[Practice groups as an alternative to individual practice].
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Germany, West↗
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A controlled trial of the effect of a prepaid group practice on use of services.
Does a prepaid group practice deliver less care than the fee-for-service system when both serve comparable populations with comparable benefits? To answer this question, we randomly assigned a group of 1580 persons to receive care free of charge from either a fee-for-service physician of their choice (431 persons) or the Group Health Cooperative of Puget Sound (1149 persons). In addition, 733 prior enrollees of the Cooperative were studied as a control group. The rate of hospital admissions in both groups at the Cooperative was about 40 per cent less than in the fee-for-service group (P less than 0.01), although ambulatory-visit rates were similar. The calculated expenditure rate for all services was about 25 per cent less in the two Cooperative groups (P less than 0.01 for the experimental group, P less than 0.05 for the control group). The number of preventive visits was higher in the prepaid groups, but this difference does not explain the reduced hospitalization. The similarity of use between the two prepaid groups suggests that the mix of health risks at the Cooperative was similar to that in the fee-for-service system. The lower rate of use that we observed, along with comparable reductions found in non-controlled studies by others, suggests that the style of medicine at prepaid group practices is markedly less "hospital-intensive" and, consequently, less expensive.
Fees, Medical↗
Academic group practice. The physicians' view.
In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.
Attitude of Health Personnel↗
The effects of a prepaid group practice on mental health outcomes.
Does a prepaid group practice relative to comparable fee-for-service plans lead to different mental health outcomes for its beneficiaries? To answer this question, we used data from the RAND Health Insurance Experiment. We observed no statistically significant or clinically meaningful differences in mental health outcomes for families randomly assigned to Group Health Cooperative of Puget Sound or to comparable fee-for-service insurance plans in the Seattle area. We found the same null result for overall mental health status as well as for psychological distress (e.g., anxiety and depression) and psychological well-being, and for the full population as well as the initially sick and poor, although our precision was low for the latter comparisons. Thus, the less intensive style of treatment in the prepaid group practice was not associated with noticeably worse mental health outcomes.
Adult↗
Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings.
OBJECTIVE: To compare health care utilization and outcomes over an 11-year period among persons with rheumatoid arthritis (RA) in fee-for-service and prepaid group practice settings. DESIGN: Cohort of persons with RA followed up for as long as 11 years. The principal measures were obtained from an annual structured telephone interview conducted by a trained survey worker. SETTING: Persons with RA presenting to a random sample of community rheumatologists in northern California. PATIENTS: Patients were enrolled in 2 cycles: in 1982 and 1983 and in 1989. Study rheumatologists listed all persons meeting criteria for RA presenting to their offices over a 1-month period. Of the 1062 so listed, we enrolled 1025, or 96.5%. Of the 1025 persons with RA, 227 (22.2%) reported receiving care in prepaid group practice settings. MAIN OUTCOME MEASURES: As of the end of 1994, 5295 person-years of observation were available for the analysis of the annual level of the utilization and outcome measures; 341 persons had been followed up for all 11 years of the study. The main utilization outcomes measured included office visits, outpatient surgeries, hospital admissions, and painful joints. RESULTS: The persons with RA in fee-for-service and prepaid group practice settings did not differ in the quantity of health care used in any 1 year for either RA or non-RA reasons. Among those followed up for all 11 years, the persons in fee-for-service and prepaid group practice settings did not differ in the cumulative quantity of health care used over the entire period of study. The 2 groups did not differ on any outcome measure on either an annual or long-term basis. The results of mortality analyses were inconsistent: using Kaplan-Meier estimates, the persons with RA in prepaid group practice settings survived significantly longer (P<.05 by long-rank test); using Cox proportional hazards methods, the proportion dying each year did not differ signficantly. CONCLUSIONS: We could find no evidence that persons with RA in fee-for-service and prepaid group practice settings received different quantities of health care or experienced different outcomes on either an annual or long-term basis.
Adult↗
Can academic group practices survive in managed care environments?
Managed care environments have proven difficult for most health care organizations. Academic medical group practices--also called faculty practice plans--in particular have faced enormous challenges in making strategic adaptations to rapidly evolving health care markets. Recent evidence suggests that academic practices have been less than successful in implementing strategies focused on cost leadership and affiliations with primary care physicians. This article asserts that academic group practices cannot succeed by copying strategies implemented by other medical group practices because they have dissimilar missions, organizational capabilities and environmental constraints. The authors use the TOWS matrix--an acronym for threats, opportunities, weaknesses and strengths--a decision analysis framework that integrates both organizational and environmental factors, to assist executives in strategically positioning academic group practices.
Academic Medical Centers↗
Understanding the forces driving medical group practice activities: an overview.
This article provides the historical context for examining the current forces driving medical group practice organizations. Prepayment has been around for some groups since the 1930s and the dual objectives of lowering costs and improving the quality of patient care were among the original reasons for forming group practices. Some of the basic issues for group practices today are discussed in light of evolution of this model of service delivery and the intensity of today's changing environment.
Group Practice↗
Outcomes comparison of solo-practitioner and group practice models.
A solo-practitioner care delivery model is utilized in the predoctoral teaching clinics at the University of Washington School of Dentistry. This model requires students to independently manage their practices using central resources. The model is perceived as cumbersome for patients and students and as failing to achieve optimum educational and productivity outcomes. During the 1995-96 academic year, a group practice model of patient care delivery was pilot tested to assess whether productivity, educational, and care delivery outcomes could be enhanced in comparison to the solo-practitioner model. This group practice model combined third- and fourth-year students for purposes of sharing resources and collaborating in patient care delivery. Resources dedicated to each group practice included a practice advisor, shared patient care coordinator, dental assistant, and shared clinic receptionist. Two group practices and twenty-five student solo practitioners participated in the study. Based upon an analysis of productivity, participant, and patient data, the group practice participants had greater billing volume, better attendance, enhanced satisfaction with the staff/faculty support and their ability to fill appointments, and generally comparable patient satisfaction ratings. These results suggest that the group practice model, through the dedication of resources and collaboration of providers, could enhance the outcomes of the clinical education program.
Analysis of Variance↗
Membership duration and utilization rates in a prepaid group practice.
The relationship between utilization rates and duration of membership in prepaid group practices can have important implications for national policy and HMO administration. The results of this study demonstrate a substantial reduction in utilization rates with increasing duration of membership over a 5-year period in a developing prepaid group practice (PGP) located in urban St. Louis. This "start-up effect" is strongly evident across different socioeconomic subgroupings of the study population (sex, race, income, education and age) and for different employers and cohorts. The implications of widespread start-ups for health care financing policy and for important PGP management decisions are discussed, and suggestions are made for future study of the start-up phenomenon.
Adolescent↗
Academic surgical group practices at the dawn of health reform.
OBJECTIVE: The authors collected, analyzed, and interpreted baseline data concerning academic surgical group practices as they function in the contemporary medical marketplace. SUMMARY AND BACKGROUND DATA: Health care reform officially began with President Clinton's recent address to Congress. Features of reform, such as universal coverage, managed competition, and regulation of graduate medical education (GME) challenge academic surgery. Data relevant to the governance, financial status, and market positions of academic surgical practices are not available. A current analysis of revenue sources and uses has not been published. METHODS: The authors used a 158-question survey to obtain information, for 1992, on adaptation to current market conditions, financial performance, and revenue uses in a sample of 100 academic surgical group practices. RESULTS: The response rate was 83%. Seventy-four selected group surveys were analyzed. Twenty-three groups are affiliated with private medical schools; 51 are affiliated with public medical schools. Fifty-seven per cent of the groups have satellite clinic networks, and 78% own or contract with managed-care entities. Eighty-six per cent of the groups derive more than 50% of referrals from outside the academic medical center. Gross revenue median was $35 million (range $10-$101 million). Revenue growth was reported by 66%. Payer mix trends show growth in government and health maintenance organization (HMO) payers. An average of 71% of faculty salaries come from practice. Practice revenues provide 68% of department expenses and 40% of research funds. Graduate medical education is supported directly by 69% of practice groups. CONCLUSIONS: Academic surgical group practices are vulnerable in the current marketplace. Revenue growth will be limited in the future because of weak payer mix and broad support of academic programs, including GME, using clinical income.
Academic Medical Centers↗
Financial and organizational factors affecting the employment of nurse practitioners and physician assistants in medical group practices.
This study examines the financial and organizational factors that are associated with the employment of nurse practitioners (NPs) and physician assistants (PAs) in medical group practices. The source of the data is a survey of 128 medical group practices in Minnesota. The findings suggest that the employment of NPs and PAs and their ratios to primary care physicians (PCPs) in practices that employ them are influenced by the organizational characteristics of the group practice but not by the degree of financial risk sharing for patient care. Although neither the number of years of experience in financial risk sharing nor more revenue from capitation payment contracts were related to employment of these midlevel practitioners (MLPs), large practices, those located in rural locations, not-for-profit practices, and those that scored low on cohesive cultural traits were more likely to employ MLPs. The data provide insights into the market for MLPs and the potential for these clinicians in the future health care system. As medical group practices become larger and have more organizational capacity, they can likely be expected to increase the employment of MLPs and integrate them into their organizations.
Capitation Fee↗
When is a group practice ready for Medicare risk contracting?
As senior citizens choose alternatives to traditional Medicare, group practices need to learn how Medicare risk contracting differs from traditional Medicare arrangements. To provide healthcare to Medicare patients, group practices should participate in both Medicare risk contracting and Medicare fee-for-service, but they need to make some operational changes to accommodate all these patients. When implementing an operational plan, group practices should consider three key factors-practice location, education of support staff and patients, and facility accessibility. The practice needs to accommodate the special needs of senior citizens to secure and retain a stable patient base.
Aged↗
Federal health policy and group practices: the double-edged sword.
This article explores the various major federal policies affecting medical group practices and whether these policies support, are neutral, or detract from group practice operations. Policies reviewed will consist of the Stark I and II laws with their self-referral and group practice organizational requirements; the Clinical Laboratory Improvement Act; physician reimbursement policies through the Medicare fee schedule (Resource Based Relative Value Scale); and other Medicare reimbursement policies related to teaching physicians, home health, rehabilitation, and rehabilitation services. The article concludes with recommendations as to how federal health policy might be reformed to be more supportive of and compatible with group medicine.
Education, Medical, Continuing↗
A survey of psychiatric group practice administrators: what does the future hold.
Twenty Psychiatric Group Practice (PGP) Administrators were surveyed regarding their perceptions of the advantages and disadvantages of PGP's, and their opinions were sought regarding the future of such groups. Their responses are examined in this article. Many of the current factors in the healthcare environment that may influence the expansion of PGP's are detailed. The result is a prediction of a trend toward PGP's in the future.
Data Collection↗
Quality of care for psychotropic drug use in internal medicine group practices.
To evaluate the care given by internists in group practices at 16 academic medical centers to patients who used minor tranquilizers or antidepressants, data were abstracted from medical records and compared with specific criteria for quality care.Of 1,532 continuing care patients, 18% used minor tranquilizers and 7% used antidepressants. Almost 90% of antidepressants were prescribed for depression and 50% of minor tranquilizers were prescribed for mental health problems. The group practice internists performed well on concrete aspects of care, such as avoiding giving minor tranquilizers intravenously or intramuscularly and scheduling follow-up visits. Relatively few patients, however, had an adequate treatment plan noted in the chart. About 25% of users of minor tranquilizers did not have an acceptable indication for the drug noted in the chart. Less than 10% of users of minor tranquilizers had a plan for discontinuing the drug use; yet, 35% had long-term regular use.
Group Practice↗
Member characteristics, participation, and interests: Public Health Nutrition Practice Group.
A survey was developed to assess the level of participation and the membership interests of the Public Health Nutrition Practice Group (PHNPG). Forty-six percent (500 members) returned a completed survey. More than 80% of members believe PHNPG to be their main professional practice area "home" within the Council on Practice structure. Members overwhelmingly viewed practice group contributions as a responsibility, with personal career benefits being of secondary importance. Reading the practice group's newsletter and voting in elections were major areas of involvement. However, willingness to contribute time was a positive finding. Areas of interest and issues of greatest concern were identified. Results of the survey can be used to prepare long-range plans for PHNPG. Membership involvement in practice group activities is the key to an increase in re-enrollments and in new memberships.
Data Collection↗
Medical care in prepaid group practice.
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Group Practice↗
[Group practice in New York. A report on 9 years of practice in a hospital-related specialist group treating insured patients].
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Group Practice↗