The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60-90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users' decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users.

METHODS

Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis.

RESULTS

Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen's model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users' expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms.

CONCLUSIONS

The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan

BACKGROUND

To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial.

OBJECTIVE

To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities.

DESIGN AND METHODS

This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates.

KEY RESULTS

Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis.

CONCLUSIONS

We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China

INTRODUCTION

Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior.

METHODS

We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied.

RESULTS

We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior.

DISCUSSION/CONCLUSION

The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.

Is Self-Referral Associated with Higher Quality Care?

OBJECTIVE

To assess the extent to which patients self-refer to cancer specialists and whether self-referral is associated with better experiences and quality of care.

DATA SOURCES

Data from surveys and medical record abstraction collected through the Cancer Care Outcomes Research and Surveillance Consortium.

STUDY DESIGN

Observational study of patients with lung and colorectal cancer diagnosed from 2003 through 2005 in five geographically defined regions and five integrated health care delivery systems.

METHODS

Multivariable logistic regression models used to assess factors associated with self-referral and propensity score-weighted doubly robust models to test the association between self-referral and experiences/quality of care.

PRINCIPAL FINDINGS

Among 5,882 patients, 9.7 percent of lung cancer patients and 14.9 percent of colorectal cancer patients self-referred to at least one cancer specialist. Black patients were less likely to self-refer than white patients (odds ratio: 0.48, 95 percent confidence interval: 0.35, 0.64); patients with high incomes (vs. low) and with a college degree (vs. non-high school graduates) were significantly more likely to self-refer. Self-referral was associated with lower ratings of overall physician communication for patients with lung cancer but, conversely, higher odds of curative surgery among patients with stage I/II lung cancer.

CONCLUSIONS

A small but significant proportion of patients self-referred to their cancer specialists; rates varied by patient race and socioeconomic status. To the extent that self-referral is associated with quality, it may reinforce disparities in care.

Surgical quality is more than volume: the association between changing urologists and complications for patients with localized prostate cancer

OBJECTIVES

To examine the association of changing urologists on surgical complications in men with prostate cancer.

DATA SOURCES/STUDY SETTING

Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005.

STUDY DESIGN

A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy.

METHODS

Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence.

PRINCIPAL FINDINGS

Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment.

CONCLUSIONS

Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.

Dropping the baton: specialty referrals in the United States

CONTEXT

In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.

METHODS

This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.

FINDINGS

PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).

CONCLUSIONS

There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

Routine care provided by specialists to children and adolescents in the United States (2002-2006)

Background

Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings.

Methods

Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected.

Results

Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit.

Conclusion

Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences

Approximately 7 of 10 (and 95% of the elderly) people in US health plans see one or more specialists in a year. Controlling for extent of morbidity, discontinuity of primary care physician visits is associated with seeing more different specialists. Having a general internist as the primary care physician is associated with more different specialists seen. Controlling for differences in the degree of morbidity, receiving care from multiple specialists is associated with higher costs, more procedures, and more medications, independent of the number of visits and age of the patient.

Ambulatory care provided by office-based specialists in the United States

PURPOSE

Increasing use of specialist services in the United States is leading to a perception of a specialist shortage. Little is known, however, about the nature of care provided by this secondary level of services. The aim of this study was to examine the content of care provided by specialists in community settings, including visits for which the patient had been referred by another physician.

METHODS

Nationally representative visit data were obtained from the National Ambulatory Medical Care Survey (NAMCS) for the years 2002 through 2004. To describe the nature of care, we developed a taxonomy of office-based visit types and constructed logistic regression models allowing for adjusted comparisons of specialty types.

RESULTS

Overall, 46.3% of visits were for routine follow-up and preventive care of patients already known to the specialist. Referrals accounted for only 30.4% of all visits. Specialists were more likely to report sharing care with other physicians for referred, compared with not referred, patients (odds ratio [OR] = 2.99; 95% confidence interval [CI], 2.52-3.55). Overall, 73.6% of all visits resulted in a return appointment with the same physician, in more than one-half of all cases as a result of a routine or preventive care visit.

CONCLUSIONS

Ambulatory office-based activity of specialists includes a large share of routine and preventive care for patients already known, not referred, to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Patient experiences with coordination of care: the benefit of continuity and primary care physician as referral source

BACKGROUND

Coordination across a patient's health needs and providers is important to improving the quality of care.

OBJECTIVES

(1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one's PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings.

DESIGN

Cross-sectional study of the 2007 Health Tracking Household Survey.

PARTICIPANTS

A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months.

MEASUREMENTS

Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient's chronic condition work together to manage that care.

RESULTS

Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient's recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001).

CONCLUSIONS

Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.

Differences in referral rates to specialised health care from four primary health care models in Klaipeda, Lithuania

Background

Lithuanian primary health care (PHC) is undergoing changes from the systems prevalent under the Soviet Union, which ensured free access to specialised health care. Currently four different PHC models work in parallel, which offers the opportunity to study their respective effect on referral rates. Our aim was to investigate whether there were differences in referrals rates from different Lithuanian PHC models in Klaipeda after adjustment for co-morbidity.

Methods

The population listed with 18 PHC practices serving inhabitants in Klaipeda city and region (250 070 inhabitants). Four PHC models: rural state-owned family medicine practices, urban privately owned family medicine practices, state-owned polyclinics and privately owned polyclinics. Information on listed patients and referrals during 2005 from each PHC practice in Klaipeda was obtained from the Lithuanian State Sickness Fund database. The database records included information on age, gender, PHC model, referrals and ICD 10 diagnoses. The Johns Hopkins ACG Case-Mix system was used to study co-morbidity. Referral rates from different PHC models were studied using Poisson regression models.

Results

Patients listed with rural state-owned family medicine practices had a significantly lower referral rate to specialised health care than those in the other three PHC models. An increasing co-morbidity level correlated with a higher physician- to self-referral ratio.

Conclusion

Family medicine practices located in rural-, but not in urban areas had significantly lower referral rates to specialised health care. It could not be established whether this was due to organisation, training of physicians or financing, but suggests there is room for improving primary health care in urban areas. Patient's place of residence and co morbidity level were the most important factors for referral rate. We also found that gatekeeping had an effect on the referral pattern with respect to co-morbidity level, so that those with a physician referral were more likely to have had higher co-morbidity.

The appropriateness of gatekeeping in the provision of reproductive health care for adolescents in Lithuania:the general practice perspective

Background

Adolescents' consultation of primary health care services remains problematic despite their accessibility. The reproductive health service seeking behavior of adolescents is the object of much research but little is known about how this behavior is influenced by the gatekeeping system. This study aimed to explore general practitioners' perceptions of the appropriateness of gatekeeping in adolescent reproductive health care.

Methods

Twenty in-depth interviews regarding factors affecting adolescent reproductive health care were carried out on a diverse sample of general practitioners and analyzed using grounded theory.

Results

The analysis identified several factors that shaped GPs' negative attitude to gatekeeping in adolescent reproductive health care. Its appropriateness in this field was questionable due to a lack of willingness on the part of GPs to provide reproductive health services for teenagers, their insufficient training, inadequately equipped surgeries and low perceived support for reproductive health service provision.

Conclusion

Since factors for improving adolescent reproductive health concern not only physicians but also the health system and policy levels, complex measures should be designed to overcome these barriers. Discussion of a flexible model of gatekeeping, encompassing both co-ordination of care provided by GPs and the possibility of patients' self-referral, should be included in the political agenda. Adolescents tend to under-use rather than over-use reproductive health services and every effort should be made to facilitate the accessibility of such services.

Do specialist self-referral insurance policies improve access to HIV-experienced physicians as a regular source of care?

Health insurance policies that require prior authorization for specialty care may be detrimental to persons with HIV, according to evidence that having a regular physician with HIV expertise leads to improved patient outcomes. The objective of this study is to determine whether HIV patients who can self-refer to specialists are more likely to have physicians who mainly treat HIV. The authors analyze cross-sectional survey data from the HIV Costs and Services Utilization Study. At baseline, 67 percent of patients had insurance that permitted self-referral. In multivariate analyses, being able to self-refer was associated with an 8-12 percent increased likelihood of having a physician at a regular source of care that mainly treats patients with HIV. Patients who can self-refer are more likely to have HIV-experienced physicians than are patients who need prior authorization. Insurance policies allowing self-referral to specialists may result in HIV patients seeing physicians with clinical expertise relevant to HIV care.

Referrals from general practice to consultants in Germany: if the GP is the initiator, patients' experiences are more positive

Background

Referrals of patients from primary care to medical specialist care are an important activity in any health care system. German data show that the number of referrals by GPs have increased since 2004, but detailed insight into the experiences of patients, GPs and consultants regarding referrals is very limited. This study aimed at describing the experiences of consultants, GPs and patients with referrals from primary care to medical specialist care. An additional objective was to examine the impact of purpose regarding the referral and of the referrer on the experiences of GPs and patients.

Methods

Referrals of 26 general practitioners (GPs) from 25 practices in Marbach, a rural region in the south of Germany were studied. All adult patients referred after consulting these GPs in a period of five weeks were eligable for the study. GPs, consultants and patients completed short structured forms to document factual characteristics of each referral and their experiences with the referral. GPs and patients completed forms before and after the referral was made, while the consultants completed forms after the patient had consulted them.

Results

Overall, consultants were very positive about appropriateness of the referral (91%). They were somewhat more critical regarding the information provided on the patients' medical history (61%) and prescriptions (48%).

In 258 referrals (63%) GPs perceived clear diagnostic benefits, while in 202 referrals (49%) they perceived clear treatment benefits. GPs' experiences were more positive if the GP's purpose was to reduce diagnostic uncertainty (beta = 0.318, p < 0.001) or if the purpose was to exclude serious illness (beta = 0.143, p < 0.010). Other purposes of the referral had no impact on their experiences.

Patients' expectations regarding the referrals mostly referred to diagnosis, including increased diagnostic certainty (80%), detailed information about the illness (66%) and exclusion of serious illness (62%). They were overall satisfied with the referral (83%). Their experiences with the referral were more positive if the initiative for the referral came from the physician (beta = 0.365, p < 0.000).

Conclusion

Patients, GPs and consultants have positive views on the value of referrals from primary care to medical specialists. Patients were most positive if the physician had initiated the referral, which supports the gate keeper role of the GP.

Patient satisfaction under managed care

PURPOSE

In the USA, health maintenance organizations (HMOs) have pledged to control health care costs. Many patients have complained about the quality of care under the HMO regime and limits imposed on them, particularly access to care. Has quality of care been degraded under the HMO regime, resulting in an impact on patient satisfaction? There have been many studies that have compared the satisfaction of HMO patients with that of patients in the traditional fee-for-service payment system. The aim of this paper is to review HMO patient satisfaction.

DESIGN/METHODOLOGY/APPROACH

A review of patient satisfaction under managed care arrangements with a focus on HMOs. The article describes the US history of managed care and its effect on the satisfaction of several patient categories including the general population, vulnerable patients and the elderly.

FINDINGS

There is much information available on patient satisfaction with their insurers and most surveys indicate the lack of choice of a provider--a major source of discontent. Therefore, patient protection laws are necessary to avoid abuse.

ORIGINALITY/VALUE

Patients have little ability or are not willing to rely on the information available when selecting a provider. The paper discusses patient awareness regarding satisfaction surveys and how the latter can be used when patients are seeking care.

Trust in insurers and access to physicians: associated enrollee behaviors and changes over time

OBJECTIVE

Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers, and have been cross-sectional rather than longitudinal studies. This study examined associations among trust in a managed care insurer, trust in one's primary physician, and subsequent enrollee behaviors relating to source of care. The study also documents changes in trust in the study population following the disclosure of physician incentives.

STUDY SETTING

A medium-sized (300,000 member) HMO, located in the southeastern United States.

DATA COLLECTION

One to two years after baseline, we randomly resurveyed a quarter (n = 558) of the initial study population of a large intervention study designed to measure the impact of disclosing HMO financial incentives on patient trust. This follow-up study was also designed to measure the effects of trust on source of care.

ANALYSES

Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral, as well as changes in trust since baseline.

RESULTS

High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician (OR = 0.55, 95 percent CI: 0.33, 0.91). No long-term effects of prior disclosure of financial incentives were observed. Overall, there was a slight increase in overall trust in the insurer (1.8 percent, p < .05) but no change in trust in one's primary physician. The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey (6.6 percent, p < .01). In multivariate analyses, changing physicians was the most significant predictor of increased insurer trust (OR = 2.17, 95 percent CI: 1.37, 3.43). CONCLUSIONS. Trust in one's insurer seems to change over time more than trust in one's primary physician, and is predictive of enrollee behaviors such as seeking care from other physicians. The ability to change physicians seems to increase trust in the insurer.

Are gatekeeper requirements associated with cancer screening utilization?

OBJECTIVE

There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer.

DATA SOURCES

Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey.

STUDY DESIGN/DATA COLLECTION

Cross-sectional, multivariate logistic regression analysis using secondary data.

PRINCIPAL FINDINGS

We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS).

CONCLUSIONS

Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.

Predicting Resource Utilization in a Veterans Health Administration Primary Care Population

BACKGROUND

Valid methods of predicting resource utilization in primary care populations are needed. We compared the predictive validity of a method based on diagnoses from administrative data (Adjusted Clinical Groups [ACGs]) and a method using medication profiles (Chronic Disease Index [CDI]).

METHODS

This retrospective cohort study included 31,212 primary care patients in a Veterans Health Administration (VA) network who received outpatient medication prescriptions in 1999 and who had VA utilization in 1999 and 2000. ACG and CDI classifications were determined using 1999 data. Analyses compared the predictive validity with respect to outpatient clinic visits and days of hospital care.

RESULTS

Both ACGs and CDI explained a higher proportion of the variance in outpatient visits than demographic data alone. However, explained variance was higher for ACGs. For example, ACGs explained 30.2% of the variance in total visits in 1999, compared with 8.8% for the CDI. Results were similar for 2000, although the explained variance declined for both methods (eg, 16.3% and 5.7%, respectively, for total visits). Results were similar in analyses examining the discrimination of the 2 methods to predict hospital use; for example, c statistics for ACGs and CDI scores were 0.86 versus 0.70, respectively (P <0.05), for 1999 and 0.72 and 0.65, respectively (P <0.05), for 2000.

CONCLUSION

Among VA patients, ACGs had superior predictive validity than the CDI, a newer nonproprietary method based on pharmacy data. The findings suggest that diagnosis-based measures could be preferable for ambulatory case-mix adjustment and are valid across a wide range of populations.

On being new to an insurance plan: health care use associated with the first years in a health insurance plan

BACKGROUND

We wanted to compare health care utilization and costs in the first year of being in a health insurance plan with those of subsequent years.

METHODS

We used claims data from an independent practitioner association (IPA)-style managed care organization in the Rochester, NY, metropolitan area from 1996 through 1999. Cross-sectional and panel analyses of up to 4 years of claims data were conducted, involving 335,547 adult patients assigned to the panels of 687 primary care physicians (internists and family physicians). Multivariate analyses, adjusting for age, sex, case mix, and socioeconomic status derived from ZIP codes, examined the relationship between the first year of health insurance and Papanicolaou tests, mammograms in women older than 40 years, physician use, avoidable hospitalization, and expenditures.

RESULTS

After multivariate adjustment, the first year of insurance was associated with a higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician, and higher expenditures, especially for testing. There was no relationship, however, between Papanicolaou test compliance and year of enrollment.

CONCLUSIONS

The findings suggest there might be adverse clinical and financial implications associated with changing insurance.

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES

Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician.

RESEARCH DESIGN

We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral.

RESULTS

Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network.

CONCLUSIONS

Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.

Comorbidity: implications for the importance of primary care in 'case' management

BACKGROUND

Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions.

METHODS

Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions.

RESULTS

Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions.

CONCLUSIONS

In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

Insurance product design and its effects: trade-offs along the managed care continuum

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.

Integrated delivery networks: a detour on the road to integrated health care?

This paper reviews the rationales and evidence for horizontal and vertical integration involving hospitals. We find a disjunction between the integration rationales espoused by providers and those cited in the academic literature. We also generally find that integration fails to improve hospitals' economic performance. We offer seven lessons from hospitals' efforts to integrate and then suggest four alternative models for achieving integrated delivery of health care services.