Ownership of clinical laboratories by referring physicians: effects on utilization, charges, and profitability.
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Ethics, Medical↗
Biomedical subjects
E Scott
Publications and source records attributed to E Scott.
Responding to workload measurement needs.
Workload measurement is a way of capturing and recording the time and/or activities of personnel in the performance of their health care duties. The traditional focus of workload systems in occupational therapy has been on resource allocation, activity tracking and long range planning. The systems are not organized to link with other institutional, financial and management tools to identify and cost client and programme resource use. The position taken in this paper is that occupational therapy workload measurement systems must be expanded to meet these new managerial responsibilities. Occupational therapists must be able to prospectively predict their workload to accommodate the move towards case costing and programme management. The paper also provides information from a national survey which indicates that there is support from the field for this position.
Canada↗
Regional and individual differences in physician practices for joint-ventured versus non-joint-ventured physicians.
OBJECTIVE: This article compares characteristics of physicians who have invested in health care business (joint ventures) to characteristics of physicians who have not, based on a survey of Florida physicians. DATA SOURCES/STUDY SETTING: In early 1990, a survey was mailed to a stratified random sample of 1,000 Florida physicians. Half were randomly selected from lists of joint-ventured physicians who had been identified as owners in a previous study by the Florida Health Care Cost Containment Board. The remaining half were assumed to be non-joint-ventured (although incomplete results from the previous study meant that some of these physicians would be joint ventured as well). We tagged survey variables with additional variables from the same year representing exogenous influences. STUDY DESIGN: The survey was mailed to a stratified random sample of physicians across specialty and geographic area, with half to identified joint-ventured physicians and half to a control group, some of whom were expected to be joint-ventured. Thus, results regarding differences would be understated. Key variables include referring versus nonreferring physician, to shed light on motivation for joint-venturing; clientele served, to see if systematic differences had implications related to access for poor or underserved persons; geographic area, to see if joint-ventures were undertaken to increase access in rural areas; and other practice variables such as size and type of practice. DATA COLLECTION/EXTRACTION METHODS: Data from all received surveys were encoded and analyzed using SPSS. Incomplete surveys were also encoded so that all information would be available for possible use. PRINCIPAL FINDINGS: Results indicate that joint-ventured physicians are more likely than non-joint-ventured physicians to be referring physicians. Also, joint-ventured physicians report serving lower proportions of Medicaid and self-pay (uninsured) patients and higher proportions of Medicare patients. Joint-ventured physicians are also more likely to practice in urban areas, to practice full time, to be members of larger practices, and to practice in group practices. Further, joint-ventured physicians are more likely to practice in areas with high proportions of Medicare patients. CONCLUSIONS: Policymakers should continue to regard physician joint ventures as problematic, since results of this study indicate that physicians who engage in a joint venture almost always have the ability to refer patients to that joint venture due to the nature of their practices. Results also show that joint ventures are associated with decreased access: that is, they provide care to lower proportions of poor and underserved patients and rural patients than their non-joint ventured counterparts.
Economics, Medical↗
A survey of workload measurement systems: the occupational therapy manager's perspective.
Interest in measuring workload for budget specific purposes has increased in recent years as health care managers are being forced to cope with the demands of cost containment and fiscal accountability. This paper reports on a survey of senior occupational therapy managers of Ontario facilities accredited by the Canadian Association of Occupational Therapists (CAOT). Respondents were surveyed on their experiences with, and attitudes toward, occupational therapy workload measurement systems and the ability of these systems to assist in management activities. The survey found that most departments were using the National Hospital Productivity Improvement Program (NHPIP) system. Seventy eight percent of managers indicated they were somewhat or very satisfied with the system, but 60% also indicated that it did not adequately meet all of their management needs. In terms of desirable features of a revised workload system, 87% of managers reported wanting a system based on diagnostic or case mix group recording. Client variables (91%), physical and psychosocial aspects of client care (89%) and therapist variables (85%) were also rated as important factors to address in developing new workload systems.
Attitude of Health Personnel↗
Surviving the management game: workload measurement systems in a cost-conscious environment.
Using a procedure-based occupational therapy workload measurement system developed at, and applied by, Sunnybrook Health Science Centre, this paper explores the objectives of such a system from the point of view of the occupational therapy manager. It also takes into account the synergistic relationship between the occupational therapist and the administrative/business aspect of health care, paying special attention to past and present trends in health-care accountability. In this paper it is argued that occupational therapy managers must relate their procedures and overhead costs to actual client care, if they are to be included in programme management and client costing. The process used by occupational therapy to describe its own procedures for the system is outlined. The system was then developed in conjunction with other institutional, financial and management tools for the client cost conversion process. By using a procedure based workload measurement system, occupational therapy is able to accurately describe client costing, thereby articulating our role in client care.
Costs and Cost Analysis↗
Involving clients in programme evaluation and research: a new methodology for occupational therapy.
Eliciting client satisfaction with services has become common in mental health settings and in the planning of service delivery systems. It is also compatible with the client-centred practice of occupational therapy. The traditional approach to collecting satisfaction information involves staff interviewing clients using questionnaires developed by staff. However, there is often a lack of variability in responses and the vast majority of clients report being satisfied. A review of the literature reveals that these favourable reports may be a result of social desirability and of clients being interviewed by treatment providers who have the power to give or withhold care. This paper reviews the relationship between occupational therapy and client involvement, examines the rationale for involving clients in programme evaluation and research, reviews the limitations with traditional methods of collecting information about client satisfaction, and discusses how clients are involved in evaluation and research in today's mental health care setting.
Canada↗
Physician ownership of physical therapy services. Effects on charges, utilization, profits, and service characteristics.
OBJECTIVE: To evaluate the effects of physician ownership of freestanding physical therapy and rehabilitation facilities on utilization, charges, profits, and three measures of service characteristics for physical therapy treatments. DESIGN: Statistical comparison by physician joint venture ownership status of freestanding physical therapy and comprehensive rehabilitation facilities providing physical therapy treatments in Florida. PARTICIPANTS: A total of 118 outpatient physical therapy facilities and 63 outpatient comprehensive rehabilitation facilities providing services in Florida during 1989. The data from the facilities were collected under a legislative mandate. MAIN OUTCOME MEASURES: Visits per patient, average revenue per patient, percent operating income, percent markup, profits per patient, licensed therapist time per visit, and licensed and nonlicensed medical worker time per visit. RESULTS: Visits per patient were 39% to 45% higher in joint venture facilities. Both gross and net revenue per patient were 30% to 40% higher in facilities owned by referring physicians. Percent operating income and percent markup were significantly higher in joint venture physical therapy and rehabilitation facilities. Licensed physical therapists and licensed therapist assistants employed in non-joint venture facilities spend about 60% more time per visit treating physical therapy patients than licensed therapists and licensed therapist assistants working in joint venture facilities. Joint ventures also generate more of their revenues from patients with well-paying insurance. CONCLUSION: Our results indicate that utilization, charges per patient, and profits are higher when physical therapy and rehabilitation facilities are owned by referring physicians. With respect to service characteristics, joint venture firms employ proportionately fewer licensed therapists and licensed therapist assistants to perform physical therapy, so that licensed professionals employed in joint venture businesses spend significantly less time per visit treating patients. These results should be of interest to the medical profession, third-party payers, and policymakers, all of whom are concerned about the consequences of physician self-referral arrangements.
Conflict of Interest↗
New evidence of the prevalence and scope of physician joint ventures.
Physician ownership of health care businesses (outside their own practice) to which they refer patients has attracted considerable attention in the medical literature, in the media, and from federal and state policymakers. Despite the concerns raised about these ownership arrangements, known as joint ventures, the prevalence and scope of joint ventures involving physicians is not well documented. This report examines the prevalence and scope of physician joint ventures in Florida based on data collected under a legislative mandate. Our results indicate that physician ownership of health care businesses providing diagnostic testing or other ancillary services is common in Florida. While this conclusion is based on our comprehensive survey of health care businesses in Florida, it is at least indicative that such arrangements are likely to occur elsewhere. We find that at least 40% of Florida physicians involved in direct patient care have an investment interest in a health care business to which they may refer their patients for services; over 91% of the physician owners are concentrated in specialties that may refer patients for services. About 40% of the physician investors have a financial interest in diagnostic imaging centers. The estimates reported here indicate that the proportion of referring physicians involved in direct patient care who participate in joint ventures is much higher than previous estimates suggest.
Data Collection↗
Second bone marrow transplants for relapsed leukemia.
Seventeen patients who had a relapse at a median of 9 months after marrow transplant (14 allogeneic and three syngeneic) received second transplants. Eight patients were in remission when transplanted. Of the nine patients with active disease at the time of transplant, six had complete remissions, and one converted from blastic to chronic phase of chronic myelogenous leukemia. The median survival was 9 months (95% confidence interval, 4 to 17 months). Four patients died within 100 days of transplantation, and three were disease-free. Ten patients died after 100 days, all except two of disease relapse. Five patients had remissions that were greater than 12 months and longer than the remission after their first transplant (inversions). Three patients remain alive and disease-free at 37+, 55+, and 61+ months, the former two despite remissions of less than 1 year after their first transplant. Second transplants with a different cytoreductive regimen can eradicate disease resistant to prior myeloablative treatment; some patients may benefit from second transplants, even if the first transplant only achieves a short remission.
Adolescent↗
A trial of the prostaglandin E1 analogue, enisoprost, to reverse chronic cyclosporine-associated renal dysfunction.
Cyclosporine (CYA) reduces the renal synthesis of prostaglandins of the E series (PGE). Analogue of PGE1 have been shown to mitigate the vasoconstriction and abnormal renal function of experimental acute CYA nephrotoxicity. We examined the hypothesis that the orally bioavailable PGE analogue enisoprost (EP) would improve renal function in renal transplant recipients chronically exposed to CYA. In a randomized double-blind study, 40 patients at two centers who were being monitored for 3 to 30 months after renal transplantation, were allocated to receive either EP 100 micrograms orally four times daily or placebo (P) for 2 weeks. CYA dosing was fixed at existing levels. There could be no evidence of concurrent acute renal injury, including that of acute rejection. Glomerular filtration rate (GFR) was measured by the clearance of radiolabeled DTPA, while effective renal plasma flow (ERPF) was measured as the clearance of p-aminohippuric acid (PAH). The acute effects of EP were examined twice, by comparing immediate postdose to predose values for GFR and ERPF on day 1 and again on day 14. Chronic effects were examined by comparing baseline (predose) values only for GFR and ERPF between days 1 and 14 and by an examination of creatinine clearances (CCR) on days 0, 14, and 21. At enrollment, patients were well matched for renal function (CCR:EP 47 +/- 5 v P 49 +/- 4 mL/min/1.73 m2; P = NS). Baseline demographics were similar, although patients treated with EP were older (46 +/- 2 v 36 +/- 3 years, mean +/- SEM, P = 0.003). CYA doses and blood levels did not change significantly.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Shift coordinators dispel myths.
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Humans↗
The effect of general practitioners' advice to heavy drinking men.
The objective of the study was to determine the effectiveness of advice from general practitioners to heavy drinking men (consuming 350-1050 grams of alcohol per week) to reduce their alcohol consumption. One hundred and fifty-four men recruited from eight general practices were allocated randomly to treatment and control groups. Men in the treatment group received advice from their own general practitioner. At one year follow-up, when analyzed according to intention to treat, the treatment group had reduced their consumption by an excess of 65 grams of alcohol per week when compared with the control group (p less than 0.05). General practitioners should be recommended to screen for alcohol consumption amongst their patients and to give advice to those found to be at risk because of their drinking.
Adult↗
The bactericidal activity of a methyl and propyl parabens combination: isothermal and non-isothermal studies.
The effect of temperature on the kill rate of Escherichia coli by methyl and propyl parabens was studied. The kill kinetics was first order. It was shown that the Arrhenius equation provided a good model for describing the relationship between the first order rate constant and the temperature. The activation energy was found to be 274 kJ/mol for exponential phase cells and 168 kJ/mol for stationary phase cells. Exponential phase cells were much more susceptible to the lethal effects of the parabens than were the stationary phase cells. For example, at 34 degrees C stationary phase cells, in chemically defined media, had a kill rate constant of 0.072/h while the corresponding value for exponential phase cells was 0.238/h. In water the rate of kill for exponential phase cells was even faster giving a rate constant of 5.25/h at 34 degrees C. Non-isothermal kinetic testing was not found to be useful for modelling bacterial kill kinetics because we could not achieve the precision required in bacterial enumeration.
Culture Media↗
Kinetic evaluation of claimed synergistic paraben combinations using a factorial design.
The antimicrobial effects of methyl and propyl parabens are investigated, with Escherichia coli as test organism, with a view to determining whether the parabens act synergistically. At appropriate concentrations, the parabens killed E. coli cells according to first order kinetics and the bactericidal effects were quantified by the first order kill rate constants. Combinations of methyl or propyl parabens, at concentrations which slow down or inhibit bacterial growth when used singly, produced definite kill. In this sense, the parabens are therefore synergistic since in combination they produce an effect which is not observed when they are used singly. This effect is not true synergism as shown by the results of our experiments with a factorial design. Analysis of variance indicated no significant interaction between the two parabens.
Analysis of Variance↗
Physician self-referral: empirical evidence and policy implications.
Ownership of health care businesses to which physicians refer patients but at which they do not directly provide services, has become commonplace in recent years. Perhaps these self-referral arrangements, known as "joint ventures," have proliferated because they are lucrative investments whereby physicians can earn legalized kickbacks for patient referrals. This article reviews existing empirical studies documenting the effects of physician self-referral arrangements. The general concensus of the empirical evidence on physician self-referral reveals that the financial incentives inherent in such arrangements are associated with increased utilization of services and higher costs to patients. None of the studies to date, however, has been able to determine whether the increased utilization that accompanies the practice of physician self-referral represents inappropriate or unwarranted services. Policy options which address the problem of physician self-referral are also discussed.
Ambulatory Care Facilities↗
Synthesis and bioactivity of copolymers with fragments of heparin.
A new type of biocompatible copolymer comprising small fragments of heparin, (octa- to dodecasaccharides) copolymerized with a synthetic monomeric component, viz. acrylamide, has been prepared. The heparin fragments are produced by enzymatic or chemical means and are copolymerized, directly or after suitable derivatization, with acrylamide as the major polymerizable component. The polymeric material incorporates the heparin segments as pendant moieties such that their essential functional groups and structural features for specific binding with the selective serine protease coagulation factor inhibitor antithrombin III are preserved. An important feature of this copolymer is its biocompatibility which relates specifically to its antithrombotic and antithrombogenic activity derived from those of heparin fragments. The biological activity of heparin fragments and copolymers thereof are determined in terms of APTT and anti-Xa activity, their antithrombotic potential being expressed as a ratio of anti-Xa activity to APTT. The copolymers reported have biological activities similar to equivalent amounts of respective heparin fragments, and show higher antithrombotic activity compared to intact heparin or commercially available low-molecular-weight heparin (4,000-6,000 Da).
Acrylamide↗
Effect of parasitism with Nematodirus battus on the pharmacokinetics of levamisole, ivermectin and netobimin.
The pharmacokinetics of levamisole, ivermectin and netobimin administered orally and by subcutaneous injection were compared in lambs exposed to a moderate challenge with Nematodirus battus and in parasite naive lambs. There were no significant differences (P greater than 0.05) in the bioavailability of any of the anthelmintics tested between parasitized and non-parasitized animals. Levamisole reduced nematode faecal egg output by more than 99% when administered by either route. Ivermectin was also highly effective (greater than 99%). Orally administered netobimin reduced egg output by more than 98% seven days after administration. However egg output was only reduced by 89% 21 days after administration, suggesting poor activity against the early parasitic stages of N. battus. Netobimin was not effective against N. battus when administered by the subcutaneous route and this was probably because very low plasma concentrations of its active albendazole metabolites were achieved.
Administration, Oral↗
Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.
Seventy two women drinking 21 units (210g) or more of alcohol per week were recruited from an opportunistic screening programme in eight English general practices. The women were randomized into control and treatment groups. Women in the treatment group received ten minutes advice from their general practitioner to reduce alcohol consumption. At one year follow-up, when analyzed by intention to treat, women in the treatment group had reduced their alcohol consumption from an average of 35-24 units per week. Similar reductions were found in the control group (from 37-27 units per week). The lack of evidence for a treatment effect may be explained by contamination of the control group by informal interventions.
Journal Article↗