Market competition and patient-oriented research: the results of a national survey of medical school faculty.

PURPOSE: To understand the effect of market competition on patient-oriented research at U.S. medical schools and teaching hospitals. METHOD: From a multi-stage stratified, random sample, the authors surveyed 3,804 research faculty at 117 U.S. medical schools. The questionnaire assessed five variables, the type of research conducted by the respondent, changes in patient-oriented and non-clinical research in the preceding three years, amount of time spent on patient care, market stage of the respondent's institution, and research productivity. RESULTS: Of the 2,336 faculty who responded (62%), 84% of those conducting patient-oriented research and 80% of those engaged in non-clinical research reported conducting the same amount of research or more in 1996-1997 than in the preceding three years. However, both patient-oriented and non-clinical researchers in the most competitive health care markets and those with high levels of patient care duties were most likely to report decreases in the amounts of such research conducted in the previous three years. Further, researchers reporting such decreases had been as productive in recent years and over their careers as had those who did not report a decrease. CONCLUSIONS: This study provides additional evidence of the negative relationships that exist between high levels of market competition and patient care services on the patient-oriented and non-clinical research missions of teaching hospitals.

Switching to gatekeeping: changes in expenditures and utilization for children.

BACKGROUND: Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. OBJECTIVE: To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. DESIGN: We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. RESULTS: Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. CONCLUSION: Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

The duration of ambulatory visits to physicians.

BACKGROUND: The objective of our study was to determine the typical length of ambulatory visits to a nationally representative sample of primary care physicians, and the patient, physician, practice, and visit characteristics affecting duration of visit. METHODS: We used an analysis of cross-sectional survey data to determine duration of visit and the characteristics associated with it. The data sources were a random sample of the 19,192 visits by adults to 686 primary care physicians contained in the 1991-1992 National Ambulatory Medical Care Survey, and the results of the Physician Induction Interview conducted by the National Center for Health Statistics. Duration of visit was defined as the total time spent in face-to-face contact with the physician. RESULTS: Mean duration of visit was 16.3 minutes (standard deviation = 9.7). Multivariate analysis allowed the calculation of the independent effect on visit length of a variety of characteristics of patients, physicians, organizational/practice setting, geographic location, and visit content. Certain patient characteristics (increasing age and the presence of psychosocial problems) were associated with increased duration of visit. Visit content was also associated with increased duration, including ordering or performing 4 or more diagnostic tests (71% increase), Papanicolaou smears (34%), ambulatory surgical procedures (34%), patient admission to the hospital (32%), and 3 preventive screening tests (25%). Reduced duration of visit was associated with availability of non-physician support personnel and health maintenance organization and Medicaid insurance. CONCLUSIONS: Multiple factors affect duration of visit. Clinicians, policymakers, and health system managers should take these considerations into account in managing physician resources during daily ambulatory practice.

Market forces and unsponsored research in academic health centers.

CONTEXT: Increased competitive pressures on academic health centers may result in reduced discretionary funds from patient care revenues to support the performance of unsponsored research, including institutionally funded and faculty-supported activities. OBJECTIVE: To measure the amount and distribution of unsponsored research activities and their outcomes. DESIGN AND SETTING: Survey conducted in academic year 1996-1997 of 2336 research faculty in 117 medical schools. Responses were weighted to provide national estimates. MAIN OUTCOME MEASURES: Institutionally funded research as a proportion of total direct costs of research was compared across stages of market competition. Logistic regression was used to assess the relationship of performing unsponsored research to faculty characteristics and market stage. RESULTS: Overall, 43% of faculty received institutional funding for research. Young faculty were more likely than others to receive institutional support (adjusted odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9; P = .004). The amount of institutional support as a proportion of total funding was more than twice as high in less competitive markets (6.1%) compared with the most competitive markets (2.5%; P = .05). Most faculty (55%) performed faculty-supported research. Clinical researchers (OR, 1.6; 95% CI, 1.1-2.3), principal investigators (OR, 4.3; 95% CI, 2.8-7.0), faculty with high levels of research effort (OR, 6.2; 95% CI, 4.0-9.5) or institutional funding (OR, 1.9; 95% CI, 1.4-2.6), and faculty in the most competitive markets (OR, 1.9; 95% CI, 1.4-2.5) were more likely than others to conduct faculty-supported research. When undertaken by clinical researchers, these activities were supported by clinical income, extra hours worked, and discretionary funds, and often led to publications (76%) or grant awards (51%). CONCLUSIONS: Many academic health center faculty receive institutional support to conduct their research or fund the research themselves. Market pressures may be affecting the level of institutional funding available to faculty.

Trends in adult visits to primary care physicians in the United States.

BACKGROUND: Although numerous changes are apparent in the US health care system, little is known about how these changes have altered the work of primary care physicians. METHODS: We analyzed a nationally representative sample of 136,233 adult office visits to general internists, general practitioners, and family physicians contained in the 1978 through 1981, 1985, and 1989 through 1994 National Ambulatory Medical Care Surveys. Annual sample sizes varied between 5662 and 19,977 visits. Measures included the characteristics of patients presenting to primary care physicians, physician activities during these visits, and the disposition of the visits to primary care physicians. RESULTS: Visits to primary care physicians have diminished as a proportion of all adult visits from 52% in 1978 to 41% in 1994. Dramatic trends in adult primary care included the growing racial or ethnic diversity of patients, the doubling (since 1985) of health maintenance organization coverage, increased provision of prevention services, changes in the most common medications, and an 18% increase in the duration of adult visits to primary care physicians. CONCLUSIONS: Trends in primary care practice reflect changes in society and in the US health care system, including demographic changes, an emphasis on prevention, and the growth of managed care. The increasing role of managed care, with its emphasis on increased productivity, appears at odds with primary care physicians' increasing responsibility for prevention and the associated increase in the duration of primary care visits.

The declining impact of race and insurance status on hormone replacement therapy.

OBJECTIVE: Socioeconomic barriers may limit the adoption of hormone replacement therapy, but little is known about recent trends in their influence. We evaluated trends in the impact of race and insurance status on national rates of hormone replacement therapy. DESIGN: We analyzed 32,608 physician office visits by nonpregnant women 40 years of age and older available from the 1989 through 1996 National Ambulatory Medical Care Surveys. The proportion of visits with new or continuing use of noncontraceptive estrogens reported was the main outcome measured. Multiple logistic regression was used to evaluate the independent effects of year, race, and expected payment source on hormone replacement therapy. RESULTS: Overall, the report of hormone replacement therapy increased from 5.7% of visits in 1989-1990 to 10.9% in 1995-1996. In 1989-1990, hormone replacement therapy was less likely in nonwhite women (3.6% vs. 6.3% for whites) and in women with Medicaid coverage (1.3% vs. 8.4% for privately insured women). These differences diminished over time, particularly for women without menopausal symptoms. In 1989-1990, the adjusted odds ratio of hormone replacement in women without menopausal symptoms was 0.31 (95% confidence interval 0.2-0.5) in nonwhites compared with whites, but increased to 0.57 (0.4-0.8) by 1995-1996. In 1989-1990, the adjusted odds ratio for hormone replacement among women with Medicaid was 0.31 (0.09-1.0) compared with those with private insurance. This ratio increased to 0.86 (0.5-1.4) by 1995-1996. CONCLUSIONS: Racial and payment source influences on hormone replacement therapy appeared to have lessened over time. Despite these changes substantial socioeconomic differences in treatment patterns remain to be addressed.

Changes in the daily practice of primary care for children.

BACKGROUND: The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on how the day-to-day practice of primary care for children has changed during this period. OBJECTIVE: To identify aspects of primary care practices for children that are undergoing substantial changes. DESIGN: Analysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1985, and 1989 to 1994. PARTICIPANTS: Primary care practitioners recorded data on 58,488 child visits. MAIN OUT COME MEASURES: Characteristics and insurance status of children, physician activities during visits, and disposition after visit. RESULTS: Child visits to primary care physicians increased by 22% between 1979 and 1994. The mean age of children visiting primary care physicians decreased from 6.7 years in 1979 to 5.7 years in 1994 (P for trend, < .001). The ethnic diversity of child visits increased primarily as a result of an increasing proportion of visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend, < .001) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend, < .001). Medicaid and managed care increased dramatically as sources of payment. Changes in physician activities included an increase in some preventive services, changes in the most commonly encountered medications, and an increased mean duration of patient visits (11.8 minutes in 1979 to 14.2 minutes in 1994, P for trend, < .001). CONCLUSIONS: These data may assist in the development of educational and research initiatives for physicians caring for children. The declining proportion of adolescent visits may present physicians with challenges in the care of adolescents. Physician prescribing practices showed changes without evidence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased mean duration of primary care visits. The increased duration of child visits may conflict with the managed care emphasis on physician productivity.

Is gatekeeping better than traditional care? A survey of physicians' attitudes.

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.

Low rates of hormone replacement in visits to United States primary care physicians.

Our objective was to determine national rates and predictors of hormone replacement therapy. We analyzed a nationally representative sample of 6341 office visits by women aged > or = 40 years to primary care physicians in the 1993 and 1994 National Ambulatory Medical Care Surveys. Independent predictors of estrogen use were determined by logistic regression. Time trends from 1989 through 1994 also were evaluated. Hormone replacement therapy was documented in 4.7% of visits in 1989 to 1990 and 8.0% in 1993 to 1994. In 1993 to 1994 women with menopausal symptoms were six times more likely to have hormone replacement reported. In the absence of symptoms, obstetrician-gynecologists were nearly four times as likely to report hormone replacement therapy. Age 50 to 59 years, white race, osteoporosis, hyperlipidemia, and residence in the West and in nonmetropolitan areas also independently-predicted hormone replacement. Low rates of estrogen therapy by non-obstetrician-gynecologists and substantial practice variations suggest missed opportunities for hormone replacement therapy.

Academic-industry research relationships in genetics: a field apart.

Academic-industry research relationships (AIRRS) have become widely accepted and increasingly common in the life sciences. Using nationwide surveys from the United States, we found significant differences between the AIRRs of genetics firms and faculty and those of other firms and faculty. Significantly more genetics than non-genetics firms funded AIRRs, and genetics firms' AIRRs were larger and longer. Genetics faculty with AIRRs were significantly more likely than non-genetics faculty to report that patents, licenses, new companies and trade secrets had resulted from their university research; and that they had refused to share research results of biomaterials with colleagues.

Withholding research results in academic life science. Evidence from a national survey of faculty.

OBJECTIVES: To identify the prevalence and determinants of data-withholding behaviors among academic life scientists. DESIGN: Mailed survey of 3394 life science faculty in the 50 universities that received the most funding from the National Institutes of Health in 1993. PARTICIPANTS: A total of 2167 faculty responded to the survey, a 64% response rate. OUTCOME MEASURES: Whether respondents delayed publication of their research results for more than 6 months and whether respondents refused to share research results with other university scientists in the last 3 years. RESULTS: A total of 410 respondents (19.8%) reported that publication of their research results had been delayed by more than 6 months at least once in the last 3 years to allow for patent application, to protect their scientific lead, to slow the dissemination of undesired results, to allow time to negotiate a patent, or to resolve disputes over the ownership of intellectual property. Also, 181 respondents (8.9%) reported refusing to share research results with other university scientists in the last 3 years. In multivariate analysis, participation in an academic-industry research relationship and engagement in the commercialization of university research were significantly associated with delays in publication. Odds ratios (ORs) and 95% confidence intervals (CIs) were 1.34 (1.07-1.59) and 3.15 (2.88-3.41), respectively. Variables associated with refusing to share results were conducting research similar to the Human Genome Project (OR, 2.09; 95% CI, 1.75-2.42), publication rate (OR, 1.02; 95% CI, 1.01-1.03), and engagement in commercialization of research (OR, 2.45; 95% CI, 2.08-2.82). CONCLUSIONS: Withholding of research results is not a widespread phenomenon among life-science researchers. However, withholding is more common among the most productive and entrepreneurial faculty. These results also suggest that data withholding has affected a significant number of life-science faculty and further study on data-withholding practices is suggested.

Participation of life-science faculty in research relationships with industry.

BACKGROUND: Recent research on academic-industrial research relationships in the life sciences has examined their frequency, benefits, risks, and evolution from the standpoint of industrial sponsors of research. We collected information on the extent and effects of academic-industrial research relationships from the standpoint of faculty members who participate in them. METHODS: We used a mailed questionnaire to collect data between October 1994 and April 1995 from 2052 faculty members (of 3169 eligible respondents; response rate, 65 percent) in the life sciences at the 50 U.S. universities receiving the most research funding from the National Institutes of Health. RESULTS: Twenty-eight percent of the respondents received research support from industry. Faculty members receiving industrial funds had more peer-reviewed articles published in the previous three years, participated in more administrative activities in their institutions or disciplines, and were more commercially active than faculty members without such funding. However, faculty members receiving more than two thirds of their research support from industry were less academically productive than those receiving a lower level of industrial support, and their articles were less influential than those by researchers with no industrial support. Faculty members with industrial support were significantly more likely than those without industrial support to report that trade secrets had resulted from their work (14.5 percent vs. 4.7 percent, P<0.001) and that they had taken commercial considerations into account when choosing research topics (35 percent vs. 14 percent, P<0.001). CONCLUSIONS: Faculty members with industrial research support are at least as productive academically as those without such support and are more productive commercially. However, faculty members who have research relationships with industry are more likely to restrict their communication with colleagues, and high levels of industrial support may be associated with less academic activity without evidence of proportional increases in commercial productivity.

Relationships between academic institutions and industry in the life sciences--an industry survey.

BACKGROUND: Despite growing acceptance of relationships between academia and industry in the life sciences, systematic, up-to-date information about their extent and the consequences for the parties involved remains scarce. We attempted to collect information about the prevalence, magnitude, commercial benefits, and potential risks of such relationships by surveying a representative sample of life-science companies in the United States to determine their relationships with academic institutions. METHODS: We collected data by telephone from May through September 1994 from senior executives of 210 life-science companies (of 306 companies surveyed; response rate, 69 percent). The sample contained all Fortune 500 companies in the fields of agriculture, chemicals, and pharmaceuticals; all international pharmaceutical companies with sales volumes similar to those of the Fortune 500 companies; and a random sample of non-Fortune 500 companies in the life sciences drawn from multiple commercial and noncommercial directories. Both the survey instrument and the survey methods resembled those of our 1984 study of 106 biotechnology companies, allowing us to assess the evolution of relationships between academia and industry over the past decade. RESULTS: Ninety percent of companies conducting life-science research in the United States had relationships involving the life sciences with an academic institution in 1994. Fifty-nine percent supported research in such institutions, providing an estimated $1.5 billion, or approximately 11.7 percent of all research-and-development funding received that year. The agreements with universities tended to be short-term and to involve small amounts, implying that most such relationships supported applied research or development. Over 60 percent of companies providing support for life-science research in universities had received patents, products, and sales as a result of those relationships. At the same time, the companies reported that their relationships with universities often included agreements to keep the results of research secret beyond the time needed to file a patent. From 1984 to 1994, the involvement of industry with academic institutions has increased, but the characteristics of the relationships have remained remarkably stable. CONCLUSIONS: After more than a decade of sustained interaction, universities and industries seem to have formed durable partnerships in the life sciences, although the relationships may pose greater threats to the openness of scientific communication than universities generally acknowledge. However, industrial support for university research is much smaller in amount than federal support, and companies are unlikely to be able to compensate for sizable federal cutbacks.

Physician and practice characteristics, frequency of performance, and the Resource-Based Relative Value Scale.

The Resource-Based Relative Value Scale is based in part on the ratings of the work of services obtained from a random sample of physicians in a specialty. Ratings are used without regard to board-certification or other characteristics of the physician, or to the physician's experience with the service. Critics have suggested that all physicians may not be equally qualified to rate the work of services. Using data obtained from the Resource-Based Relative Value Scale surveys and analyzed using multiple regression methods, the authors found that physician and practice characteristics explain, at most, a small fraction of the variation in ratings of work. Any increase in the precision of the work scale obtained by adjusting physicians' work ratings according to physicians' characteristics could be achieved at lower cost by a slight increase in sample size. Associations between frequency of performing a service and ratings of work are about as likely to be in one direction as another. Most of the differences between estimates of work, excluding and including physicians who have not performed a service, are less than 2% in absolute value, and all are less than 10%. Estimates of work using ratings of physicians in the upper half in frequency of performance are usually within 10% of estimates using other ratings. Even if the observed associations are not due to chance, the potential improvement in accuracy of estimates of work appears too small to justify using data on frequency of performance.

Results and impacts of the Resource-Based Relative Value Scale.

On January 1, 1992, the Health Care Financing Administration implemented the 1989 legislation reforming the Medicare payment system for physicians' services. The cornerstone of the new payment reform is the Medicare Fee Schedule (MFS), which is based on the Resource-Based Relative Value Scale (RBRVS). In this article, the major findings of the RBRVS study and its impacts on physician payment are summarized. The authors report the impacts of a RBRVS-based fee schedule on Medicare fees and physicians' income if it were fully implemented, assuming budget neutrality and absence of volume changes in services. Under this scenario, fees for evaluation and management services increase by 15% to 45%, while fees for invasive services and diagnostic tests decrease by 20% to 30%. These changes increase the Medicare income of family practitioners by more than 30% while decreasing the income of most surgical specialties by 10% to 20%.

Resource-based relative values for invasive procedures performed by eight surgical specialties.

We surveyed approximately 850 physicians in eight surgical specialties to investigate physicians' work in performing invasive services. Building on our analysis of physician work, we developed a relative value scale of physicians' services based on resource costs. First, we found that physician charges are not set in proportion to the resources required to perform a given procedure: there is a threefold variation, across hospital-based invasive procedures, in the ratio of charges to resource-based relative values. Second, for most procedures, the preoperative and postoperative periods represent 60% to 75% of a physician's total service time, but only 35% to 50% of the total service work. Lastly, intraoperative work per unit of time varies greatly. Work per minute for invasive procedures is two to three times that of medical office visits and is strikingly greater for some specialties. The Resource-Based Relative Value Scale, at a minimum, represents a useful tool for payers to identify procedures with potentially aberrant charges and also offers unique insights into the nature of physicians' work.