Do physicians not offer useful services because of coverage restrictions?

Ethically, physicians should discuss all medically appropriate services with patients, but coverage restrictions can make these discussions difficult. In a national survey of physicians, we asked how often physicians elected not to offer their patients useful services because of health plan coverage rules. During the course of a year, 31 percent reported having sometimes not offered their patients useful services because of perceived coverage restrictions. Among these, 35 percent reported doing so more often in the most recent year than they did five years ago. It can be frustrating for doctors to discuss uncovered services with their patients, but open communication is necessary for shared decision making and to improve coverage decisions.

Impact of provider continuity on quality of care for persons with diabetes mellitus.

BACKGROUND: Many patients with diabetes fail to receive recommended monitoring tests. One reason might be inadequate continuity of care. This study examined the association between provider continuity and completion of monitoring tests for patients with diabetes mellitus. METHODS: A cross-sectional analysis was conducted on claims data from a private national health plan for 1 year (January 1, 1999, through December 31, 1999). Participants had a diagnosis of diabetes mellitus and at least 2 outpatient visits during the study year (N = 1,795). The association was measured between continuity of care with an individual provider and completion of 3 diabetes monitoring tests: a glycosylated hemoglobin test, a lipid profile, and an eye examination. RESULTS: Eighty-one percent of patients had a glycosylated hemoglobin test, 66% had a lipid profile, and 28% had an eye examination during the study year. After controlling for demographics, number of diabetes visits, case mix, and diabetes complications, provider continuity was not significantly associated with the receipt of a glycosylated hemoglobin test (odds ratio [OR] = 0.61, 95% confidence interval [CI], 0.32-1.16), a lipid profile (OR = 0.97, 95% CI, 0.57-1.64) or an eye examination (OR = 0.60, 95% CI, 0.30-1.19). When continuity was measured only among primary care providers, there was no significant association for receipt of a glycosylated hemoglobin test (OR = 0.73, 95% CI, 0.41-1.33), a lipid profile (OR = 0.88, 95% CI, 0.53-1.47) or an eye examination (OR = 0.70, 95% CI, 0.35-1.36). CONCLUSIONS: This study found no association between provider continuity and completion of diabetes monitoring tests in a national privately insured population. Whereas continuity might benefit other aspects of health care, it does not appear to benefit improved monitoring for diabetes.

Type of health insurance and the quality of primary care experience.

OBJECTIVES: This study examined the association between type of health insurance coverage and quality of primary care as measured by its distinguishing attributes--first contact, longitudinality, comprehensiveness, and coordination. METHODS: The household component of the 1996 Medical Expenditure Panel Survey was used for this study. The analysis primarily focused on subjects aged younger than 65 years who identified a usual source of care. Logistic regressions were used to examine the independent effects of insurance status on primary care attributes while individual sociodemographic characteristics were controlled for. RESULTS: The experience of primary care varies according to insurance status. The insured are able to obtain better primary care than the uninsured, and the privately insured are able to obtain better primary care than the publicly insured. Those insured through fee-for-service coverage experience better longitudinal care and less of a barrier to access than those insured through health maintenance organizations (HMOs). CONCLUSIONS: While expanding insurance coverage is important for establishing access to care, efforts are needed to enhance the quality of primary health care, particularly for the publicly insured. Policymakers should closely monitor the quality of primary care provided by HMOs.

Should insurers pay the same fees under an all-payer system?

Medicare's use of diagnosis-related groups (DRGs) and the resource-based relative value scale (RBRVS) has led to interest in developing a national all-payer system in which insurers use the same payment methods and payment rates. Using data for 81 high-volume DRGs from 457 California hospitals, we conclude that a single set of rates for hospital care would not be appropriate. On average, Medicare patients were 11.7 percent more expensive than commercially insured patients, but less expensive in many DRGs. Further research is needed to determine if Medicare patients require more physician resources compared with non-Medicare patients, particularly for surgical procedures.

Quality of care for colorectal cancer in a fee-for-service and health maintenance organization practice.

This study assessed the effectiveness of two types of health plans, offered by the same health care provider, in the diagnosis and treatment of colorectal cancer. Data on 330 cases diagnosed from 1984 through 1989 were abstracted from medical records. Of these, 205 (62%) used fee-for-service (FFS) and 125 (38%) used health maintenance organization (HMO) plans. Overall, there were no differences between FFS and HMO cases for duration of symptoms before diagnosis, training of physician who diagnosed the tumor, anatomic location of the tumor, type of primary treatment, Dukes' stage at final diagnosis, or survival. There were differences between the groups for age, presence of symptoms at diagnosis, time from detection to treatment, and method of detection. Cox regression analysis showed no difference in survival by type of health plan before or after adjusting for age and stage at diagnosis. The findings from this study are consistent with those from studies reporting little or no difference in the process or outcome of care for patients with different types of medical insurance coverage.

Is there a doctor in the house?

Unless employees can readily access your physician network, even the best physicians won't do them much good. Here is a state-of-the-art system for measuring access to care.