[Return to Work after a Work Accident: Is Coordination between the Occupational Physician and the Insurance Physician Possible?]

Occupational physicians and insurance physicians each have their own roles in managing the consequences of work accidents and their interaction is pivotal in the administrative and clinical process of return to work. We wanted to analyse the barriers and facilitators of this collaboration in Belgium.A qualitative study was conducted based on individual interviews of a sample of insurance physicians and occupational physicians working in French-speaking Belgium. This sample was selected to represent all insurance companies and most prevention and protection services operating on the territory. The interview scheme was designed to explore the various dimensions of the RDIC model (Resource Dependence Institutional Collaboration) of collaboration between professionals.This study highlighted certain obstacles to collaboration, related to the mutual perception of the 2 professions, ignorance of the other profession’s work context, lack of independent resources blocking the willingness to cooperate (sufficient time, fees). Some facilitating factors were also identified : occupational physicians’ willingness to cooperate, a positive attitude towards the ability to cooperate, as well as proposals for immediate improvement of some factors. Collaboration between these 2 professions has rarely been studied and the results of the present study provide tracks for improvement that can be applied in the short or medium term to enable those two categories of physicians to be better organized and more efficient in managing disability consequences of work accidents.

Coding and billing for radiology physician extenders

Correct coding and billing for services provided by physician extenders can be challenging and complex and it is critical that organizations perform these functions correctly to ensure compliance. Incident-to is the only provision that allows physicians to charge and be paid for services that they did not directly perform. It is important that individuals responsible for charge capture understand how incident-to may or may not apply in their organization. What extenders are allowed to do in their scope of service may not coincide with what is allowed from a billing perspective.

Of primary importance. Primary-care physicians seek to legitimize the 'medical home' concept to improve quality, costs--but will insurers buy it?

As primary-care physicians seek to promote the cause of establishing a "medical home" for patients, many questions still remain over how the system would work, and how payments would be structured. "This is not going to be sustainable unless it's linked to reimbursement," says Greg Pawlson, left, executive vice president of the National Committee for Quality Assurance.

Don't LOL at virtual visits. Technology is allowing more doctors and patients to consult via e-mail, and insurance companies are reimbursing for it

In today's "I-gotta-know-now" society, many patients turn to e-mail to contact doctors on matters, as opposed to waiting for an in-person office visit. Now, some insurers are actually reimbursing doctors for their electronic time, which is also known as a "virtual visit." Internist Paul Tang, left, doesn't consider the practice mainstream yet. "No one is reimbursing us," he says.

Variations in activity and practice patterns: a French study for GPs

OBJECTIVES

To identify the different practice profiles of general practitioners (GPs) in order to test the hypothesis of heterogeneity in physician behaviour.

DATA

For the year 2000, 4,660 GPs from two regions in France.

VARIABLES

volume and structure of the physicians' medical activity, income level, personal characteristics, socioeconomic and geographical environment, characteristics of their patients.

METHODS

A cluster analysis to identify different practice profiles and a regression analysis to display the determinants of the physicians' activity.

RESULTS

Four different homogeneous groups can be identified, each one associating a physician's level of activity to his socioeconomic status. The level and the intensity of medical activity depend on individual factors, patients' characteristics as well as the socioeconomic context.

CONCLUSIONS

There is no uniformity in the way GPs practice medicine. An immediate consequence is that any cost-containment measure that is applied uniformly to all GPs inevitably results in different outcomes according to the physicians' category type.

A dynamic analysis of GP visiting in Ireland: 1995-2001

This paper examines the determinants of GP visiting in Ireland, using panel data from the Living in Ireland Survey from 1995-2001. While cross-sectional studies provide important information on GP visiting patterns at a certain point in time, with panel data we can also control for unobserved individual heterogeneity, as well as identify whether it is the same individuals who consistently visit their GP year on year, or whether there is more mobility in visiting. We therefore estimate dynamic models of GP utilisation, and attempt to decompose the observed variation in GP visiting into components attributable to observed individual characteristics, unobserved individual heterogeneity and state dependence.

The financing of hospital-based emergency departments

This article describes the principal channels of reimbursement for hospital-based emergency departments, and considers the impact of these funding streams on the organization and delivery of emergency care. We describe the services offered in the emergency department setting, reimbursement methodologies, factors affecting reimbursement, and the costs of hospital-based emergency services. We examine hospital financing and the contribution of the emergency department to the hospital's patient and service mixes and to its financial bottom line. We identify perverse payment incentives in terms of quality, efficiency, and broad system goals, and consider how payment incentives can be used to improve patient safety and quality of care.

Consumer satisfaction with primary care provider choice and associated trust

BACKGROUND

Development of managed care, characterized by limited provider choice, is believed to undermine trust. Provider choice has been identified as strongly associated with physician trust. Stakeholders in a competitive healthcare market have competing agendas related to choice. The purpose of this study is to analyze variables associated with consumer's satisfaction that they have enough choice when selecting their primary care provider (PCP), and to analyze the importance of these variables on provider trust.

METHODS

A 1999 randomized national cross-sectional telephone survey conducted of United States residential households, who had a telephone, had seen a medical professional at least twice in the past two years, and aged > or = 20 years was selected for secondary data analyses. Among 1,117 households interviewed, 564 were selected as the final sample. Subjects responded to a core set of questions related to provider trust, and a subset of questions related to trust in the insurer. A previously developed conceptual framework was adopted. Linear and logistic regressions were performed based on this framework.

RESULTS

Results affirmed 'satisfaction with amount of PCP choice' was significantly (p < .001) associated with provider trust. 'PCP's care being extremely effective' was strongly associated with 'satisfaction with amount of PCP choice' and 'provider trust'. Having sought a second opinion(s) was associated with lower trust. 'Spoke to the PCP outside the medical office,' 'satisfaction with the insurer' and 'insurer charges less if PCP within network' were all variables associated with 'satisfaction with amount of PCP choice' (all p < .05).

CONCLUSION

This study confirmed the association of 'satisfaction with amount of PCP choice' with provider trust. Results affirmed 'enough PCP choice' was a strong predictor of provider trust. 'Second opinion on PCP' may indicate distrust in the provider. Data such as 'trust in providers in general' and 'the role of provider performance information' in choice, though import in PCP choice, were not available for analysis and should be explored in future studies. Results have implications for rethinking the relationships among consumer choice, consumer behaviors in making trade-offs in PCP choice, and the role of healthcare experiences in 'satisfaction with amount of PCP choice' or 'provider trust.'

An exploration of the ethical, legal and developmental issues in the care of an adolescent patient

Providers of health care to adolescent patients face numerous challenges. In addition to increased risk for many health problems, adolescent patients may bring complex ethical, legal and developmental questions to bear as they seek medical services. This article describes the case of one such adolescent patient and discusses some of the attendant issues faced by her physician. For example, providing reproductive health care to teenage patients without the knowledge of parents or guardians requires familiarity on the part of providers with relevant state and federal law. Additionally, providers must be aware of financial barriers and they need to acquaint themselves with available services such as New York State's Family Planning Benefit Program. Attention to their patients' stages of cognitive and emotional development should inform providers' advice to adolescents, and an understanding of the importance that supportive adult relationships play during adolescence is essential to fostering healthy development. Open communication between adolescent patients and their parents or guardians should be encouraged, while maintaining the primary obligation of providing confidential care.

Economic Impact of Bariatrics on a General Surgery Practice

Bariatric surgery is currently a rapidly growing subsection of general surgery, with exponential expansion over the past decade. Many residency programs lacked sufficient experience in bariatrics, necessitating established surgeons to consider re-training and re-vamping of their practice to enter the field. The addition of bariatric surgery to a general surgery practice can present economic consequences, which are both positive and negative. Positive consequences include a potential new revenue source with a large population base. Negative consequences include increased employees, required paper-work and office resources, increased malpractice premiums, difficulties with appropriate reimbursement, and limitations on access to appointment time for non-bariatric cases. This paper reviews the potential economic impact of bariatric surgery on a general surgery practice and possible alternatives to manage these efficiently.

Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison

Background

The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector.

Methods

Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization.

Results

The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001).

Conclusion

Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices.

Evaluating freestanding ambulatory surgery center ventures

Projecting revenues and expenses The second of a two-part series, this article discusses the projected revenues and expenses of a hypothetical ambulatory surgery center and analyzes the potential impact of a hypothetical new payment method by the Centers for Medicare & Medicaid Services.

Insurance status and access to urgent ambulatory care follow-up appointments

CONTEXT

There is growing pressure to avoid hospitalizing emergency department patients who can be treated safely as outpatients, but this strategy depends on timely access to follow-up care.

OBJECTIVE

To determine the association between reported insurance status and access to follow-up appointments for serious conditions that are commonly identified during an emergency department visit.

DESIGN, SETTING, AND PARTICIPANTS

Eight research assistants called 499 randomly selected ambulatory clinics in 9 US cities (May 2002-February 2003) and identified themselves as new patients who had been seen in an emergency department and needed an urgent follow-up appointment (within 1 week) for 1 of 3 clinical vignettes (pneumonia, hypertension, or possible ectopic pregnancy). The same person called each clinic twice using the same clinical vignette but different insurance status.

MAIN OUTCOME MEASURE

Proportion of callers who were offered an appointment within a week.

RESULTS

Of 499 clinics contacted in the final sample, 430 completed the study protocol. Four hundred six (47.2%) of 860 total callers and 277 (64.4%) of 430 privately insured callers were offered appointments within a week. Callers who claimed to have private insurance were more likely to receive appointments than those who claimed to have Medicaid coverage (63.6% [147/231] vs 34.2% [79/231]; difference, 29.4 percentage points; 95% confidence interval, 21.2-37.6; P<.001). Callers reporting private insurance coverage had higher appointment rates than callers who reported that they were uninsured but offered to pay 20 dollars and arrange payment of the balance (65.3% [130/199] vs 25.1% [50/199]; difference, 40.2; 95% confidence interval, 31.4-49.1; P<.001). There were no differences in appointment rates between callers who claimed to have private insurance coverage and those who reportedly were uninsured but willing to pay cash for the entire visit fee (66.3% [132/199] vs 62.8% [125/199]; difference, 3.5; 95% confidence interval -3.7 to 10.8; P = .31). The median charge was 100 dollars (range, 25 dollars-600 dollars). Seventy-two percent of clinics did not attempt to determine the severity of the caller's condition.

CONCLUSIONS

Reported insurance status is associated with access to timely follow-up ambulatory care for potentially serious conditions. Having private insurance and being willing to pay cash may not eliminate the difficulty in obtaining urgent follow-up appointments.

Approaches to the office care of the older adult and the specter of dementia

The influx of older patients into the office-based primary care setting is a demographic reality for most practices. A shift from the disease-driven model of care delivery to one that focuses on function and quality of life should occur if primary care clinicians are to provide appropriate services to their aging patients, especially as those patients reach a state of vulnerability as defined in the ACOVE studies. Incremental functional assessment may be a first step in making the shift and probably can be implemented in most office-based practices. The specter of dementia, however, is beginning to materialize and affect the approach to addressing the needs of older adults and the expected outcomes of care.