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At least 487 records · Page 27Linked to original sources
PubMed2004

Psychosocial impact of breast/ovarian (BRCA1/2) cancer-predictive genetic testing in a UK multi-centre clinical cohort.

This multi-centre UK study assesses the impact of predictive testing for breast and ovarian cancer predisposition genes (BRCA1/2) in the clinical context. In the year following predictive testing, 261 adults (59 male) from nine UK genetics centres participated; 91 gene mutation carriers and 170 noncarriers. Self-report questionnaires were completed at baseline (pre-genetic testing) and 1, 4 and 12 months following the genetic test result. Men were assessed for general mental health (by general health questionnaire (GHQ)) and women for general mental health, cancer-related worry, intrusive and avoidant thoughts, perception of risk and risk management behaviour. Main comparisons were between female carriers and noncarriers on all measures and men and women for general mental health. Female noncarriers benefited psychologically, with significant reductions in cancer-related worry following testing (P<0.001). However, younger female carriers (<50 years) showed a rise in cancer-related worry 1 month post-testing (P<0.05). This returned to pre-testing baseline levels 12 months later, but worry remained significantly higher than noncarriers throughout (P<0.01). There were no significant differences in GHQ scores between males and females (both carriers and noncarriers) at any time point. Female carriers engaged in significantly more risk management strategies than noncarriers in the year following testing (e.g. mammograms; 92% carriers vs 30% noncarriers). In the 12 months post-testing, 28% carriers had bilateral risk-reducing mastectomy and 31% oophorectomy. Oophorectomy was confined to older (mean 41 yrs) women who already had children. However, worry about cancer was not assuaged by surgery following genetic testing, and this requires further investigation. In all, 20% of female carriers reported insurance problems. The data show persistent worry in younger female gene carriers and confirm changes in risk management consistent with carrier status. Men were not adversely affected by genetic testing in terms of their general mental health.

Adult↗
PubMed2002

Patient protection and risk selection: do primary care physicians encourage their patients to join or avoid capitated health plans according to the patient's health status?

BACKGROUND: Individual physicians who are paid prospectively, as in capitated health plans, might tend to encourage patients to avoid or to join these plans according to the patient's health status. Though insurance risk selection has been well documented among organizations paid on a prospective basis, such physician-level risk selection has not been studied. OBJECTIVE: To assess physician reports of risk selection in capitated health plans and explore potentially related factors. DESIGN AND PARTICIPANTS: National mailed survey of primary care physicians in 1997-1998, oversampling physicians in areas with more capitated health plans. RESULTS: The response rate was 63% (787 of 1,252 eligible recipients). Overall, 44% of physicians reported encouraging patients either to join or to avoid capitated health plans according to the patients' health status: 40% encouraged more complex and ill patients to avoid capitated plans and 23% encouraged healthier patients to join capitated plans. In multivariable models, physicians with negative perceptions of capitated plan quality, with more negative experiences in capitated plans, and those who knew at each patient encounter how they were being compensated had higher odds of encouraging sicker patients to avoid capitated plans (odds ratios, 2.0, 2.2, and 2.0; all confidence intervals >1). CONCLUSIONS: Many primary care physicians report encouraging patients to join or avoid capitated plans according to the patient's health status. Although these physicians' recommendations might be associated primarily with concerns about quality, they can have the effect of insulating certain health plans from covering sicker and more expensive patients.

Adult↗
PubMed2005

[Switching sickness funds and risk compensation mechanisms in the statutory health insurance system in Germany--empirical results from the cooperative health research in the region of Augsburg (KORA)].

Since 1996, all citizens of the Federal Republic of Germany who are insured in the statutory health insurance system are entitled to switch their sickness fund. The rationale of this regulation was to strengthen elements of competition in this system in order to stimulate the sickness funds to improve the efficiency of health care and to respond to consumers' preferences. Simultaneously, to avoid the implicit incentives for sickness funds to engage in risk selection, a risk compensation mechanism was introduced, including as morbidity-related risk adjusters age, sex and incapacity to work. Based on the KORA survey S4 (1999/2001) we take the case of switching behaviour in the region of Augsburg, and analyse whether this risk adjustment scheme was working effectively. The results show that persons changing their sickness fund were characterised by a comparatively smaller burden of chronic diseases and by a less frequent utilization of inpatient health care. Under these conditions, differences in the contribution rates do not accurately reflect differences in the performance and efficiency of sickness funds. Moreover, the migration of good risk to sickness funds with favourable contribution rates threatens the principle of financial solidarity. Therefore, the system of risk equalisation has to be developed towards measuring the risk volume borne by the sickness funds more precisely than hitherto.

Adult↗
PubMed2005

Genetic consultations in primary care: GPs' responses to three scenarios.

OBJECTIVE: This study investigated general practitioners' responses to three scenarios in which patients consulted regarding genetic conditions. DESIGN: Self-completed postal study. Setting. Primary care in Northern Ireland. SUBJECTS: Questionnaire were distributed to all the GPs in Northern Ireland (n = 1079). A total of 541 GPs participated (50%). MAIN OUTCOME MEASURES: Responses to three scenarios in which patients consulted regarding their family history and risk of bowel cancer, breast cancer, and cystic fibrosis. RESULTS: Most GPs correctly identified the patients' risk of bowel cancer, recommended regular colonoscopy, advised lifestyle changes, and did not refer to the genetic clinic. GPs who were qualified for longer were more likely to recommend colonoscopy and less likely to advise lifestyle changes. With the breast cancer patient GPs adopted a cautious approach; most would refer to the genetic and mammography clinics. With the cystic fibrosis example, most correctly identified the patient's risk of carrying the gene, would refer to the genetic clinic, and would encourage the patient to discuss the risk with his partner. In general, doctors were unsure, but would pass on genetic information to insurance companies if requested. CONCLUSION: The study suggests that, in most cases, general practitioners correctly identify at-risk individuals but there may still be some uncertainty regarding referrals. The results suggest that ways of educating GPs should be explored. Educational interventions should be linked to a greater understanding of factors involved in referral (including the influence of gender and experience). The guidelines provided to GPs in relation to the provision of genetic information to insurance companies may need to be reviewed in some countries.

Adult↗
PubMed2003

The Australian joint inquiry into the Protection of Human Genetic Information.

The Australian Law Reform Commission (ALRC) and the Australian Health Ethics Committee are currently engaged in an inquiry into the Protection of Human Genetic Information. In particular, the Attorney-General and the Minister for Health and Ageing have asked us to focus, in relation to human genetic information and tissue samples, on how best to ensure world's best practice in relation to: privacy protection; protection against unlawful discrimination; and the maintenance of high ethical standards in medical research and clinical practice. While initial concerns and controversies have related mainly to aspects of medical research (e.g. consent; re-use of samples) and access to private insurance coverage, relevant issues arise in a wide variety of contexts, including: employment; medical practice; tissue banks and genetic databases; health administration; superannuation; access to government services (e.g. schools, nursing homes); law enforcement; and use by government authorities (e.g. for immigration purposes) or other bodies (e.g. by sports associations). Under the Australian federal system, it is also the case that laws and practices may vary across states and territories. For example, neonatal genetic testing is standard, but storage and retention policies for the resulting 'Guthrie cards' differ markedly. Similarly, some states have developed highly linked health information systems (e.g. incorporating hospitals, doctors' offices and public records), while others discourage such linkages owing to concerns about privacy. The challenge for Australia is to develop policies, standards and practices that promote the intelligent use of genetic information, while providing a level of security with which the community feels comfortable. The inquiry is presently reviewing the adequacy of existing laws and regulatory mechanisms, but recognizes that it will be even more important to develop a broad mix of strategies, such as community and professional education, and the development of official standards and industry codes that reflect emerging international best practice in the area.

Advisory Committees↗
PubMed2001

Psychosocial impact of C282Y mutation testing for hemochromatosis.

The aim of this study was to investigate the psychological effects of genetic testing for hemochromatosis. Study participants included cases discovered through a population screening study in 5211 voluntary blood donors (n = 25) and patients referred for diagnostic evaluation for hemochromatosis (n = 117). Participants completed questionnaires (Spielberger State-Trait Anxiety Index, Medical Outcomes Survey Short Form 36) before and after genetic testing. A subset of participants from the screening study was also interviewed 1 year after testing (Feelings About Test Results Measure). Additional questions included data on insurance applications, time off from work, and family issues. Anxiety significantly decreased in homozygotes and heterozygotes after genetic testing and remained constant in C282Y mutation-negative cases. Vitality and physical composite scores improved after genetic testing. There were no significant deleterious psychological effects of genetic testing on anxiety and on mental and physical health status. There were no negative effects discovered on insurance or time off work. This study has not demonstrated deleterious effects of genetic testing for hemochromatosis on anxiety, mental health and physical health status, insurance, or time off from work. Genetic testing for hemochromatosis is well accepted and should not be discouraged on the basis of potential adverse psychosocial effects.

Absenteeism↗
PubMed2000

Preliminary explorations of the harmful interactive effects of widowhood and marital harmony on health, health service use, and health care costs.

This study examined effects of widowhood and marital harmony on health, health service use, and health care costs. The Americans Changing Lives data set contains 694 subjects who remained married and 61 subjects who became widowed between 1986 and 1989. Estimated annual mean 1989 health costs, adjusting for 1986 costs, age, sex, socioeconomic status, mental/physical health, 1989 health insurance, and selection biases are: $2,384 for widowed, $1,498 for married subjects. Adjusted annual 1989 estimates are: $2,766 for those widowed after harmonious marriages; $2,100 for those widowed after discordant marriages; $1,790 for spouses in discordant marriages; $1,228 for spouses in harmonious marriages. Harmonious marriages appear protective until widowhood, after which higher health costs result.

Aged↗
PubMed2005

Economic modeling of methods to stimulate quality improvement.

OBJECTIVE: This paper uses an economic model to compare three methods for stimulating quality improvement: payment incentives, competition for patients, and emphasis on professional ethics. DESIGN: Use an economic model to simulate the impact on quality distortions (risk selection) of differences in payment incentives, competition for patients, and emphasis on professional ethics. SETTING: Health care policymakers in many countries seek to use incentives and competition to spur quality improvement. However, strong incentives often promote risk selection: insurers and providers financially benefit from distorting quality to attract profitable patients. RESULTS: The analysis suggests that intense competition for patients and strong financial rewards for cost control can exacerbate quality distortions and compromise social solidarity. CONCLUSIONS: Carefully regulated competition and mixed forms of provider payment (risk sharing) appear to be the best options. Moreover, designing competition, regulation, payment, and other forms of health policy to promote suppliers' professional ethics can help society to reap the quality and efficiency benefits of competition and incentives without sacrificing social solidarity.

Altruism↗
PubMed1999

Paying a premium: how patient complexity affects costs and profit margins.

OBJECTIVE AND BACKGROUND: Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. MATERIALS AND METHODS: The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. RESULTS: The profit margin on nonsurvivors was $5,898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. CONCLUSIONS: There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors' trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured.

Cost Allocation↗
PubMed1998

Using risk assessment to evaluate adverse selection under capitated contracts.

Most provider organizations rely on health plan or market-based information about capitation rates, per member per month costs, and utilization trends to benchmark their performance. However, these statistics can be misleading because of differences in enrollee mix and contracting terms across provider organizations. This article describes the limitations of health plan contract provisions in protecting against adverse selection. It describes various actuarial and statistical data sources for evaluation of adverse selection. The article then presents various approaches to risk adjustment on population basis and their use in quantifying adverse selection for health plan contract negotiations.

Actuarial Analysis↗
PubMed1999

The prospective risk adjustment system.

The Episode Classification System is intended to perform two tasks. First, it will be a prospective capitation risk adjuster and predict future health care costs. It will do this by assigning each individual a single capitation risk adjustment category based on an analysis of the medical history and of health care services rendered during a specific period of time. Second, the Episode Classification System will create retrospective severity adjusted Episodes of illness or Episodes of Care. These latter Episodes will provide a framework for relating patient characteristics to the amount, type, and duration of services provided during the treatment of a specific disease. These Episodes will give users the ability to understand past costs and the risk of mortality. As such they will form the basis for provider profiling by allowing users to analyze a complete clinical episode.

Actuarial Analysis↗
PubMedDate not supplied

Medicaid's role in ambulatory health care.

Medicaid plays an enormously important role in ambulatory care financing, both primary and specialized, for patients with routine health needs, as well as individuals with chronic illness and disability. Nearly all Medicaid beneficiaries receive the vast bulk of their health care in ambulatory settings. Medicaid plays a critical role for low-income persons, including children, pregnant women and families, and elderly and disabled Medicare beneficiaries. The Bush administration's proposal to subject federal Medicaid spending to annual aggregate limits could be expected to have especially severe effects on states' capacity to support ambulatory services and achieve innovations in community-based care.

Adult↗
PubMed1991

Evaluating PPO performance using prior expenditure data.

Preferred provider organizations (PPOs) have grown dramatically since 1983, a growth that has been spurred by the hope that they will be able to moderate the rate of growth in health care costs. This remarkable growth has taken place despite the small number of empiric studies that have been published evaluating the effectiveness of PPOs in controlling costs. The experience in the first year of operation of a PPO established by an insurance company for the employees and the dependents of a large midwestern manufacturer is reported. It shows that substantial selection effects were observed, with PPO enrollees substantially more likely to be younger, have more and younger dependents, and to be non-bargaining-unit employees. Enrollees in the PPO also tended to have substantially lower expenditures in the prior year ($596 vs. $821). The effect of the PPO on expenditures was estimated in multivariate regression models controlling for demographic and prior expenditure differences. PPO enrollees were found to have increased their expenditures substantially (P less than 0.0001). Increased expenditures stemming from expansions in outpatient benefits and ineffective utilization management had swamped the effects of reductions in inpatient expenditures and of discounted fees.

Adult↗