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Biomedical subjects

R Feldman

Publications and source records attributed to R Feldman.

At least 19 recordsLinked to original sources
PubMed1992

Economies of scope and payment for physician services.

Physician payment reform will base payment largely upon physician work. Current reforms assume that services are provided independently, yet physicians may often perform two or more services at one time. There is evidence from other industries that services provided jointly may not require the same total resources as identical services provided independently. This study evaluated whether physician-reported work and time were the same for some common services when provided jointly and when provided separately. Six case vignettes were constructed consisting of two services each. Forty-four general internists rated the total work and time required for each vignette performed as a whole, and for the two services performed separately. Total work was estimated using a magnitude estimation technique similar to that used in developing the resource-based relative value scale. For five of the six vignettes, the work rating for performing the services together was significantly less than the sum of the ratings for the separate services. The work savings associated with providing services together ranged from 4% to 30% of the total work of the separate services. A similar reduction was observed for the estimated time to perform services jointly in four of the six vignettes. In no case was work or time lower when services were provided separately. Physicians report lower work and time for at least some pairs of services, compared with providing the same services separately. Reimbursement mechanisms that fail to account for these reductions may provide incentives to combine or add services.

Data Collection↗
PubMed1992

The relationship between low vision and performance of activities of daily living in nursing home residents.

OBJECTIVE: To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents. DESIGN: Survey. SETTING: A non-profit geriatric long-term care facility. SUBJECTS: 21 males, 82 females, aged 66-98. MEASURES: Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist. RESULTS: In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age-related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident). CONCLUSIONS: There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders.

Activities of Daily Living↗
PubMed1992

Employer-sponsored health insurance in 1991.

Since 1987 the Health Insurance Association of America (HIAA) has documented features of employer-sponsored group health insurance through detailed surveys of over 3,000 U.S. firms. The 1991 employer survey reveals several noteworthy developments. The percentage of small firms (100 employees and under) that offer health insurance to their employees has declined since 1989. With a significant increase in health maintenance organization (HMO) market share, more than half (54 percent) of employees in employer-sponsored plans are now covered by managed care plans. Premiums increased 14 percent in 1991, showing identical increases for conventional, HMO, and preferred provider organization (PPO) plans. The percentage of employees in self-insured health plans decreased from 45 percent in 1990 to 40 percent in 1991.

Cost Control↗
PubMed1992

Issues regarding health plan payments under Medicare and recommendations for reform.

The failures of the market for current Medicare health plans include poor information and price distortions and can be attributed to government policy. Reforms that could improve its structure are annual open enrollment periods, premium rebates from health management organizations (HMOs) to members, and termination of the federal government's subsidy of Medicare supplementary insurance. However, the price for a basic Medicare benefits package would still be distorted because Medicare bases its contribution on the cost of a comparable package in the fee-for-service (FFS) sector rather than on the cost of the most efficient plan available to beneficiaries in each market area. The present Medicare HMO program almost certainly increases total Medicare costs and actually discourages HMO growth by shielding beneficiaries from the true price difference between basic benefits in the HMO and FFS sectors. Lacking payment reforms, the Medicare HMO program should be terminated.

Capitation Fee↗
PubMed1992

Factors related to the provision of hospital discounts for HMO inpatients.

Using 1986 AHA hospital survey data, we analyzed hospital-HMO contract provisions, hospital operating characteristics, and market conditions for a national sample of 801 hospitals with HMO contracts to determine the factors related to provision of a discount and the magnitude of the discount if present. Seventy-eight percent of the hospitals reported that at least one of their HMO contracts provided a discount for inpatient services. Risk-sharing provisions, the number of hospitals within a five-mile radius, the proportion of the population enrolled in HMOs, and the number of HMOs operating in the metropolitan statistical area (MSA) were directly related to provision of discounts. Public hospitals were less likely than other facilities to provide discounts. For the magnitude of the discounts, risk-sharing provisions and the number of hospitals within a five-mile radius were again related, as was the number of HMOs operating in the MSA--but this time the number-of-HMOs variable had an inverse relationship. The results suggest that increased HMO market activity does result in price competition for hospital services but that hospital discounting strategies are extremely complex and may not follow conventional market theories. Hospitals appear to be using contracts both to stabilize their relationships with HMOs and increase market share, and they are increasingly giving discounts to achieve those ends.

American Hospital Association↗
PubMed1992

Insurer competition and protection from risk redefinition in the individual and small group health insurance market.

Analyses of problems in the health insurance market usually focus on the individual and small group market. Consumers in this market who experience an illness or diagnosis of illness in one time period are likely to have their future risk redefined by insurers. Despite the fact that risk-averse consumers should desire protection against redefinition of risk, policies featuring that protection currently are not common in the individual and small group market. Contracts offering that protection must either be offered by pools that can guarantee replenishment of good risks over time, or be multiperiod contracts. Risk replenishment is impossible for individuals and may be technically difficult for many small groups. Also, the terms of multiperiod contracts with a single insurer may be unattractive to individuals and small groups, given the current structure of the market. Multiperiod contracts with a pool, rather than an individual insurer, may make it possible for individuals and small groups to enjoy the same advantages as consumers who obtain employment-based health insurance through large firms.

Consumer Advocacy↗
PubMed1991

Coronary angioplasty using new 6 French guiding catheters.

Coronary angioplasty (PTCA) was performed with specially constructed 6-French guiding catheters with an internal lumen of 0.051 inches. In 154 patients these guiding catheters were used in a variety of configurations in conjunction with miniature balloon-on-a-wire dilatation catheters in 1.5 to 3.5 mm sizes to perform PTCA. Overall patient success was 94%. PTCA was attempted in 24 totally occluded arteries with a success rate of 83% and 174 stenoses with a success rate of 97%. 6 French guiding catheters can be used to successfully perform PTCA.

Adult↗
PubMed1991

The alpha-L-(1----2)-trirhamnopyranoside epitope on the group-specific polysaccharide of group B streptococci.

A number of epitope specificities associated with the group antigen (group B polysaccharide) of group B streptococci have been identified in a polyclonal antiserum induced in rabbits by a nonencapsulated variant strain of group B streptococci. This was achieved by using a series of oligosaccharide inhibitors, obtained by both synthetic and degradative procedures, to inhibit the binding of the group B polysaccharide to the polyclonal antiserum. While the dominant epitope expressed in the antiserum was alpha-L-Rhap(1----2)alpha-L-Rhap(1----2)alpha-L-Rhap, specificities associated with alpha-L-Rhap and alpha-L-Rhap(1----3)alpha-D-Galp(1----3)beta-D-Glcp-NAc(1----4)alp ha-L-Rhap were also identified. The dominant expression of the former epitope is consistent with its terminal location on the group antigen and also with highly branched multiantennary structure of this antigen. Antibodies specific for the alpha-L-trirhamnopyranoside epitope were purified by affinity chromatography, using the synthetic trisaccharide glucitol as the hapten. Oligosaccharide inhibition studies indicate that the specificity of these antibodies is identical to that of a murine monoclonal antibody induced by the same nonencapsulated strain of group B streptococci.

Animals↗
PubMed1991

Lipid composition and biosynthesis in the gingiva of the domestic cat.

Periodontal disease in the domestic cat may assume debilitating and serious consequences; however, little is known of the biochemical composition or metabolism of feline gingiva in health or disease. In this report the chemical composition and metabolism of gingival lipids from inflamed an non-inflamed sites is presented and compared to other species with naturally occurring periodontitis. The neutral and phospholipid composition of feline gingiva was found to be distinct from that of porcine and human. As a measure of de novo lipid synthesis, the total incorporation of 14C-acetate into fractionated lipid components was determined and revealed an approximate 2 to 3 fold decrease in inflamed versus non-inflamed gingiva. The decrease in 14C-acetate incorporation appeared to result from a 2-fold increase in free acetate pools in inflamed compared to non-inflamed gingival samples, since total lipase and phospholipase activity were comparable in inflamed and non-inflamed gingiva and total lipid composition was not changed between inflamed and non-inflamed sites. These data are similar to those reported for periodontally involved human gingival tissue and suggest a common effect of periodontal inflammation on lipid metabolism in both species.

Acetates↗
PubMed1991

A simultaneous equations model of employer strategies for controlling health benefit costs.

We estimated a simultaneous equations model of employer health insurance cost control strategies and their effectiveness in reducing health plan premiums. We hypothesized that as premiums increase, employers will shop more actively for health plans, place incentives on providers to control medical care costs, increase employee cost sharing for medical care, and be more likely to offer an HMO. In turn, we expected each of these strategies, except offering an HMO, to reduce average health plan premiums. The model was estimated with 1985 data from a sample of 922 Minnesota employers. We found that high premiums are related to three of the proposed cost control strategies. Employers with higher premiums shop more, are more likely to seek provider incentives, and offer an HMO. However, these employers appear to have lower employee cost sharing. Employers with higher employee cost sharing and those that offer an HMO had lower health plan premiums.

Community Participation↗
PubMed1991

Strategies employed by HMOs to achieve hospital discounts: a case study of seven HMOs.

This article is a summary of seven health maintenance organization (HMO) case studies focusing on strategies used to obtain favorable prices for inpatient hospital services. All of the HMOs stressed that the effort should be based on the local environment and should accommodate the special circumstances of organization of physicians' practices and hospitals, as well as the structure of the HMO and its strategic plan for growth.

Health Care Coalitions↗
PubMed1990

Hemoccult screening in detecting colorectal neoplasm: sensitivity, specificity, and predictive value. Long-term follow-up in a large group practice setting.

STUDY OBJECTIVE: To determine the sensitivity, specificity, and predictive value of Hemoccult II tests for detecting colorectal neoplasm (colorectal carcinoma or polyp or both). STUDY DESIGN: Prospective analyses of asymptomatic patients (greater than or equal to 45 years) followed for 4 years after screening with Hemoccult II testing and retrospective analyses of patients, with known colorectal carcinoma or polyps or both who had Hemoccult II testing within 2 years of diagnosis. SETTING: A large, health maintenance organization practice. MEASUREMENTS AND MAIN RESULTS: In the prospective analysis, the sensitivity of Hemoccult II was 50% for colorectal carcinoma diagnosed within 1 year of testing, 43% within 2 years, and 25% within 4 years. For polyps, sensitivity was 36% at 1 year, 28% at 2 years, and 17% at 4 years. Specificity was 99%. The predictive value of a positive test for colorectal carcinoma was 8% at 1 year, 10% at 2 years, and 11% at 4 years. On the basis of the retrospective analyses, the sensitivity of Hemoccult II for colorectal carcinoma diagnosed within 1 year of testing was 66% and was 61% within 2 years. Many of these patients had symptoms when tested. CONCLUSIONS: An asymptomatic patient age 45 or older with a positive Hemoccult II test has about a chance of 1 in 10 for having colorectal carcinoma and a 1-in-3 chance of having either a colorectal carcinoma or polyp: The same patient with a negative Hemoccult test has a 0.2% chance of having a colorectal carcinoma diagnosed within 2 years of testing and a 0.7% chance of having a polyp. Within 4 years of testing the chance increases to 0.5% for colorectal carcinoma and 1.5% for polyps. If Hemoccult II slides are the only screening method used for detecting asymptomatic colorectal neoplasms, 50% to 60% of lesions will remain undetected. Clinical interpretation of Hemoccult screening requires appreciation of its limits as well as its benefits.

Aged↗
PubMed1990

Contracts between hospitals and health maintenance organizations.

This article describes the contractual relations that are emerging between health maintenance organizations (HMOs) and hospitals. Six HMOs in four large metropolitan areas provided information on 102 hospital contracts. The authors found that the HMOs are becoming more aggressive in placing hospitals in competition with each other for HMO patients. Staff and network HMOs are able to obtain a higher concentration of patients and substantially larger discounts for inpatient services than are individual practice association (IPA) plans in this study.

Competitive Bidding↗