Prepaid coordinated care for patients with diabetes: practices and patients bear the risks.

The Australian Government is planning to pilot a model of prepaid funding for coordinated care of patients with diabetes in general practice. Patients will register with a practice that undertakes to coordinate their care, and practices will manage pre-allocated funds to provide services instead of billing Medicare. Systems to manage prepaid funds in Australian general practice have not yet been developed. In the model that has been proposed, practices with a small register of patients will be at risk of overspending, which may threaten practice viability and patient services. If the initiative is to have integrity, all patient services should be paid from the prepaid funds and patients should only attend the practice with which they have registered. Risks should be delineated and contingency plans made explicit before practices and patients commit to the initiative.

The metamorphosis of managed care: implications for health reform internationally.

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change.

Hysteroscopic sterilization in a large group practice: experience and effectiveness.

OBJECTIVE: To estimate device placement and tubal occlusion rates for hysteroscopic sterilization and evaluate risk factors for failure. METHODS: Women undergoing hysteroscopic sterilization at Kaiser Permanente Northern California from January 2004 to December 2006 were identified. Risk factors assessed included age, parity, body mass index (BMI), operative location, and provider experience with the technique. Occlusion was determined by hysterosalpingogram. Univariable analyses were performed to identify factors predictive of successful placement and occlusion. The Cochrane-Armitage test was performed for trend analysis. RESULTS: Hysteroscopic sterilization was attempted in 884 women by 118 physicians at 30 Kaiser Permanente Northern California facilities. The initial placement attempt was successful in 850 patients (96.2%). Patient age, nulliparity, and BMI were not predictive of successful placement. Bilateral occlusion was demonstrated by hysterosalpingogram in 687 of 739 patients (93.0%). There were no significant differences in age, nulliparity, and BMI between those with and without occlusion. Loss to follow-up before a hysterosalpingogram was obtained was 13%. There was no significant increase in occlusion rate with experience (P for trend=.6). CONCLUSION: High placement and occlusion rates were noted from the first insertions, and success was not related to age, parity, BMI, or operator experience. LEVEL OF EVIDENCE: III.

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.

Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity.

OBJECTIVE: To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice. DATA SOURCES: Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information. STUDY DESIGN: Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics. PRINCIPAL FINDINGS: Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation. CONCLUSIONS: This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.

A randomized trial of strategies to increase chlamydia screening in young women.

OBJECTIVE: Despite the recommendations of numerous clinical practice guidelines, testing of at-risk women for Chlamydia trachomatis infection remains low. We evaluated an intervention to increase guideline-recommended chlamydia screening. METHOD: In a two-by-two factorial design randomized trial conducted in 2001-2002, 23 primary care clinics at Group Health Cooperative in Washington State were randomized to either control (standard) or intervention (enhanced) guideline implementation arms. Clinic-level intervention strategies included use of clinic-based opinion leaders, individual measurement and feedback, and exam room reminders. A second patient-level intervention, a chart prompt to screen for chlamydia, was delivered in a random sample of 3509 women. The outcome measure was post-intervention chlamydia testing rates among sexually active women ages 14-25. RESULTS: The clinic-level intervention did not significantly affect overall chlamydia testing (odds ratio (OR) = 1.08, 95% confidence interval (CI) 0.92-1.26, P = 0.31). However, testing rates increased significantly among women making preventive care visits (OR, Pap test visit = 1.23, 95% CI, 1.01-1.51, P = 0.04; OR, physical exam visit = 1.22, 95% CI 1.06-1.42, P = 0.009, intervention vs. control clinics). The chart prompt intervention had no significant effect (OR = 1.08, 95% CI 0.94-1.23, P = 0.27). CONCLUSIONS: Interventions to improve guideline-recommended chlamydia testing increased testing among women making preventive care visits. Additional organizational change and/or patient activation strategies may improve plan-wide testing, particularly among asymptomatic women.

Prepaid group using prevention focus to lure back employers.

Prepaid medical groups like Grand Valley Health Plan, Grand Rapids, MI, are facing declining membership as employers shift to lower-priced PPOs. But some employers are starting to look more closely again at the value of managed care networks.

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.

Economic evaluation of four treatments for low-back pain: results from a randomized controlled trial.

OBJECTIVE: We sought to compare total outpatient costs of 4 common treatments for low-back pain (LBP) at 18-months follow-up. METHODS: Our work reports on findings from a randomized controlled trial within a large medical group practice treating HMO patients. Patients (n = 681) were assigned to 1 of 4 treatment groups, ie, medical care only (MD), medical care with physical therapy (MDPt), chiropractic care only (DC), or chiropractic care with physical modalities (DCPm). Total outpatient costs, excluding pharmaceuticals, were measured at 18 months. We did not perform a cost-effectiveness analysis because previously published findings showed no clinically meaningful difference in outcomes among the 4 treatment groups. Thirty-seven participants were lost to follow-up at 18 months, leaving a final sample size of n = 654. RESULTS: Adjusting for covariates, DC was 51.9% more expensive than MD (P < 0.001), DCPm 3.2% more expensive than DC (P = 0.76), and MDPt 105.8% more expensive than MD (P < 0.001). The adjusted mean outpatient costs per treatment group were 369 US dollars for MD, 560 US dollars for DC, 579 US dollars for DCPm, and 760 US dollars for MDPt. CONCLUSIONS: This study is the first randomized trial to show higher costs for chiropractic care without producing better clinical outcomes, but our findings are likely to understate the costs of medical care with or without physical therapy because of the absence of pharmaceutical data. Physical therapy provided in combination with medical care and physical modalities provided in combination with chiropractic care do not appear to be cost-effective strategies for treatment of LBP; they produce higher costs without clinically significant improvements in outcome.

Implementing evidence-based practices to improve quality. One medical group's experience.

HealthPartners Medical Group and Clinics uses evidence-based guidelines for diabetes and other chronic diseases. This article reviews how HealthPartners has redesigned its care processes and implements the diabetes guidelines. It also summarizes the lessons the organization has learned about how to choose guidelines and how to get the most from them.