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Managed Care

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Medicaid managed care lagging in rural counties

Medicaid managed care enrollment is growing at an explosive rate, except in rural America where, according to a new nationwide study sponsored by the Agency for Health Care Policy and Research, it is progressing more slowly. Findings show that Medicaid enrollees in only slightly over half of all rural counties in the United States were covered by some type of Medicaid managed care in early 1997, compared with enrollees in nearly three-fourths of urban counties, and that there are important differences in the types of managed care programs.

According to the study, mandatory fully capitated programs are less common in rural counties than in urban ones (10 percent vs. 23 percent), although seven States do have statewide mandatory fully capitated Medicaid programs. Fully capitated programs pay the organizations or providers with whom they contract a set amount per enrollee each year, regardless of services provided. Rural counties also are less commonly covered by programs that combine types of managed care. The study also found that primary care case management (PCCM), a form of managed care involving no financial risk to the provider, is more common in rural counties than in urban ones.

According to lead author Rebecca T. Slifkin, Ph.D., of the University of North Carolina at Chapel Hill, these findings can serve as benchmarks for research on the impact of the Balanced Budget Act of 1997. As Dr. Slifkin notes, it remains to be seen whether the legislation will spur States to expand fully capitated programs in rural areas.

The most common reasons given by State Medicaid officials for including their rural enrollees in managed care programs is to save money and/or improve access to health care and establish a medical home. Yet over half of the States that said their main motivation was to reduce costs operated PCCM or mixed type plans rather than full-risk programs. The study further found that:

  • Many States do not plan to implement capitated programs statewide.
  • Aside from the statewide capitated programs, most other States have not yet attempted nor been successful at generating significant rural enrollment in capitated programs.
  • Provider resistance and inadequate provider supply are major obstacles to implementing Medicaid managed care in rural areas.
  • Other obstacles include lack of health plan interest in rural markets, consumer resistance, and lack of education and communication in rural areas about managed care.

However, many States are determined to at least partially overcome these obstacles and have taken diverse approaches to implementing capitated Medicaid managed care in rural areas.

These findings are based on telephone interviews conducted in 1997 with Medicaid officials in all 50 States—the first stage of a larger collaborative effort between staff at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill and staff at Mathematica Policy Research, Inc.

Details are in "Medicaid managed care programs in rural areas: A fifty-state overview," by Dr. Slifkin, Sheila D. Hoag, M.A., Pam Silberman, Dr.P.H., J.D., and others, in the November-December 1998 issue of Health Affairs 17(6), pp. 217-227.

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Health Care Delivery

Physicians who are bothered by uncertainty tend to order more tests and incur higher charges than other physicians

Doctors vary in the degree to which the uncertainty of medicine bothers them. And according to a new study, those who are uncomfortable with uncertainty and are reluctant to disclose their uncertainty to patients tend to order more tests to confirm diagnoses or treatment effects. As a result, they incur higher patient charges than doctors more at ease with medical uncertainty. On the other hand, physicians who are more inclined to be risk-takers—and, thus, probably have a higher tolerance for uncertainty—and are reluctant to disclose mistakes to other physicians are more likely to have lower patient charges.

Although the researchers did not gather data on the reasons for these effects, they do have some theories. For example, physicians who tend to take risks might not be so compulsive in evaluating patient complaints. Also, physicians who fear disclosing their uncertainty about a diagnosis or treatment to their colleagues might be less willing to send patients for consultation or to order tests that might raise the need for consultation, explain Jeroan J. Allison, M.D., M.S., and Catarina I. Kiefe, Ph.D., M.D., of the University of Alabama at Birmingham.

In a recent study, supported in part by the Agency for Health Care Policy and Research (HS09446), Drs. Allison and Kiefe and their colleagues surveyed 20 internists at a health maintenance organization clinic about their attitudes toward uncertainty and risk taking. The researchers linked results with administrative data on physician use of medical resources for 792 primary care patient visits from April through November 1995.

Each standard deviation increase in "anxiety due to uncertainty" corresponded to a 17 percent increase in mean charges and each similar increase in "reluctance to disclose uncertainty to patients" corresponded to a 12 percent increase. In contrast, each standard deviation increase in "reluctance to disclose mistakes to physicians" and physician risk-taking propensity was associated with 10 percent lower total charges. According to the researchers, these findings indicate that measures of physician uncertainty could be used to improve prediction of patient care costs.

See "The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO," by Dr. Allison, Dr. Kiefe, E. Francis Cook, Sc.D., and others, in the July 1998 Medical Decision Making 18, pp. 320-329.

Men receive slightly more hospital laboratory and radiology tests than women

Subtle differences in the ways physicians treat men and women may be most apparent in discretionary areas of care such as ancillary laboratory tests or x-rays. Some studies have suggested that up to 50 percent of ancillary tests performed on hospitalized patients are unnecessary.

According to a recent study supported by the Agency for Health Care Policy and Research (HS07107), men are slightly more apt to receive these tests than women. The study found that while hospitalized, women had 3.7 percent fewer laboratory tests performed and 10.4 percent fewer radiology exams than men who stayed at the same hospital. However, it was not clear whether receipt of ancillary tests affected patient outcomes and thus whether men or women received more appropriate care, note the Harvard Medical School researchers.

The researchers examined hospital records of laboratory and radiology tests ordered for medical and surgical inpatients (excluding obstetric patients) over 16-month and 20-month periods, respectively. They found that women received 2 fewer laboratory tests than men and 0.31 fewer radiographs, a significant but small difference. This resulted in 4.8 percent lower and 4.1 percent lower respective charges for women.

The researchers' initial calculations showed much larger differences between men and women in receipt of ancillary tests, but these differences shrunk considerably once patients' diagnoses and lengths of hospital stay were considered. This indicates that factors such as case mix are more important than the patient's sex as determinants of ancillary test use, explain the researchers. They suggest that differences in treatment given to men and women might be more evident in areas of greater physician discretion, such as cardiac procedures.

Details are in "Gender and utilization of ancillary services," by Ashish K. Jha, M.D., Gilad J. Kuperman, M.D., Ph.D., Eve Rittenberg, M.A., and David W. Bates, M.D., M.Sc., in the July 1998 Journal of General Internal Medicine 13, pp. 476-481.

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Primary Care

Physician practice style affects patient outcomes and satisfaction

Family physicians tend to have a practice style that emphasizes health behavior (for example, discussion of nutrition and exercise), counseling, and personal conversation, whereas internists tend to use a more technical style. Internists are likely to confine the office visit to details related to the current complaint or prior illness, medical history, physical examination, lab work results, and the medication or treatment plan. However, it is the physician's behavior, not specialty per se, that affects patient satisfaction and outcomes, finds a study supported by the Agency for Health Care Policy and Research (HS06167).

The study found that patients of physicians whose practice style emphasized the psychosocial aspects of care were more likely to report better health status. Also, patients of doctors who encouraged them to discuss health information and ask questions (patient activation) and who chatted with them about personal topics were more apt to report satisfaction with their care, notes Klea D. Bertakis, M.D., M.P.H., of the University of California, Davis. Dr. Bertakis and her colleagues randomly assigned 509 patients at a university medical center to a family practice or internal medicine clinic at the center and followed them for 1 year of care. They observed patient-physician interactions during office visits and administered the health status and patient satisfaction questionnaires.

Results showed that internists spent significantly more visit time on technical practice behaviors than family physicians (71 vs. 68 percent). During initial visits, family physicians spent 15 percent of the time discussing health behavior and 1 percent on counseling compared with 13 percent and 0.5 percent, respectively, for internists. Patients who received more counseling were more likely to report improved health status. Those whose care was marked by patient activation had the greatest improvement in their satisfaction scores after 1 year, which in turn was significantly related to improved health status.

See "Physician practice styles and patient outcomes: Differences between family practice and general internal medicine," by Dr. Bertakis, Edward J. Callahan, Ph.D., L. Jay Helms, Ph.D., and others, in Medical Care 36(6), pp. 879-891, 1998.

Intensive program improves care satisfaction among frail elderly patients and their doctors

Geriatric evaluation and management (GEM) improves care satisfaction among frail elderly patients and their primary care doctors, concludes a study supported by an interagency agreement between the National Institute on Aging and the Agency for Health Care Policy and Research (AG/HS11047). GEM includes a comprehensive geriatric assessment, followed by an average of seven primary care office visits, and continuous case management by a team consisting of a geriatrician, a nurse, a social worker, and a gerontological nurse practitioner.

In this study, University of Minnesota Medical School researchers randomized Medicare beneficiaries in one Minnesota county who were at high risk of repeated hospitalizations to a usual care group (274) and a GEM group (248). A team social worker initiated the GEM evaluation with a home visit and arranged the patient's initial visit to the GEM clinic for a history and physical examination. In subsequent visits, the team developed treatment goals and a plan of care; provided medical treatment, educational information, counseling, referrals to agencies and other professionals; and provided assistance with advance directives. Patients were discharged from GEM after achieving treatment goals or when their plan of care could be continued successfully without the GEM team.

Based on post-care satisfaction questionnaires, a higher percentage of GEM patients expressed high satisfaction with their care compared with usual-care patients (41 vs. 20 percent, respectively). Patients believed that the GEM had helped them feel better and improved their understanding of their health, decreased their worries, helped them to do more and exercise more, and made taking medications easier. On average, primary care physicians agreed that the GEM care of their patients had been appropriate, helpful to their patients, and helpful to them (the physicians) in the continuing care of their patients.

For more details, see "Satisfaction with outpatient geriatric evaluation and management (GEM)," by Lynne Morishita, M.S.N., Chad Boult, M.D., M.P.H., Lisa Boult, M.D., M.P.H., and others, in The Gerontologist 38(3), pp. 303-308, 1998.

Targeted recruitment strategies can overcome barriers to physicians' involvement in office-based research

To examine how practicing physicians actually deliver care during routine visits requires research involving community-based physicians' offices. However, relatively few studies are conducted in these offices. A new study, supported in part by the Agency for Health Care Policy and Research (HS07289), demonstrates how to boost recruitment of physicians for office-based research. It shows that use of advisory boards to identify potential barriers to doctors' research participation, use of respected members of the medical community as physician recruiters, and obtaining endorsements from physician organizations and prominent members of the medical community resulted in recruitment of 81 percent of contacted physicians to participate in a community-based research project.

These recruitment methods were part of a study designed to investigate the relationship between physician-patient communication and medical malpractice claims. Wendy Levinson, M.D., of the University of Chicago, and her colleagues selected a sample of physicians from the records of Northwest Physicians Mutual, which insures about 40 percent of practicing physicians in Oregon, and Copic, a physician-owned company insuring 70 percent of Colorado's physicians. They created advisory boards consisting of prominent members of the medical community, used well-respected and well-known physicians as recruiters, and crafted recruitment letters endorsed by physician organizations.

Overall, 81 percent of the 169 primary care physicians and surgeons contacted agreed to participate in the research, and 74 percent actually participated. Sixty-nine percent of physicians reported that they were motivated to participate by the promise of personalized feedback about their interviewing style, and 58 percent agreed to take part because of their affiliation with the endorsing organization. Nearly half (47 percent) cited the study topic, 27 percent cited knowing the person who called, and 13 percent cited other reasons for participating.

More details are in "Recruiting physicians for office-based research," by Dr. Levinson, Valerie T. Dull, Ph.D., Debra L. Roter, Dr.P.H., and others, in the June 1998 Medical Care 36(6), pp. 934-937.

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AHCPR News and Notes

AHCPR has grant money available in fiscal year 1999

Congress has appropriated $171.055 million for the Agency for Health Care Policy and Research in fiscal year 1999, a 17 percent increase over FY 1998. This budget level, which is what President Clinton requested for the Agency, clearly demonstrates that bipartisan support for AHCPR continues to grow and strengthen on Capitol Hill.

This budget level will allow the Agency to double the amount awarded by AHCPR last year for investigator-initiated grants and to pursue critical national priorities, including research on quality and outcomes. In fiscal year 1999, AHCPR is looking for outstanding proposals that advance the following research priorities, including:

  • Outcomes for the elderly and chronically ill.
  • Clinical preventive services.
  • Centers for Education and Research in Therapeutics.
  • Improvement in the quality of children's health care.
  • Pharmaceutical outcomes research.
  • Evidence-based practice.
  • Consumer decisionmaking.
  • Shared decisionmaking.
  • Primary care research.
  • Costs, quality, and outcomes.
  • Quality measurement and improvement.

AHCPR is looking for proposals that put a special focus on the needs of vulnerable populations and promote partnerships with potential users of the research findings, such as managed care organizations, primary care organizations, and health care systems, to speed the translation of research into practice.

Select for more information on the grants program and application procedures.

AHCPR announces new evidence report topics

The Agency for Health Care Policy and Research has announced the next topics to be investigated by the Agency's Evidence-based Practice Centers (EPCs). The EPCs will conduct rigorous, comprehensive reviews of the relevant scientific literature on these topics, including meta-analyses and cost analyses, if appropriate. Their findings will be published as evidence reports or technology assessments.

The reports will form the basis of other organizations' efforts to develop and implement their own practice guidelines, performance measures, review criteria, and other clinical quality improvement tools. Potential users of the evidence reports and technology assessments include a wide range of health care providers, medical and professional associations, health system managers, researchers, and others who play key roles in the effort to improve the quality of health care services nationwide. In addition, the reports may give health plans and payers information needed to make informed decisions about coverage policies for new and changing medical devices and procedures. The new EPC topics are as follows:

  • Use of erythropoietin in hematology and oncology. Blue Cross and Blue Shield Association Technology Evaluation Center, Chicago, IL.
  • Management of acute chronic obstructive pulmonary disease. Duke University, Durham, NC.
  • Criteria for determining disability in patients with end-stage renal disease. ECRI, Plymouth Meeting, PA.
  • Treatment of acne. Johns Hopkins University, Baltimore, MD.
  • Anesthesia management during cataract surgery. Johns Hopkins University, Baltimore, MD.
  • Criteria for weaning from mechanical ventilation. McMaster University, Hamilton, Ontario, Canada.
  • Management of cancer pain. New England Medical Center, Boston, MA.
  • Management of acute otitis media. Southern California EPC/RAND Corporation, Santa Monica, CA.
  • Prevention of venous thromboembolism after injury. Southern California EPC/RAND Corporation, Santa Monica, CA.
  • Management of preterm labor. Research Triangle Institute and University of North Carolina at Chapel Hill, NC.
  • Management of chronic hypertension during pregnancy. University of Texas Health Sciences Center, San Antonio, TX.
  • Management of unstable angina. University of California, San Francisco, and Stanford University, Palo Alto, CA.

Attention readers:

AHCPR is very interested in hearing how research funded by the Agency is being used by clinicians to improve patient care, by employers and other organizations to make purchasing decisions, and by policymakers and others to improve the Nation's health care system.

Please let us know if you can provide examples of how AHCPR-funded research findings are being used. Please send an E-mail to Kevin Murray at

HHS Secretary appoints new members to AHCPR's National Advisory Council

HHS Secretary Donna E. Shalala has appointed seven new members to the National Advisory Council for Health Care Policy, Research, and Evaluation. Harold S. Luft, Ph.D., continues to serve as chairman of the council. Select for Overview with Members and Biographies.

The council comprises representatives from academia, health services researchers, health care providers, consumers, and people familiar with the business, legal, and ethical aspects of health care. Its role is to provide advice to the Secretary and to the Administrator of the Agency for Health Care Policy and Research on matters related to AHCPR's activities to enhance the quality, outcomes, effectiveness, access, cost, and use of health care services. The new council members are:

  • Donald M. Berwick, M.D., M.P.P., President and CEO, Institute for Healthcare Improvement, Boston, MA.
  • Jose Julio Escarce, M.D., Ph.D. (re-appointment), Senior Natural Scientist, RAND, Santa Monica, CA.
  • Larry A. Green, M.D., Professor and Woodward Chisholm Chairman of Family Medicine, University of Colorado, Center for Studies in Family Medicine, Denver, CO.
  • Brent C. James, Vice President for Medical Research, Executive Director, Institute for Health Care Delivery Research, Intermountain Health Care, Salt Lake City, UT.
  • Sheila Leatherman, Executive Vice President, United HealthCare Corporation, Minnetonka, MN.
  • James M. Perrin, M.D., Associate Professor and Director of General Pediatrics, Massachusetts General Hospital, Boston, MA.
  • Peter W. Thomas, J.D., Principal Attorney, Powers, Pyles, Sutter, and Verille, P.C., Washington, DC.

Continuing council members are:

  • Colleen Conway-Welch, Ph.D., Professor and Dean, Vanderbilt University School of Nursing, Nashville, TN.
  • Nancy Wilson Dickey, M.D., President, American Medical Association, and Associate Professor, Texas A&M University, College Station, TX.
  • Dennis G. Fryback, Ph.D., Professor, Department of Preventive Medicine, University of Wisconsin, Madison, WI.
  • Vanessa Northington Gamble, M.D., Ph.D., Director, Center for the Study of Race and Ethnicity in Medicine, Associate Professor, History of Medicine and Family Medicine, University of Wisconsin School of Medicine, Madison, WI.
  • Ada Sue Hinshaw, Ph.D., R.N., Dean and Professor, University of Michigan School of Nursing, Ann Arbor, MI.
  • Harold S. Luft, Ph.D., Director, Institute for Policy Studies, University of California School of Medicine, San Francisco, CA.
  • Woodrow A. Myers, Jr., M.D., M.B.A., Director, Health Care Management, Ford Motor Company, Dearborn, MI.
  • Stephen M. Shortell, Ph.D., Professor, Health Policy and Management, University of California, Berkeley School of Public Health, Berkeley, CA.
  • Ruby Takanishi, Ph.D., President, Foundation for Child Development, New York, NY.

Special advisors to the council are:

  • Elliott S. Fisher, M.D., M.P.H., Associate Professor of Medicine, Dartmouth Medical School, Hanover, NH.
  • Nelda P. Wray, M.D., M.P.H., Director, Houston Center for Quality of Care and Utilization Studies, Veterans Affairs Medical Center, Houston, TX.

In addition to the private-sector members, the following Federal officials serve as ex-officio members: Director, National Institutes of Health; Commissioner, Food and Drug Administration; Administrator, Substance Abuse and Mental Health Services Administration; Director, Centers for Disease Control and Prevention; Administrator, Health Care Financing Administration; Assistant Secretary for Defense (Health Affairs); and Chief Medical Officer, Department of Veterans Affairs.

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