Do employees use report cards to assess health care provider systems?

OBJECTIVE

To investigate consumers' use of report cards that provide information on service quality and satisfaction at the provider group level.

DATA SOURCES

In 1998 we conducted a telephone survey of randomly selected employees in firms aligned with the Buyers Health Care Action Group (BHCAG) in the Minneapolis-St. Paul market.

STUDY DESIGN

Univariate probit models were used to determine report card utilization, perceived helpfulness of the report card, and ease of selecting a provider group. The characteristics used in the models included health status, age, gender, education, residency, job tenure, marital status, presence of dependent children, household income, and whether consumers changed provider groups.

DATA COLLECTION

Our sample consists of survey responses from 996 single individuals (a response rate of 91 percent) and 913 families (a response rate of 96 percent). The survey was supplemented with data obtained directly from employers aligned with BHCAG.

PRINCIPLE FINDINGS

Consumers who changed to a new provider group are more likely to use report card information and find it helpful, consumers employed in large firms are less likely to use the report card, and families who use information from their own health care experiences are less likely to find the report card helpful. In addition, individuals who changed to a new provider group are more likely to find the selection decision difficult.

CONCLUSION

The findings show that health care consumers are using satisfaction and service-quality information provided by their employers.

Do consumers use information to choose a health-care provider system?

This study examines the use of information by employees in the Buyers Health Care Action Group, a purchasing coalition of large employers in Minneapolis. BHCAG employers contract directly with multiple health-care provider systems and attempt to inform employees about those choices. Shortly after the close of the 1998 open-enrollment period, a survey of 927 BHCAG employees with single-coverage health insurance was conducted. Seventy-six percent of the employees relied on information from their employer when selecting their current care system. Use of information from the employer was positively related to education and years of residence in the Twin Cities. Previous experience with doctors and hospitals in the care system also was a common information source. Older and low-income workers were more likely to use information from advertisements. The survey results suggest that employers can predict which information sources their employees will use.

Early experience with a new model of employer group purchasing in Minnesota

The Buyers Health Care Action Group (BHCAG) in the Twin Cities has implemented a new purchasing initiative that offers employees a choice among care systems with nonoverlapping networks of primary care providers. These systems offer a standardized benefit package, submit annual bids, and are paid on a risk-adjusted basis. Employees are provided with information on quality and other differences among systems, and most have financial incentives to choose lower-cost systems. Generally, providers have responded favorably to direct contracting and to risk-adjusted payments but have concerns about the risk-adjustment mechanism used and, more importantly, the strength of employers' commitment to the purchasing model.

Performance failure of an evidence-based upper respiratory infection clinical guideline

BACKGROUND

We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization.

METHODS

Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation.

RESULTS

A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05).

CONCLUSIONS

Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.

Rural radiology: who is producing images and who is reading them?

The purpose of this study is to identify the local availability and trends in local availability of imaging technology and interpretation services in rural hospitals in the northwestern United States during the period between 1991 to 1994. Another objective is to describe hospital and community factors associated with the diffusion of image production and interpretation services. The information for this study was gathered through telephone surveys of rural hospital administrators in eight northwestern states in 1991 and 1994. The availability of magnetic resonance imaging (MRI) equipment, computed tomography (CT) scanners, ultrasonography equipment, and dedicated mammography equipment increased between 1991 and 1994. The increases in MRI units were primarily in mobile equipment, while ultrasonography and mammography equipment increases were primarily fixed hospital-based units. In 1994, image interpretation in the rural hospitals was provided by both primary care and radiology physicians. Forty-six (11.5%) of the rural hospitals had no on-site radiology services and only 73 (18%) had daily radiology services. Between 1991 and 1994, 12 hospitals gained at least once-a-week radiology services, but 24 lost all radiology services. Teleradiology availability more than doubled during the three years. Radiology technology has diffused widely into rural communities in this region of the United States at differing rates for large and small hospitals. Radiologists are available to these hospitals only 46 percent of the days each year, with more days of availability in the larger hospitals and fewer days in the smaller hospitals. Teleradiology capability is increasing more rapidly in the larger hospitals that have radiologists more readily available.

The financial impact on community mental health centers of capitated contracts with Medicaid: the Utah Prepaid Mental Health Plan

Under the Utah Prepaid Mental Health Plan, three of the eleven Community Mental Health Centers in Utah signed capitation contracts with the state Medicaid program. The capitated Centers initially accepted the risk for inpatient care, with the risk later being extended to also include outpatient services. This study contrasts the financial experiences of the capitated Centers and five noncontracting Centers. While various patterns of financial management are evident in the data, it appears that the decision to contract had, at worst, a neutral effect on overall financial performance. Managed care programs with different designs may have different results.

Potential effects of managed care organizations in rural communities: a framework

This article has provided a conceptual framework regarding the implications of a growing MCO presence in rural areas. This framework addresses factors likely to influence the degree of MCO presence in any given rural community, as well as the possible effects of that presence on rural consumers, employers, providers, and the uninsured. These factors vary across communities and will result in variation in the nature and importance of MCOs among rural communities. The arguments and considerations presented are based on analysis of MCO, employer, and consumer behavior, informed by research findings relating to MCOs in urban areas. The issues discussed raise a number of questions that deserve to be addressed through empirical research focused specifically on rural populations. The appendix contains a summary list of these questions. The next article reviews the results of existing research studies as they bear on these research questions and other issues raised in this article.

Changes in the process of care for Medicaid patients with schizophrenia in Utah's Prepaid Mental Health Plan

OBJECTIVE

Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan.

METHODS

Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site.

RESULTS

By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs.

CONCLUSIONS

Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

Understanding integrated rural health networks

In an era of constraints on public and private sector health care budgets, organizational restructuring of hospital and physician practice, and the shifting of financial risk to patients and providers, rural health professionals and communities are grappling with the issue of how to assure access to a comprehensive and affordable set of health care services. In recent years, rural health providers have turned to the strategy of developing voluntary network relations as an alternative to system or diversification strategies that entail ownership and management by one entity. A systematic analysis of the cooperative efforts of selected providers results in a proposed definition of integrated rural health networks and highlights critical aspects of their formation and development.

Expenditures for mental health services in the Utah Prepaid Mental Health Plan

This article examines the effect of a mental health carve-out, the Utah Prepaid Mental Health Plan (UPMHP), on expenditures for mental health treatment and utilization of mental health services for Medicaid beneficiaries from July 1991 through December 1994. Three Community Mental Health Centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. The analysis uses data from Medicaid claims as well as "shadow claims" for UPMHP contracting sites. The analysis is a pre/post comparison of expenditures and utilization rates, with a contemporaneous control group in the Utah catchment areas not in the UPMHP. The results indicate that the UPMHP reduced acute inpatient mental health expenditures and admissions for Medicaid beneficiaries during the first 2 1/2 years of the UPMHP. In contrast, the UPMHP had no statistically significant effect on outpatient mental health expenditures or visits. There was no significant effect of the UPMHP on overall mental health expenditures.

Mechanism of action and impact of a cystitis clinical practice guideline on outcomes and costs of care in an HMO

BACKGROUND

A study was conducted in 1995 at five primary care clinics of a staff-model health maintenance organization in the Midwest to assess the impact of a cystitis clinical guideline and to help elucidate the guideline implementation process.

METHODOLOGY

Two hundred one eligible women with uncomplicated cystitis were treated in a three-month period before the guideline, and 241 similar cases were treated in a three-month period after the guideline. Nursing supervisors and clinic managers at each clinic were interviewed about how the cystitis guideline was implemented at each clinic.

RESULTS

Use of a recommended three-day antibiotic treatment increased from 28% to 52% of cases (chi-square = 25.01, p < 0.001). Use of urine cultures decreased from 70% to 37% of cases (chi-square = 48.19, p < 0.001). The proportion of eligible cystitis cases coordinated primarily by the nurse increased from 21% to 78% (chi-square = 142.93, p < 0.001). However, desired changes in use of antibiotics and urine cultures were limited to nurse-coordinated cases. There was no increase in hospital admissions, emergency room visits, repeat office visits (p > 0.05), or repeat antibiotic courses (p > 0.05) after cystitis guideline implementation. Cost of cystitis care delivered after guideline implementation was 35% lower than before guideline implementation.

CONCLUSIONS

Use of the guideline was associated with desirable changes in antibiotic use, nurse coordination of care, costs of care, and comparable clinical outcomes. Clinics that used clinical systems and tools to support nurse-coordinated cystitis care had greater guideline adherence than clinics that did not support nurse-coordinated care.

Mobile technology in rural hospitals: the case of the CT scanner

OBJECTIVE

This study evaluates the relationship between hospital and regional characteristics and the prevalence of mobile computed tomography in rural hospitals.

DATA SOURCES AND STUDY SETTING

Primary data were gathered from all rural hospitals in eight northwestern states (n = 471) in 1991. Secondary data sources include the AHA Annual Survey, the Area Resource File, and HCFA's PPS data sets for 1987-1990.

STUDY DESIGN

Primary data are a single observation taken in the summer of 1991. Key hospital characteristics include patient volume, distance to the nearest referral center, distance to the nearest hospital, financial performance, and medical staff size. Key regional variables include beds per unit area, hospitals per unit area, and physician supply.

DATA COLLECTION

A structured telephone interview was conducted with the hospital administrator at each hospital. For many hospitals, detailed information was gathered with additional calls to hospital personnel.

PRINCIPAL FINDINGS

Where hospitals are closely spaced, mobile CT suppliers are more readily available, and hospitals are more likely to choose mobile CT than in areas where hospitals are farther apart. Hospitals may realize economies of scale and scope in their decisions about CT adoption.

CONCLUSIONS

Transportation costs are an important determinant of hospital decisions about acquiring CT, but may be less important for higher-priced medical technologies. There is no support for the proposition that rural hospitals compete with referral centers for patients by purchasing technological equipment.

Effect of mergers on health maintenance organization premiums

This study estimated the effect of mergers on health maintenance organization (HMO) premiums, using data on all operational non-Medicaid HMOs in the United States from 1985 to 1993. Two critical issues were examined: whether HMO mergers increase or decrease premiums; and whether the effects of mergers differ according to the degree of competition among HMOs in local markets. The only significant merger effect was found in the most competitive markets, where premiums increased, but only for 1 year after the merger. Our research does not support the argument that consolidation of HMOs in local markets will benefit consumers through lower premiums.

A descriptive economic analysis of HMO mergers and failures, 1985-1992

This study examines all 81 health maintenance organization (HMO) mergers that occurred in the United States from 1985 to 1992. The primary emphasis is on describing organizational factors that are associated with mergers, identifying market environments in which mergers are more likely to occur, and analyzing the financial status of merging HMOs. Overall, the study presents an up-to-date portrait of mergers in this important health care industry. We found that HMO mergers are relatively rare, but, over time, a substantial proportion of HMOs and their enrollees are affected by mergers. Ouranalys is suggests that some financially weak HMOs might have failed if they had not merged into stronger plans. This finding gives qualified support to the failing-company antitrust defense for HMO mergers. However, mergers between large, financially sound HMOs may have anticompetitive effects on consumers of HMO services.

Managed care in the Twin Cities: what can we learn?

Minneapolis/St. Paul, because of its history of health maintenance organization development and active employer participation in the health care arena, is often cited as a community in which managed competition has been tested to some degree. This paper reviews the historical development of the Twin Cities health care market and summarizes findings from past studies of this market. It also describes the recent consolidation of providers in the Twin Cities, as well as the activities of large purchasing coalitions. Finally, it assesses the elements of the Twin Cities experience that seem most relevant to managed competition-based health care reform proposals.

Rural hospital networks: implications for rural health reform

This article summarizes the perspectives gained in the course of evaluating a 4-year demonstration program that supported rural hospital networks as mechanisms for improving rural health care delivery. Findings include: (1) joining a network is a popular, low-cost strategic response for rural hospitals in an uncertain environment; (2) rural hospital network survival is enhanced by the mutual resource dependence of members and the presence of a formalized management structure; (3) rural hospitals join networks primarily to improve cost efficiency but, on average, hospitals do not appear to realize short-term economic benefit from network membership; and (4) some of the benefits of these networks may be realized outside of the communities in which rural hospitals are located.

The use of new technologies by rural family physicians

BACKGROUND

Although office procedures that involve special training and office equipment are often performed by a specialist in an urban setting, they are increasingly being performed by family physicians in rural settings. This study documents the prevalence of four such procedures in rural family practice: flexible sigmoidoscopy, cardiac stress testing, colposcopy, and nasopharyngoscopy. Individual and community characteristics of physicians who perform each of the procedures are compared with those of physicians who do not.

METHODS

Data were collected on office technology and the characteristics of physicians, their practices, and their communities through telephone interviews with 403 randomly selected, rural family physicians and general practitioners in eight states. Descriptive and univariate analyses were used.

RESULTS

Flexible fiberoptic sigmoidoscopy was performed by 57% of the physicians in our sample. The presence of another physician in the group or in the community who performed this procedure increased the probability of a rural physician performing it. Being male, recent licensure, board certification, and patient volume were also positively associated with the performance of this procedure.

CONCLUSIONS

This study found evidence of a collegial effect among rural physicians and of a significant number of rural physicians seeking postresidency training in new procedures.

The effects of capitation on health and functional status of the Medicaid elderly. A randomized trial

PURPOSE

To determine the effect on health and functional status outcomes of enrollment of noninstitutionalized elderly Medicaid recipients in prepaid plans compared with traditional fee-for-service Medicaid.

DESIGN

A randomized controlled trial. Beneficiaries were randomly assigned to prepaid care in one of seven capitated health plans compared with fee-for-service care. Only the Medicaid portion of their care was capitated. Patients were followed for 1 year.

SETTING

The Medicaid Demonstration Project in Hennepin County, Minnesota, which includes Minneapolis.

PATIENTS

800 Medicaid beneficiaries who were 65 years or older at the beginning of the evaluation. Beneficiaries were interviewed at baseline (time 1) and 1 year later (time 2). Ninety-six percent of beneficiaries were available for follow-up interviews at time 2.

MAIN OUTCOME MEASURES

General health status, physical functioning, mental health status, activities of daily living, instrumental activities of daily living, corrected visual acuity, and blood pressure and glycosylated hemoglobin measurements for hypertensive and diabetic persons, respectively.

RESULTS

There were no differences between prepaid and fee-for-service groups in the number of deaths (20 compared with 24, P > 0.2), the proportion in fair or poor health (56.5% compared with 59.7%, P > 0.2), physical functioning, activities of daily living, visual acuity, or blood pressure or diabetic control. Patients in the prepaid group reported a trend toward better general health rating scores (10.2 compared with 9.8, P = 0.06) and well-being scores (10.0 compared with 9.7, P = 0.07) than patients in the fee-for-service group. The difference in the likelihood of a patient in the prepaid group having a physician visit relative to the fee-for-service group was -16.5% (adjusted odds ratio, 0.46; 95% CI, 0.29 to 0.74) and for an inpatient visit was -11.2% (adjusted odds ratio, 0.55; CI, 0.32 to 0.94).

CONCLUSIONS

There was no evidence of harmful effects of enrolling elderly Medicaid patients in prepaid plans, at least in the short run. Whether these findings also apply to settings in which health maintenance organizations are formed exclusively for Medicaid patients should be studied further.

Cost comparison of immediate angioplasty versus thrombolysis followed by conservative therapy for acute myocardial infarction: a randomized prospective trial. Mayo Coronary Care Unit and Catheterization Laboratory Groups

OBJECTIVE

Immediate angioplasty and thrombolysis followed by conservative therapy are treatment strategies for acute myocardial infarction. The objective of this study was to compare the costs of these two strategies during a 12-month period.

METHODS

Of 103 patients with acute myocardial infarction who sought medical assistance within 12 hours after onset of symptoms, 4 were excluded from analysis for various reasons, 51 received tissue plasminogen activator, and 48 underwent immediate angioplasty as the initial revascularization strategy. The main outcome determinants were direct monetary costs and indirect measures of costs, including duration of hospital stay and return to work.

RESULTS

No significant difference in monetary costs between the two initial treatment strategies could be demonstrated. A trend was noted toward a briefer hospital stay and fewer late in-hospital procedures for patients treated initially with immediate angioplasty. Other measures of indirect costs were not statistically different.

CONCLUSION

The hypothesis that thrombolysis followed by conservative therapy would be more cost-effective than immediate angioplasty in the treatment of patients with acute myocardial infarction could not be substantiated. The two strategies seem to have similar cost-effectiveness.

Health care reform and rural health networks

Health care reform is likely to raise unique issues for rural communities and providers. This paper identifies and discusses several of these issues, with a particular focus on the potential relationship between health care reform and rural health networks. Topics addressed include the likely impact of health reform on the organization and development of rural health networks, the reimbursement of rural providers, rural medical practice, and state roles in the organization, delivery, and oversight of rural health care.

Access and use of health services by chronically mentally ill Medicaid beneficiaries

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.

A clinically based service limitation option for alternative model rural hospitals

Alternative model rural hospitals are designed to address problems faced by small, isolated rural hospitals. Typically, hospital regulations are reduced in exchange for a limit on the services that alternative models may offer. The most common service limitation is a limit on length of stay (LOS), a method with little empirical or conceptual support. The purpose of this article is to present a clinically based service limitation for alternative model rural hospitals, such as the rural primary care hospital. The proposal is based on an analysis of Medicare discharges from rural hospitals most likely to convert and the judgments of a technical advisory panel of rural clinicians.

Turnover of membrane and opsin in visual receptors of normal and mutant Drosophila

Electron microscopy was used to investigate membrane turnover in the photoreceptors of Drosophila. Coated pits and vesicles, multivesicular bodies, primary lysosomes, multilamellate bodies, residual bodies and Golgi complexes are present throughout a light/dark cycle. Serial sections reveal that the membrane bounding of multivesicular bodies is only seen at an optimal plane of section. The temperature-sensitive shibire (shi(ts)) mutant has a defect in conversion of coated pits into vesicles which may also affect visual receptors. We used monoclonal antibodies to Rh1 in R1-6 receptors in the compound eye (also to Rh2 in ocellar receptors in the simple eyes) ro relate turnover processes at the visual pigment compared with membrane levels. Compound eye rhabdomeres but not rhabdomere caps stained selectively. Immunogold labelling was equivocal in multivesicular bodies. Further, early in the process of carotenoid replacement therapy, labelling is high in the rough endoplasmic reticulum, demonstrating de novo opsin synthesis.