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PubMed1992

Maternity leave for practicing family physicians.

BACKGROUND: Approximately 37% of all medical students and 36% of family medicine residents in training in the United States are women. The American Academy of Family Physicians (AAFP) has developed a recommended parental leave policy for residents in training but has not established a similar policy for physicians in practice. The purpose of this study was to assess the prevalence of maternity leave policies for practicing family physicians. METHODS: A 14-item self-administered survey questionnaire was designed and mailed to 940 AAFP members randomly selected from the total active female membership. RESULTS: A 52% response rate was obtained. The mean age of respondents was 35 years. Only one third of the physicians not in solo practice reported having a stated maternity leave policy in their current place of practice. Academic programs, when compared with single specialty family practice groups, multispecialty groups and health maintenance organization (HMO) or preferred provider organization (PPO) groups, were more likely to have maternity leave policies and to provide salary on leave. Practice groups with eight or more partners were more likely to have policies that provided salary and benefits while on leave. Ninety percent of respondents requested maternity leave guidelines for practicing family physicians. CONCLUSIONS: Women family physicians expressed strong interest in the development of maternity leave guidelines for their specialty. Guideline components are outlined.

Adult↗
PubMed2004

Awakening consumer stewardship of health benefits: prevalence and differentiation of new health plan models.

CONTEXT: Despite widespread publicity of consumer-directed health plans, little is known about their prevalence and the extent to which their designs adequately reflect and support consumerism. OBJECTIVE: We examined three types of consumer-directed health plans: health reimbursement accounts (HRAs), premium-tiered, and point-of-care tiered benefit plans. We sought to measure the extent to which these plans had diffused, as well as to provide a critical look at the ways in which these plans support consumerism. Consumerism in this context refers to efforts to enable informed consumer choice and consumers' involvement in managing their health. We also wished to determine whether mainstream health plans-health maintenance organization (HMO), point of service (POS), and preferred provider organization (PPO) models-were being influenced by consumerism. DATA SOURCES/STUDY SETTING: Our study uses national survey data collected by Mercer Human Resource Consulting from 680 national and regional commercial health benefit plans on HMO, PPO, POS, and consumer-directed products. STUDY DESIGN: We defined consumer-directed products as health benefit plans that provided (1) consumer incentives to select more economical health care options, including self-care and no care, and (2) information and support to inform such selections. We asked health plans that offered consumer-directed products about 2003 enrollment, basic design features, and the availability of decision support. We also asked mainstream health plans about their activities that supported consumerism (e.g., proactive outreach to inform or influence enrollee behavior, such as self-management or preventive care, reminders sent to patients with identified medical conditions.) DATA COLLECTION/EXTRACTION METHODS: We analyzed survey responses for all four product lines in order to identify those plans that offer health reimbursement accounts (HRAs), premium-tiered, or point-of-care tiered models as well as efforts of mainstream health plans to engage informed consumer decision making. PRINCIPAL FINDINGS: The majority of enrollees in consumer-directed health plans are in tiered models (primarily point-of-care tiered networks) rather than HRAs. Tiers are predominantly determined based on both cost and quality criteria. Enrollment in HRAs has grown substantially, in part because of the entry of mainstream managed care plans into the consumer-directed market. Health reimbursement accounts, tiered networks, and traditional managed care plans vary in their capacity to support consumers in managing their health risks and selection of provider and treatment options, with HRAs providing the most and mainstream plans the least. CONCLUSIONS: While enrollment in consumer-directed health plans continues to grow steadily, it remains a tiny fraction of all employer-sponsored coverage. Decision support in these plans, a critical link to help consumers make more informed choices, is also still limited. This lack may be of concern in light of the fact that only a minority of such plans report that they monitor claims to protect against underuse. Tiered benefit models appear to be more readily accepted by the market than HRAs. If they are to succeed in optimizing consumers' utility from health benefit spending, careful attention needs to be paid to how well these models inform consumers about the consequences of their selections.

Consumer Behavior↗
PubMed1989

The triple option choice: self-selection bias in traditional coverage, HMOs, and PPOs.

Health care costs and utilization by salaried employees and their dependents at a large self-insured midwestern industrial manufacturing corporation were analyzed for the year before employees were first offered a triple option choice. Members had the option of retaining traditional Blue Cross and Blue Shield of Michigan (BCBSM) coverage or switching to either a number of health maintenance organizations (HMOs) or a number of preferred provider organizations (PPOs). Members who switched to HMOs or PPOs were generally younger and had lower average expenses and utilization rates than those who retained the traditional BCBSM plan. The results suggest that a selection bias does occur in this population, as lower cost members were more attracted to the HMOs and PPOs than were more expensive members. Implications for the corporation as well as for the drive toward managed care alternatives are discussed.

Age Factors↗
PubMed1988

Use of a preferred provider by employees of the preferred provider.

Little is known about the use of services in a preferred provider organization. We studied Pacific Medical Center (PMC) in Seattle which offered a preferred provider arrangement to its employees who selected a Blue Cross-Blue Shield type of plan. PMC offered to waive copayments and reduce deductibles for those employees when they (or their dependents) used PMC. PMC was thus a preferred provider. In the first 16 months of this program, 632 subjects made at least one claim; of these, 444 (70 percent) used the preferred provider at least once. The use of PMC was highest for male employees (84 percent had at least one visit), next for female employees (74 percent), and lowest for dependents (58 percent). Approximately one-third (32 percent) used PMC exclusively, 30 percent used other providers exclusively, and 37 percent used a combination of PMC and other providers. These may be thought of as best-case estimates, since the subjects--particularly the male employees--had a high level of familiarity with the program and ease of access, while the dependents had high familiarity but less convenient access. Female employees may have used PMC less because of relationships already established with other physicians. Outpatient and inpatient charges were more than twice as high for those who used both PMC and other providers as for those who used one provider exclusively. It may be that the preferred provider arrangement encourages higher charges or, alternatively, that it provides additional flexibility for those who have the most need for care.

Adolescent↗
PubMed1997

Alternative insurance arrangements and the treatment of depression: what are the facts?

Using insurance claims data from nine large self-insured employers offering 26 alternative health benefit plans, we examine empirically how the composition and utilization for the treatment of depression vary under alternative organizational forms of insurance (indemnity, preferred provider organization networks, and mental health carve-outs), and variations in patient cost-sharing (copayments for psychotherapy and for prescription drugs). Although total outpatient mental health and substance abuse expenditures per treated individual do not vary significantly across insurance forms, the depressed outpatient is more likely to receive anti-depressant drug medications is preferred provider organizations and carve-outs than when covered by indemnity insurance. Those individuals facing higher copayments for psychotherapy are more likely to receive anti-depressant drug medications. For those receiving treatment, increases in prescription drug copayments tend to increase the share of anti-depressant drug medication costs accounted for by the newest (and more costly) generation of drugs, the selective serotonin reuptake inhibitors.

Antidepressive Agents↗
PubMed1990

Health services use among the elderly under alternative health service delivery systems.

This article compares patterns of health care utilization for hospitalizations and ambulatory care in a sample of 1855 urban, elderly, community residents who report obtaining their health care from one of four types of arrangements: a fee-for-service (FFS) physician, a hospital-based health maintenance organization, a network model HMO, or a preferred provider organization (PPO). Utilization rates reported by respondents at six month intervals over three years were adjusted for health and socioeconomic characteristics of enrollees. PPO plan members consistently have mean and total lengths of hospital stay one-third to one-half those of the others. Although rates of use of particular categories of ambulatory care vary across systems of care, total ambulatory care rates are highest for network model HMO plan members. Specific features of alternative delivery systems, rather than general model types, may have an impact on utilization rates and the costs of care.

Aged↗
PubMedDate not supplied

Perceived need and receipt of outpatient mental health services. Factors affecting access in Israeli HMOs.

The finance and provision of care have been suggested as variables that affect the utilization of mental health services. This study compared perceived need and receipt of outpatient mental health services in a staff-model health maintenance organization (HMO) and in three HMOs with preferred provider organization (PPO) arrangements. A national random phone survey (n = 1,394) of perceived need for and receipt of mental health assistance was conducted in Israel in 1995. Health care is provided by four HMOs that differ in mental health benefits, utilization management (i.e., prior authorization and referral requirements), and availability of mental health services (i.e., pool of providers and geographic dispersal). About one-quarter of the respondents had perceived a need for help at some time in their life. Significantly fewer respondents from the HMO with a small pool of providers got help (20%) than respondents from the other HMOs, which had almost identical rates of obtaining care (40.3%, 37.3% and 40.3%). Providing generous outpatient mental health care benefits does not appear to increase the proportion of persons in need who get help. However, severely limiting the availability of services does reduce the proportion of persons getting care. Implications for regulating insurers are discussed.

Adult↗
PubMed1999

Characteristics of families who attend free vaccine fairs.

OBJECTIVE: To determine the health care resources and perceived barriers to care of families attending free vaccine fairs. DESIGN: A cross-sectional survey. SETTING: Twelve free vaccine fairs in Denver, Colorado, in 1994. PARTICIPANTS: A total of 533 consecutive parents or guardians of children receiving vaccine at the fairs. Interventions. None. MEASUREMENTS/RESULTS: Survey respondents reported that their children received regular health care through a private physician or health maintenance organization (HMO) (47%), a public clinic (20%), or a hospital-based clinic (14%); 18% had no regular site for health care. Twenty-seven percent of the families carried private insurance, although less than half of these plans covered children's vaccines: 9% were enrolled in an HMO or a preferred provider organization and 13% had Medicaid, whereas 50% had no health insurance. Families who received primary care at a private physician's office (OR: 1.7; 95% CI: 1.01-2.7) and those with no regular site for health care (OR: 2.0; 95% CI: 1.01-4.0) were more likely than those who went to a public clinic or hospital clinic to report free vaccine as the most important reason for attending a vaccine fair. Conversely, families who received well-child care at a hospital clinic were more likely to identify no appointment needed as the most important reason (OR: 2.7; 95% CI: 1. 4-5.1). Families with private health insurance (OR: 2.3; 95% CI: 1. 05-4.0) or no health insurance (OR: 2.3; 95% CI: 1.1-4.6) were more likely to identify free vaccine as the most important reason for attending a vaccine fair, whereas those enrolled in an HMO or preferred provider organization identified convenient time as the most important reason (OR: 3.2; 95% CI: 1.2-8.3). Families with Medicaid (OR: 3.2; 95% CI: 1.3-8.3) or with no insurance (OR: 2.1; 95% CI: 1.02-4.6) were more likely than were those with private insurance to identify no appointment needed as the most important reason for attending a vaccine fair. CONCLUSIONS: Most families attending free vaccine fairs have a regular source of health care. For families with private health insurance or with no health insurance, the availability of free vaccine is the major reason to bring their children to a vaccine fair, whereas for families whose insurance routinely covers the cost of childhood vaccine (HMO, Medicaid), convenience is the major determinant.

Colorado↗
PubMed1997

The role of managed care "products" in managed care "plans".

This paper presents information about the form and structure of managed care products offered by group/staff health maintenance organizations (HMOs), network/independent practice association (IPA) HMOs, and preferred provider organizations (PPOs). The information comes from a 1994 national survey of managed care plans and their arrangements with physicians. The findings confirm that multiple product offerings are now common in managed care plans. The two reasons plans most often cite for including these expanded offerings are to respond to customer interest and to ease the transition to more traditional managed care. Though plans commonly use a consistent provider network for different products, they also vary some arrangements with physicians across their products and pay them in different ways. We discuss the implications of our findings-the most comprehensive study of these issues to date-to aid in understanding the evolution of markets and of managed care, and as a basis for the design of future research and the databases it will require.

Data Collection↗
PubMed1998

Collection from third party payers of reasonable costs of healthcare services--DoD. Proposed rule.

This proposed rule implements several recent statutory changes and makes other revisions to the Third Party Collection Program. The primary matter include implementation of new statutory authority to include workers' compensation programs under the Third Party Collection Program; the addition of special rules for collections from preferred provider organizations; and other program revisions.

Government Agencies↗
PubMedDate not supplied

Reproductive and sexual health benefits in private health insurance plans in Washington State.

CONTEXT: Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems. METHODS: A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations. RESULTS: Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally. CONCLUSIONS: A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.

Family Planning Services↗
PubMed2003

Cost-effectiveness of anastrozole versus tamoxifen as first-line therapy for postmenopausal women with advanced breast cancer.

BACKGROUND: In a recent trial of first-line therapy in 353 postmenopausal women with predominantly hormone receptor-positive advanced breast cancer (the North American trial), anastrozole 1 mg QD produced a significantly longer time to disease progression (TTP) than tamoxifen 20 mg QD (11.1 months vs 5.6 months; P = 0.005). Both treatments were well tolerated, but there were fewer thromboembolic events and a reduced incidence of vaginal bleeding with anastrozole. OBJECTIVE: The aim of this study was to conduct an economic analysis of anastrozole versus tamoxifen based on data from the North American trial. METHODS: Quality-adjusted TTP (QATTP) was determined by combining TTP values with uniform or graded weights for adverse events using the Quality-adjusted Time Without Symptoms and Toxicity method. Direct health care costs before and after disease progression were determined from the perspective of 4 types of health care insurers in the United States: health maintenance organizations (HMOs), indemnity plans, preferred provider organizations (PPOs), and point-of-service (POS) plans. RESULTS: Median QATTP with graded weights was 9.7 months for anastrozole, compared with 4.6 months for tamoxifen (P = 0.003). A resultant reduction in health care resource utilization was observed, particularly the requirements for hospitalization, outpatient visits, and chemotherapy, but the statistical significance of this observation was not assessed. Incremental cost savings per patient before and after disease progression were observed with anastrozole compared with tamoxifen (9064 dollars for HMO, 9678 dollars for indemnity plan, 14,273 dollars for PPO, and 12,715 dollars for POS; all P < 0.01). CONCLUSIONS: In the US managed care setting, anastrozole produced a higher QATTP and incurred lower treatment costs than tamoxifen in a population of postmenopausal women with predominantly hormone receptor-positive advanced breast cancer. Therefore, anastrozole was more cost-effective than tamoxifen as first-line endocrine therapy in the population studied.

Anastrozole↗
PubMed1994

The effectiveness of health care cost management strategies: a review of the evidence.

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.

Cost Control↗
PubMed1994

Legal implications of managed care arrangements.

Prior to the 1980s, managed care was virtually nonexistent as a force in health care. Presently, 64 percent of employees in America are covered by managed care plans, including health maintenance organizations (20 percent) and preferred provider organizations (44 percent). In contrast, only 29 percent of employees were enrolled in managed care plans in 1988 and only 47 percent in 1991. To date, the primary reason for this incredible growth in managed care has been economic-market pressure to reduce health care costs. For the foreseeable future, political pressures are likely to fuel this growth, as managed care is at the center of President Clinton's national health care plan. Although there are numerous legal issues surrounding managed care, this article focuses primarily on antitrust implications when forming managed care entities. In addition, the corporate practice of medicine doctrine, certain tax issues, and the fraud and abuse laws are discussed.

Antitrust Laws↗
PubMed1998

Do California trends foreshadow national ones?

Take a look at what's in California's future, and maybe yours as well, through the California Healthcare Association's recently released report, California Health Care 1998-2005: View of the Future. Key themes in this year's report include incremental health care reform, expanded access to health care coverage for the uninsured, purchasers refocusing on price and quality, and integration in rural health care. Preferred provider organizations will regain popularity, and fewer physicians will remain in solo practice.

Annual Reports as Topic↗
PubMed1991

Patterns of stability and change in health use among elderly people. Do service systems leave an imprint on behavior?

Stability and change in patterns of health service use over a 3-year period were determined for a sample of elderly people in an urban area who claimed one of five types of health service provider as a primary source of health care--a hospital, a private physician, a network model health maintenance organization (HMO), a hospital-based group practice program (G-HMO), or a preferred provider organization (PPO). Despite certain differences in use rates for individual services, the total volume of ambulatory service use was equivalent for all five groups as was the relative rank order of use of specific ambulatory services for four of the five groups. People who claimed a hospital as their primary care source had the most unique use patterns over a full range of health care services, characterized by extremely low rates of physician visits and the highest rates of visits to hospital outpatient clinics across three time periods. G-HMO members used health-related services more frequently than did all others. PPO members, at baseline, had lower rates of total and mean hospital days than other source group members except hospital users. People who changed principal source of care during the study period were most likely to report a hospital as their care source initially. Although there is much consistency in hospital and ambulatory use across groups, the persistence of certain use patterns for members of some groups suggests that health care systems can leave an imprint on the health service use of people for whom they provide regular care.

Aged↗
PubMed2006

Behind the slow enrollment growth of employer-based consumer-directed health plans.

Despite the buzz about empowering consumers and controlling rising health costs, consumer-directed health plans (CDHPs)--defined as high-deductible plans coupled with savings accounts--have barely gained a toehold among Americans with employer-sponsored insurance, according to a new national study by the Center for Studying Health System Change (HSC). CDHP proponents often assert the plans offer employees greater choice and autonomy in the health care marketplace, but 39 percent of the estimated 2.7 million workers enrolled in employer-sponsored CDHPs had no choice of another type of health plan in 2006. Moreover, among workers with a choice of plans, relatively few (19%) choose CDHPs when offered another type of plan option, such as preferred provider organizations (PPOs) or health maintenance organizations (HMO). Comparable take-up rates for PPO and HMO plans when employees have a choice of another plan type were 55 percent and 40 percent, respectively.

Community Participation↗
PubMed1991

Note. Evaluating exclusionary interventions.

In evaluation research, some interventions are designed to affect both the subjects that receive the intervention and those that do not. Preferred provider organizations (PPOs) are an example, because if they are successful, PPOs will direct patients away from non-preferred providers towards preferred providers. When the intervention affects all subjects, the excluded group cannot serve as a control group if one wishes to estimate the experience of subjects in the absence of the intervention. That estimate must come from subjects completely unaffected by the treatment.

Contract Services↗