HMO direct costs and health care resources use after implementation of a monthly limit on sumatriptan.

The health care costs and resource use of patients with migraine before and after a quantity limit on sumatriptan was introduced in an HMO were compared. A longitudinal, retrospective review of a medical claims database and a pharmacy claims database was conducted for two six-month periods before and after a monthly limit (four tablets or injections) on sumatriptan reimbursement was instituted at an independent practice association-model HMO in February 1997. Patients with at least one medical claim with a diagnosis code for migraine or at least two pharmacy claims for sumatriptan, methysergide, ergotamine, dihydroergotamine, or an ergotamine combination product in 1996 or 1997 were eligible for inclusion. A total of 557 patients were included in the analysis. Migraine-related medical costs and total medical costs increased 1.5% and 24.4%, respectively; neither change was statistically significant. Physician office visits related to migraine increased by 7.8%. The number of hospital admissions for the cohort increased from three to five, but hospital costs decreased by 55.0%. The overall costs of medications for migraine therapy decreased by 4.5%. There was an 8.2% increase in prescriptions for drugs to treat migraine but a 40.0% decrease in their cost, primarily because of decreased sumatriptan use. There was a 33.9% increase in prescriptions for medications that could be used as prophylaxis for migraine and a 49.6% increase in their cost. Implementation of a monthly limit on sumatriptan decreased an HMO's pharmacy costs but did not significantly alter migraine-related direct medical costs and health care resource use of patients with migraine.

Caveat doctor: how to analyze claims-based report cards.

"Report cards" based on claims (billing) data are being widely used to evaluate the quality of care given by providers, even though they often lack sufficient clinical detail to render definitive judgments. Furthermore, their accuracy, especially for outpatient care, is quite variable. Nevertheless, claims data will continue to be used until better clinical information becomes widely available. To determine the suitability of automated claims data for measuring clinical performance, careful attention should be paid to the integrity of the data. Providers profiled by claims-based report cards should ask four questions about the source, robustness, management, and analysis of the data: 1. What are the key characteristics of the data set used to construct the profile? These include the insurer's name, coverage type, time period, geographic area, and number of patients, claims lines, and providers. 2. What clinical conditions and events are being measured and how well? In short, are the patients' conditions and their clinical encounters reasonably well characterized? 3. Is the information about the patients and providers accurate and up to date? 4. Once the insurer receives the medical claim, are data elements deleted or altered in ways that might affect their accuracy and completeness? Ensuring data integrity is not sufficient; the analysis of the data must be scrutinized. Potential pitfalls in analyzing claims data arise in choosing clinically meaningful measures, recognizing important differences in patients and their providers, and making fair comparisons against appropriate benchmarks. Monitoring patient care outcomes is no longer voluntary. By routinely constructing and augmenting profiles using outpatient claims data, provider groups become proactive rather than reactive in evaluating their patients' care.

Effect of a legislative mandate on mammography use and coding practices in Maryland.

PURPOSE: To analyze the effect of the 1991 Maryland legislative mandate of screening mammography benefits. MATERIALS AND METHODS: Claims submitted between January 1991 and December 1993 for outpatient mammograms obtained in women covered under Blue Cross Blue Shield of Maryland insurance indemnity contracts were analyzed for the distribution of services and charges. RESULTS: For 184,723 women, 285,241 claims were submitted by 851 Maryland providers. Claims for "mammography bilateral," which were considered "diagnostic," represented 67%; 24% were submitted for "screening mammography bilateral," and 9% were submitted for "mammography unilateral." Mammography claims increased only 25% during the 3 years, despite an estimated fivefold increase in the number of women with the screening mammography benefit. Mammography coding shifted from bilateral to screening. CONCLUSION: The number of mammograms obtained increased only modestly after the mandate, but claims coded for mammography bilateral declined dramatically. Removal of financial barriers appears to be insufficient to increase appropriate use of screening mammography.

Medical students and abortion: reconciling personal beliefs and professional roles at one medical school.

A survey was used from 1983 through 1990 in a required first-year course, Ethics and Medical Care, at The Johns Hopkins University School of Medicine, to explore where students drew the line about moral issues. Starting in 1988, a similar questionnaire was administered to each class of fourth-year medical students. This report summarizes the students' attitudes--reported anonymously in both surveys--regarding circumstances under which they would perform or refer for an abortion. Attitudes towards abortion changed little in four years. Comfort levels with patient referral were greatest when the life of the mother was threatened and in the case of rape. Students' attitudes correlated most strongly with personal beliefs about when a fetus was considered a human life and less so with students' genders. The first-year survey results were shared with the students in the course's annual sessions on abortion in order to aid them in understanding the assumptions underlying ethical dilemmas surrounding abortion and to make visible the class's moral pluralism on the subject. The survey also helped them determine their tolerance, if any, for patients' views or actions that conflicted with their personal moral stances.

Reproductive technology: drawing the line.

An anonymous survey was administered to clinical clerks rotating through obstetrics and gynecology during weekly ethics rounds. Students were asked to judge the moral acceptability as participants and as referring physicians of 11 reproductive technology scenarios ranging from artificial insemination using a husband's sperm in a conjugal relationship to instances involving in vitro fertilization, uterine donation, surrogacy contracts, self-insemination, and single or lesbian parenthood. Positive judgments regarding personal moral acceptability ranged from 30-100% and as a referring physician from 36-99%. Though most students were consistent in their judgments about personal and professional moral acceptability, some (1-15%) could see themselves acting as referring physicians for something they personally found morally unacceptable. Those students who were opposed to contracting for children (more women than men) were more likely to find the reproductive scenarios morally unacceptable. This survey seemed to be a useful tool for discussing where students draw the line morally and why, and whether they would distance themselves from actions they found morally unacceptable. This technique for teaching applied analytic ethics is especially applicable to obstetrics and gynecology because it addresses fundamental questions involving day-to-day practice in the specialty.

Intravenous drug abuse and one academic health center.

Increasing reports of management problems involving intravenous drug abuse patients prompted our study. From 1983 to 1988, the recorded inpatient prevalence of diagnoses consistent with drug abuse/dependence, other than alcohol or nicotine, rose hospitalwide from 0.6% to 3.5%. Disruptive behavior was documented in the records of 38 of 71 active cocaine or heroin users admitted during 1988 vs 12 of 64 matched control subjects. Care and teaching focused principally on secondary complications of intravenous drug use. Study recommendations included (1) establishment of a comprehensive substance abuse treatment education, and research program with a dedicated inpatient unit; (2) use of an explicit social contract between patients and care givers; and (3) staff education about legal limits in managing disruptive patients and searching for illegal substances. Primary and secondary prevention, including combating societal enabling of substance abuse, should be the institution's long-term goals.

Improving a university hospital obstetric clinic: better but not best.

The Obstetric Clinic at the Johns Hopkins Hospital was evaluated on four occasions during the past 8 years. In 1980, there were major inefficiencies because of a block patient appointment system and late physician arrival. Clinic goals were largely undefined. The institution of a staggered appointment system, the naming of an on-site physician director who encouraged physicians to arrive on time, and the delegation of specific responsibilities to the nurses and clerks resulted in improved patient transit time. In 1981, 72% of patients had left by 2 hours after their arrival, compared with only 4% in 1980. The departure of the physician director was associated with considerable backsliding in patient transit time because of late physician arrival. There was a corresponding decrease in appointment-keeping from 90 to 78%. Patients were satisfied with their care but very dissatisfied with the waiting time. The return of the physician director and the reaffirmation of the roles of nurses and clerks reversed much of the backsliding. Our study suggests that improvements in teaching-hospital obstetric clinics are difficult to sustain without strong leadership. We believe that further improvement will require a major reorganization of ambulatory care for women. The feasibility of establishing a comprehensive program based on a group practice model is currently being studied.

What physicians should know about small area variation analysis.

Geographic variations in the use of medical care may occur because of differences in patient severity of illness, patient access or use of medical care, physician practice patterns, availability of technology, economic incentives, and malpractice concerns. These variations are leading to greater scrutiny of appropriateness and cost effectiveness of medical care.