Informed decision making before initiating screening mammography: does it occur and does it make a difference?

OBJECTIVE: Informed decision making regarding screening mammography is recommended for women under age 50. To what extent it occurs in clinical settings is unclear. METHODS: Using a mailed instrument, we surveyed women aged 40-44 prior to their first screening mammogram. All women were members of a large health maintenance organization and received care at a large medical practice in the Greater Boston area. The survey measured informed decision making, decisional conflict, satisfaction, and screening mammography knowledge and intentions to undergo screening. RESULTS: Ninety-six women responded to the survey (response rate 47%). Overall, women reported limited informed decision making regarding screening mammography, both with respect to information exchange and involvement in the decision process. Less than half (47%) reported discussing the benefits of screening; 23% the uncertainties; and only 7% the harms. About 30% reported discussing the nature of the decision or clinical issue; and 29% reported their provider elicited their preferred role in the decision; 38% their preferences; and 24% their understanding of the information. Women who were uninformed had higher decisional conflict (2.37 vs. 1.83, P=0.005) about screening mammography and were more likely to be dissatisfied with the information and involvement. Women's screening mammography knowledge was limited in most areas; however being presented with information did not diminish their intentions to undergo screening. CONCLUSION: Informed decision making before initiating screening mammography is limited in this setting. There appears to be little indication that information about the benefits and harms decreases women's intentions to undergo screening. Methods to communicate information to women before initiating screening mammography are needed.

Union Health Service celebrates 50th year managing capitated patients.

Union Health Services is celebrating its 50th year managing capitated patients. One measure of its success is the staff model HMO's ability to hold down premium hikes to 3.4% compared with the national average of 11.5%. Read about how the Chicago-based non-profit does it.

Managed health care and the Massachusetts experience.

Managed health care, through prepaid health delivery systems and utilization review organizations, is perhaps the greatest trend in modern health care. The authors examine the remarkable growth of managed care and outline its clinical, economic, ethical, and practical implications. They then review examples of how organized psychiatry has been involved in managed care and describe the efforts to date of the Massachusetts Psychiatric Society in this area. Managed care is here to stay. The future climate of psychiatric practice and the care available to psychiatric patients are dependent on informed and organized activities by psychiatrists and their local and national representatives.

Physicians and prepaid group practices.

Prepaid group practices (PGPs) are complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. PGPs' ability to manage their physician staffing efficiently must be placed in context with the cost and quality of their care. It seems unlikely that PGPs or their use of staff will proliferate. With increased integration of care through disease management programs and use of clinical information technology, it should be possible for the United States as a whole to come closer to achieving the care delivery goals that PGPs have set in the past.

Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study.

BACKGROUND: Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care. METHODS: We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994-95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care. RESULTS: On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34-38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14-26 percentage points). CONCLUSION: According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.

A comparison of patient satisfaction among prepaid and fee-for-service patients.

This study compares levels of patient satisfaction (a valid, indirect measurement of quality of care) between prepaid and fee-for-service patients. A chart audit approach was used to determine whether prepaid and fee-for-service patients seen in an academic family health center at the end of the first six months of a new cost-containment program were comparable in terms of demographic characteristics and indirect measures of health and health behavior. Next, using a 26-item patient satisfaction questionnaire, 436 patients from a single group of providers in the same family health center seen six months after the programs began were randomly surveyed. Sociodemographic and health-related characteristics of prepaid and fee-for-service patients were similar for both groups in the chart audit. There was no statistically significant difference between the overall satisfaction levels of prepaid and fee-for-service patients. Individual constructs that comprise general satisfaction were also statistically similar except for an unexpected finding of dissimilar levels of satisfaction with "physician conduct/humaneness" (P less than .05). Assessed from at least one standpoint, cost containment does not seem to affect overall quality of care, but further investigation is needed, especially in the realm of "physician conduct/humaneness."

Health promotion/disease prevention guideline development: process and results.

As part of its strategic plan, Physician Plus Insurance Corp. (PPIC), an 80,000-enrollee, provider-owned, network-model, prepaid insurance plan has targeted improvement in enrollee and community health. Health promotion/disease prevention (HP/DP) guidelines were developed as one tool to promote health screening and to close identified gaps between desired and actual rates of health screening. Additional efforts within the health plan have focused on identifying barriers to health screening and on identifying and implementing solutions to overcome these barriers. Opportunities in health screening are identified from in-house data: mammography, Pap smear, cholesterol screening, immunization rates, and the like. Note that these screening topics are among those that the Health Plan Employer Data and Information Set (HEDIS) has selected. This article will describe the processes to develop HP/DP guidelines, obtain provider participation, obtain buy-in from providers, and educate enrollees and employers. It will also show the results that have been obtained in the form of HP/DP Guidelines and outcomes measures.

Give physicians incentives to deliver value, boost outcomes.

The secret of success under capitation for this New England physician group is to pay physicians extra for delivering value. Here's how they determine who gets the money.

Lack of interest in accreditation for prepaid groups dooms TMQC (The Medical Quality Commission).

The Medical Quality Commission will cease operations on March 31, citing financial constraints and flat demand for medical group and IPA accreditation. What does the loss of this organization say about the importance of quality in capitated care?

IT products save small groups money under capitation.

Small physician groups now are able to pick and choose among affordable freestanding information technology (IT) products that can help practices reduce costs and improve quality. Read about a new report on IT solutions prepared by First Consulting Group for the California HealthCare Foundation.

Disease-specific report card pushes for improved care.

A California plan has unveiled a report card rating physician groups on their treatment of asthma patients. Is this the long-awaited signal that capitated physicians will be evaluated more by their management of care than their impact on the bottom line?

Capitated groups track practice guideline data with 'eMaxx'.

Software systems can help groups track physician compliance with clinical practice guidelines. Find out how these systems can improve quality and reduce costs.

Successful physician groups are 'sleeping with the enemy'.

Successful physician groups are "sleeping with the enemy." Groups that consider health plans as their partners rather than their opponents have a much better chance of success in the risk contracting game.

Capitation remains a strong factor in 'best practice' medical groups.

Data Insight: What characteristics are common to better performing medical groups? For one, they are more likely to have a higher percentage of capitation revenue. Get all the details, plus one expert's view of the reinsurance market and prospects for capitation in today's economic climate.