Relative value units in health care: Friend, foe, or necessary evil?

The purpose of this article is to describe this use of relative value units (RVUs) among nurse practitioners (NP), including the challenges NPs may experience. Relative value units were developed as a means to determine reimbursement for health care based on time spent with the patient and skills required to complete the interaction, while addressing any disparities of reimbursement based on geography or insurance. Increasingly, providers such as NPs are being evaluated based in large part on how many RVUs they generate, which seems to prioritize productivity and may overlook many nonbillable aspects of the NP role such as emotional support or patient education. Nurse practitioners working in settings that require more invasive procedures may seem to be more productive on paper, regardless of the number of patients seen. Relative value units may not adequately reflect the skill and time taken to care for patients with chronic illness. Gender differences have been noted, both in terms of the number of RVUs generated for care of male or female patients, and those generated by male or female providers. If NPs are evaluated primarily based on productivity as measured by RVUs, we must consider how this might minimize or even invalidate the therapeutic relationship and holistic approach to patient care. Relative value units may negatively affect the willingness of NPs to serve as preceptors. Finally, as NPs experience less face-to-face time with patients and more demands for productivity, there may be a loss of quality care and professional integrity, which raises the risk of burnout among NPs.

Letramento nutricional: desempenho de dois grupos populacionais brasileiros / Nutrition literacy: performance of two Brazilian population groups

In this study, we aimed to compare the level of nutritional literacy of twodifferent population groups. It is a cross-sectional quantitative study withsecondary data analysis. We investigated 140 individuals, both maleand female, divided in two groups: 70 were customers of a mall (Group1) and 70 were patients of the National Health System - NHS (Group 2)in Fortaleza, Ceará state, Brazil. The level of nutritional literacy wasdetermined by the Nutritional Literacy Scale (NLS) questionnaire, whichwas translated into Portuguese. The two groups were compared usingChi-square test or Fisher exact test and Student?s t test, adopting p<0.05as significance level. Adequate performance was found in the NLS evaluation, which was different from the literature results. Group 2 showed worse performance (p<0.05) when compared with Group 1 for both male and female participants. The educational background of participants also influenced this performance. There were significant statistical differences according to most groups of questions considering the total female individuals. Male participants presented the best performance. The present study demonstrated that there are different performances considering various issues related to nutrition and the population groups evaluated. Further investigation should be carried out for the design of educational activities. It is suggested that the instruments of nutritional literacy assessment be validated for the Brazilian population.

Comparar el grado de letramento nutricional de dos grupos de población diferentes. Estudio transversal, de naturaleza cuantitativa, con análisis de datos secundarios. Participaron del mismo 140 individuos de ambos sexos, siendo 70 visitantes de un centro comercial (grupo 1) y 70 pacientes de la Seguridad Social - SS (grupo 2) de la ciudad de Fortaleza, Ceará. El grado de letramento nutricional se determinó mediante un cuestionario Escala de Letramento nutricional (NLS), traducido al portugués. Los grupos se compararon mediante el test de Chi-cuadrado o el test exacto de Fisher y el test t-Student, adoptándose una p<0,05 como nivel de significación. A diferencia de lo expuesto en la literatura, en el presente estudio el desempeño de los entrevistados en el NLS fue equivalente a un letramento nutricional adecuado, siendo, sin embargo, inferior entre los miembros del grupo 2 (p<0,05) para ambos sexos. La escolaridad también influenció el desempeño en el referido instrumento. Al analizar los bloques de preguntas que formaban parte del NLS, hubo diferencias estadísticamente significativas entre las respuestas conferidas, para la mayoría de las preguntas, por las mujeres pertenecientes al grupo 1, cuando fueron comparadas a las del grupo 2. Ya entre los hombres, al comparar las respuestas entre los dos grupos (1 y 2) la diferencia no resultó significativa. El presente estudio demostró que existen desempeños diferenciados teniendo en cuenta tanto los diversos temas ligados a lanutrición como el grupo poblacional evaluado, y que dicho aspecto debe ser investigado para el delineamiento de las acciones educativas. Sesugiere realizar la validación de instrumentos que midan el letramento nutricional para la población brasileña.

Comparar o grau de letramento nutricional de dois diferentes grupos populacionais. Estudo transversal, de natureza quantitativa, com análise de dados secundários. Participaram do mesmo 140 indivíduos de ambos os gêneros, sendo 70 frequentadores de um shopping center (grupo 1) e 70 pacientes do Sistema Único de Saúde ? SUS (grupo 2) da cidade de Fortaleza, Ceará. O grau de letramento nutricional foi determinado por meio do questionário Nutritional Literacy Scale (NLS), traduzido para o português. Os grupos foram comparados por meio dos testes Qui-quadrado ou Exato de Fisher e do teste t de Student, adotando-se p<0,05 como nível de significância. Diferentemente do exposto na literatura,no presente estudo, o desempenho dos entrevistados no NLS foi equivalente a um letramento nutricional adequado, sendo, no entanto,inferior entre os integrantes do grupo 2 (p<0,05), para ambos os gêneros. A escolaridade também influenciou o desempenho no referido instrumento.Ao se analisarem os blocos de questões que integravam o NLS, houve diferenças estatisticamente significativas entre as respostas conferidas,para a maioria das questões, pelas mulheres pertencentes ao grupo 1, quando comparadas às do grupo 2. Já entre os homens, a maioria dascomparações de respostas entre os dois grupos (1 e 2) não foi estatisticamente significativa. O presente estudo demonstrou que há desempenhos diferenciados, considerando-se diversos temas ligados à Nutrição e o grupo populacional avaliado; assim, tal aspecto deve ser investigado para o delineamento de ações educativas. Sugere-se arealização de validação de instrumentos de aferição de letramento nutricional para a população brasileira.

Evaluating scholarship productivity in COAMFTE-accredited PhD programs.

Due to an increasing trend among states to cut higher education funds, many universities are relying more on private donations and federal funding to keep programs afloat. Scholarship productivity in general has become an integral factor in terms of universities granting tenure to faculty, allocating resources, and supporting program goals due to the fact that more research in a particular area tends to increase the likelihood that one will obtain funding from federal, state, and private sources. In the past, ranking systems have also been used to evaluate programs. However, most ranking systems use methodologies that do not quantify research productivity or evaluate factors that match current university trends. The purpose of this article is to explore current scholarship productivity trends among COAMFTE-accredited doctoral programs through the use of several evaluation methods. Specifically, productivity was examined in regard to the following areas: (a) family therapy journal publications; (b) family science journal publications; (c) historic journal publication trends; and (d) recent journal publication trends.

Worker productivity outcome measures in arthritis.

Arthritis is a leading cause of work disability and makes up a significant amount of the socioeconomic cost and health burden to the working age population. We discuss the measurement of worker productivity: that is, absenteeism and presenteeism. Absenteeism refers to the time missed from work due to health reasons and presenteeism refers to the time of impaired performance while at work due to health reasons resulting in productivity loss. While the term absenteeism is commonly used and has several definitions by itself, the current arthritis literature lacks the use of presenteeism as a work outcome measure in describing health states of the workers and for economic costing. Due to advanced medical management and job accommodations that allow workers to stay at work, absenteeism alone may not be enough to give us a complete picture of worker productivity. From our review, we found that the conceptualization and measurement of absenteeism and presenteeism differ. Our research agenda was to carry forward a work outcome measurement that can be used for cost calculation and that can determine levels or states of productivity loss so we can accurately measure the influence of arthritis and advance arthritis care. We recognize the need to perform psychometric testing of work outcome measures and to improve our ability to identify transitions (i.e., move in and out of a productivity state over time) made by workers with arthritis.

The relationship between productivity and health-related quality of life: an empirical exploration in persons with low back pain.

OBJECTIVE: In economic evaluation of health care programmes normally health-related quality of life is part of measurement of a programme's effectiveness and productivity part of its costs. In this paper the relationship between quality of life and productivity is highlighted and empirically assessed in persons suffering from low back pain. METHODS: A secondary analysis was performed on data from a sample of 483 patients treated for low back pain. Periodically, both quality of life (EQ-5D) and productivity indicators for both paid and unpaid work were measured. Mean EQ-5D scores were compared for groups of patients classified by level of productivity. The relationship between quality of life and productivity was also assessed using Spearman rank correlation coefficients. RESULTS: Mean EQ-5D scores for patients without productivity losses were a half to a full standard deviation higher than for patients with the lowest levels of productivity. The correlation between quality of life and productivity was moderate. CONCLUSION: Lower levels of quality of life were associated with efficiency loss and absenteeism. However, due to the moderate strength of the relation the use of information on quality of life to model productivity costs in case of absence of productivity data was not recommended.

Performance decrements resulting from illness in the workplace: the effect of headaches.

OBJECTIVES: Studies on the impact of illness on work productivity are important to rationally allocate healthcare resources and to design programs to mitigate these effects. This investigation was conducted to develop and apply daily measures of illness episodes, and to collect subjective and objective data on work performance impacts. Medical bill reviewers completed daily responses to a questionnaire about headache manifestations, severity, and speed of work using interactive voice response (IVR). Of 134 eligible enrolled subjects, 117 (86%) provided at least 30 daily reports over 3 months. Their responses were matched to difficulty-adjusted objective measures: daily output, time on the system, and productivity. Respondents were clinically classified as migraineurs (n = 56), other headache disorders (n = 47), or having no headache disorder (n = 14). Each headache episode was classified as a migraine or nonmigraine headache based on reported manifestations. RESULTS: The three groups were similar in a variety of demographic factors, and mean subject-specific measures of speed, output, and productivity. In a multivariate model using general estimating equations, only episode severity (not type of headache or person-specific diagnosis) was found to be associated with a significant decrement in speed or productivity. The self-reported decrement in speed (approximately 20%) was much greater than the actual measured effect on productivity (approximately 8%). Intensive daily diary collection by IVR on symptoms and work performance is feasible. However, analysis of detailed daily objective productivity data can be complex, with significant unmeasured sources of variance. Severity may be a more important determinant of headache effect on work performance than specific diagnosis. Future studies on illness episodes and work performance should measure informal accommodations that may enable employees to compensate for episodic illnesses.

Effects of compensation method on physician behaviors.

OBJECTIVE: To examine physician and leader perceptions of the relationship between physician compensation and the productivity of physicians practicing in medical groups. STUDY DESIGN: Key informant interviews identified subjects' perceptions of factors influencing physician productivity and the behavioral effects of individual financial incentives. Interview transcripts were analyzed by a team of physicians, economists, and other researchers. STUDY POPULATION: Physicians, medical leaders, and group practice administrators (n = 114) representing 46 medical group practices in California, Oregon, Washington, and Wisconsin were interviewed. RESULTS: Five major themes emerged: (1) Most physicians reported that financial incentives did not substantially affect their own behavior, except for productivity. However, they suggested that specific compensation models do lead to certain seemingly undesirable physician behaviors. (2) By contrast, medical group leaders reported that financial incentives do affect a variety of physician behaviors. (3) Four productivity drivers emerged: financial incentives, demand-side factors, systems and infrastructure, and other individual or group attributes. (4) Physician compensation systems are evolving toward a blend of production-based and production-neutral incentives, plus new metrics aligned with the demands of managed care. (5) Culture, size, and specialty mix are significant determinants of group physician compensation systems. CONCLUSIONS: Compensation method is perceived to be a significant influence on physician productivity, particularly among group practice leaders. The changing context of medical practice represents another powerful "macro" lever on physician behavior.

How many rural doctors do we have?

The number of physicians practicing in the nonmetropolitan areas of the United States in relation to population has increased over the past two decades, but more slowly than the number of physicians in metropolitan counties. During the same period, there was a growing acceptance of the perception that the physician work force in the United States exceeded the number necessary to meet the requirements of an efficient health care system. This has caused policy-makers to consider reforming the incentives for training physicians and restricting the entry of physicians from other countries into the United States. The supply figures on which these assessments of oversupply were made are based on "head counts" of the number of licensed, active physicians. By using more detailed data describing the licensed practicing physicians in the states of North Carolina and Washington, and by using estimates of professional activity collected as part of the Socioeconomic Monitoring System of the American Medical Association, estimates of the number of full-time equivalent physicians actually in practice in the two states and the comparative productivity of those physicians were made. Based on the state-level data, the estimates of actively practicing physicians are approximately 14 percent lower than the head-count number in North Carolina and, by using a more conservative estimation method, are approaching a 10 percent lower number than the head-count number in Washington. Using national productivity data, the effective supply of nonmetropolitan physicians appears to have not grown significantly over the past 10 years, and for family physicians the supply has declined by 9 percent. These estimates of the effective physician supply support long-held claims that rural communities continue to experience a severe undersupply of practitioners. These results suggest that the way in which physicians are counted needs to be re-examined, especially in rural places where the ratios of providers to population are more sensitive to small changes in supply.

Productivity growth in health-care delivery.

OBJECTIVES: The authors compute and compare productivity growth in the health-care sectors for a sample of Organization for Economic Cooperation and Development countries over the period from 1974 to 1989. The authors compute Malmquist productivity indexes, which allow productivity growth to be decomposed into efficiency changes and technical change. These indexes also allow the use of primary quantity data (recently available from the Organization for Economic Cooperation and Development), rather than expenditure data, which the authors argue reduces bias resulting from distorted prices. METHODS: The authors specify two models. The first model focuses on the hospital sector; inputs include physicians and medical care beds, whereas outputs are the "intermediate" type used in hospital efficiency studies, namely, inpatient days and discharges. RESULTS: For the 19 countries with complete data, the authors found little productivity growth based on this model (with the exception of Denmark, with 15.4% cumulated growth, and the United States, with about 5% from 1974 to 1989). The authors did find, however, that the highest productivity levels are found in the United States (Italy and Finland were also on the frontier of technology in the base period, 1974). The second model uses the same inputs as the first (but in per capita terms), but it specifies simple proxies of health outcomes as outputs: life expectancy of women at age 40 and the reciprocal of the infant mortality rate. CONCLUSIONS: For the 10 countries with complete data for this model, the authors found evidence of much more widespread and rapid productivity growth: Denmark's cumulated growth was close to 33%, with the United States close behind. In both these countries, this growth was due solely to technical change over this period.