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PubMed1994

Impact of managed care organizations on ethnic Americans and underserved populations.

Health care reform focuses on cost containment, which in turn focuses on managed care organizations (MCOs). MCOs use strict utilization review and financial risk-shifting to assure that doctors and providers act as gatekeepers to health care services. The gatekeepers are assumed to continue to order necessary care and to eliminate only "unnecessary" care. However, significant potential for abuse exists. In fact, the very foundations on which MCO decisions are made are culturally biased, because they are based on information from largely middle-class, European-American, healthy males. Ultimately, MCOs will change the perceptions and expectations of society regarding health care. These altered perceptions may be contrary to the needs of ethnic Americans, and without safeguards, could worsen existing disparities in health status.

Ethnicity↗
PubMedDate not supplied

Specialty referrals made during telephone conversations with parents: a study from the pediatric research in office settings network.

OBJECTIVES: To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians. METHODS: We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes. RESULTS: Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups. CONCLUSIONS: Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.

Female↗
PubMed2006

The epithelial Mg2+ channel transient receptor potential melastatin 6 is regulated by dietary Mg2+ content and estrogens.

The kidney is the principal organ responsible for the regulation of the body Mg(2+) balance. Identification of the gene defect in hypomagnesemia with secondary hypocalcemia recently elucidated transient receptor potential melastatin 6 (TRPM6) as the gatekeeper in transepithelial Mg(2+) transport, whereas its homolog, TRPM7, is implicated in cellular Mg(2+) homeostasis. The aim of this study was to determine the tissue distribution in mouse and regulation of TRPM6 and TRPM7 by dietary Mg(2+) and hormones. This study demonstrates that TRPM6 is expressed predominantly in kidney, lung, cecum, and colon, whereas TRPM7 is distributed ubiquitously. Dietary Mg(2+) restriction in mice resulted in hypomagnesemia and renal Mg(2+) and Ca(2+) conservation, whereas a Mg(2+)-enriched diet led to increased urinary Mg(2+) and Ca(2+) excretion. Conversely, Mg(2+) restriction significantly upregulated renal TRPM6 mRNA levels, whereas a Mg(2+) enriched diet increased TRPM6 mRNA expression in colon. Dietary Mg(2+) did not alter TRPM7 mRNA expression in mouse kidney and colon. In addition, it was demonstrated that 17beta-estradiol but not 1,25-dihydroxyvitamin D(3) or parathyroid hormone regulates TRPM6 renal mRNA levels. Renal TRPM7 mRNA abundance remained unaltered under these conditions. The renal TRPM6 mRNA level in ovariectomized rats was significantly reduced, whereas 17beta-estradiol treatment normalized TRPM6 mRNA levels. In conclusion, kidney, lung, cecum, and colon likely constitute the main sites of active Mg(2+) (re)absorption in the mouse. In addition, Mg(2+) restriction and 17beta-estradiol upregulated renal TRPM6 mRNA levels, whereas a Mg(2+)-enriched diet stimulated TRPM6 mRNA expression in colon, supporting the gatekeeper function of TRPM6 in transepithelial Mg(2+) transport.

Animals↗
PubMed1995

Managed care and capitation in California: how do physicians at financial risk control their own utilization?

OBJECTIVE: To describe the structure and range of utilization management methods initiated by physicians in response to capitation. DESIGN: Cross-sectional questionnaire. SETTING: A large network-model health maintenance organization (133 contracting physician groups) in California. PARTICIPANTS: 94 (71%) physician groups caring for 2.9 million capitated patients. MEASUREMENTS: Self-reported use of five major utilization management methods. RESULTS: All physician groups reported using gate-keeping and preauthorization for certain referrals or tests. Most also used profiling of utilization patterns (79%), guidelines (70%), and managed care education (69%). Most physician groups asked gatekeepers to submit preauthorization requests for specialty referrals and restricted patient self-referral. For example, 60% of groups required preauthorization for an internal medicine subspecialty referral, and 7% allowed patient self-referral. Most groups also asked gatekeepers to obtain preauthorization for many tests (for example, 95% for magnetic resonance imaging and 53% for pulmonary function tests). Preauthorization requests were denied infrequently (less than 10% of the time) by more than 75% of groups. Of the 54 groups reporting utilization profiles to their physicians, 61% never adjusted for case-mix among patients and more than 60% suggested practice changes to their physicians based on utilization. Fewer than 35% of the groups used written guidelines for expensive tests that required preauthorization (such as angiography). CONCLUSIONS: Physicians are responding to capitation by using utilization management techniques, some at early stages of development, that were previously used only by insurers. This physician-initiated management approach represents a fundamental transformation in the practice of medicine.

California↗
PubMed1996

How HMOs structure primary care delivery.

To promote a shared understanding of how health maintenance organizations (HMOs) deliver primary care, the primary care staffing strategies of 23 HMOs are described: who they use as "gatekeepers," how they use nurse practitioners (NPs) and physician assistants (PAs), their referral policies, and their views on how the scope of practice of primary care may change. The study is based on on-site interviews with senior health plan personnel, and finds wide variations in primary care strategies, from open access to primary care and loose referral policies, to tight gatekeeping systems. In network/independent practice association (IPA) model plans, provider groups and IPAs, not the HMO, often determine who provides primary care. Implications are discussed.

Health Maintenance Organizations↗
PubMed1997

Specialist capitation improves specialty and primary care physician relationships.

Physicians involved in managed care contracting serve as gatekeepers to manage their patients' care and receive payments through capitation arrangements. In serving as gatekeepers, primary care physicians assume financial risk for patients' care. A growing number of specialists, however, are entering into specialist capitation contracts, thereby sharing financial risk and patient care responsibilities. Primary care and specialist physicians should understand the terms of capitation contracts and develop positive working relationships to coordinate efficient, cost-effective patient care. Capitation contracts should define roles and responsibilities of primary care physicians and specialists and should delineate capitated payment rates. When primary care physicians and specialists share financial risk and divide responsibilities, patient care can be managed to the satisfaction of providers, payers, and patients.

Capitation Fee↗
PubMed1996

Back to the Future for Clinical Oncology.

Dear Colleague: I remember, but just barely, what it was like to practice medicine in the first half of this century. My Dad was a general practitioner in a very small farming community in central Illinois, with a hospital of six beds and a trusting clientele. His patients thought he knew how to do everything: deliver babies, set broken bones and take out an appendix. He was an advocate for his patients, not for an HMO or an insurance company. He derived great satisfaction from his practice and was comfortable in this role, up to a point, but knew that he frequently needed the help of specialists from Decatur, St. Louis, and the Mayo Clinic. As his experience and practice evolved, and as medicine itself changed, referrals became a sign of good practice and not an indication of weakness or inadequacy. Some doctors in our town continued to do more than they should have and resisted the trend, and their patients, many with blind faith in their doctor, suffered for it. Clearly, there were economic as well as emotional factors that contributed to this reluctance to ask for help. Clinical oncology is facing much the same situation today. Scientific and economic forces are revolutionizing medicine, but not always in compatible directions. Practice and research have evolved to the point where old patterns of practice are no longer optimal. Few cancer patients can be managed without the input, advice, and even direct involvement of specialists from sister disciplines. Thus, multimodality management of cancer patients is now the norm rather than the exception. At the same time, strong economic forces are dictating a movement in the opposite direction, undermining the strength of traditional academic centers and limiting choices, streamlining patient evaluation, and creating "pathways" to standardize patient management. Who should be setting the course for the cancer patient? We agree that it should not be a clerk at the other end of the phone at the HMO, a computerized practice manual, or even the gatekeeper, who watches his or her capitated bottom line with great nervousness. It should be the physician(s) best able to evaluate the alternatives and communicate these choices to the patient and family. Often it is not possible for a solo physician to make these choices in isolation, particularly when the decisions involve multiple specialties and multimodality therapies. At presentation, many primary cancers now require an integration of the opinion of more than one specialist, and increasingly this integration occurs before surgery. Breast, lung, and prostate cancer, three of our most common diseases, illustrate this point with growing clarity. While less convenient for the doctor, and perhaps less efficient than the "old style" of practice, multimodatity disease center clinics offer significant advantages both to the patient and to the research effort, and are here to stay. Certainly for the payer it is faster and cheaper to have one doctor do it all, but I doubt that the results will be as good. Obviously not all patients need this cooperative approach. It would waste good physicians' time to require that all patients be seen by a radiotherapist, surgeon, and medical oncologist or pediatric oncologist. The specific circumstances may clearly dictate a simple approach and an uncomplicated decision, particularly in dealing with metastatic solid tumors, or at the other extreme, in managing easily resectable, low-risk tumors. However, even here, optimal management of local disease or of potentially resectable metastases may require consideration of an expanded series of options. Thus, all cancer specialists need to be aware of the potential of their colleagues to contribute to disease management. ellipsisWhich brings us to the reason for this journal. The editorial board members of The Oncologist hold the belief that the various subspecialists in oncology should share the same information base and read from the same journal. We believe that cancer specialists should resist the trend to capitulate our responsibilities in disease management to payers, gatekeepers, and hospital administrators. It is up to us to defend the patient's turf and to assure that the patient has an advocate. In order to do so, we will have to be united and fully informed. In this journal, we hope to put the best and latest information on cancer management before our readership, to prepare them for the future, and to do their best as a team for every patient. To this end, we hope to challenge the reader to understand what is new and better, and to let you glimpse the future, not only in terms of research, but also in terms of new team approaches to disease management. We hope to explore how cancer medicine could be and will be practiced as we pass through the economic revolution and return to the future.

Journal Article↗
PubMedDate not supplied

[General medicine in France and in Germany: current situation and future trends].

The health care system has been built up, both in France and Germany, on the same Bismarckian model: health insurance is financed by contributions from employers and employees, ambulatory care is provided by GPs and specialists in private practice ... etc... Since the 90's, in both countries, there has been a move to strengthen the prestige of GPs and broaden their functions in view of lowering the cost of the health system. However, cost containment has not been the single objective. Several laws have been voted for initiating the gatekeeping function of GPs, controlling the installation of specialists in ambulatory care (private practice), reducing the free choice of care providers by the patients... At the same time, post-graduate training in general practice has been strengthened. Due to historical and cultural reasons, several differences appear in the two countries. For example, confidentiality is strictly observed in Germany and health ID appears only in the French system. We are at the start of a long process. Its success will depend on two conditions: the generalization of the gatekeeping function (which should be entrusted to GPs) and the separation of physicians' income level from the amount of the services they provide to the patients.

Confidentiality↗
PubMed1992

Case management in long-term care: it can be ethical and efficacious.

The present-day concept of case management combines two opposing functions, advocacy and gatekeeping, which creates an ethical tension. To maintain a balance between these activities and thus avoid untenable ethical situations, long-term-care programs must at the very least have sufficient dollars to provide required services, those dollars must be committed to the program and not subject to allocation elsewhere, and the services must be distributed fairly among those who need them. Various case management models attempt to separate the advocacy and gatekeeping functions with varying degrees of success.

Aged↗
PubMed2005

Endoscopic therapeutic esophageal interventions: what is new? What needs further study? What can we forget?

PURPOSE OF THIS REVIEW: Endoscopic esophageal interventions form an important part of gastrointestinal endoscopy. This article reviews the most notable results of esophageal endoscopy and interventions published in 2004. RECENT FINDINGS: Both argon plasma coagulation and photodynamic therapy were shown to have high success rates in removing Barrett's epithelium. After ablative treatment, residual Barrett's esophagus still poses an increased esophageal cancer risk and is a concern. Endoscopic resection is now an accepted alternative to surgical resection of early-stage squamous cell and adenocarcinoma of the esophagus. Four studies convincingly demonstrated that covered plastic stents could be used in the initial therapy of patients with refractory benign esophageal strictures, and anastomotic leaks after esophageal surgery. Evidence was presented that intraluminal radiotherapy (brachytherapy) is a valuable alternative to stent placement in patients with malignant dysphagia. It has become clear that injections with botulinum toxin at the gastroesophageal junction in patients with achalasia are often only temporarily effective. It was shown that endoluminal gastroplication produced good symptomatic results; however, data on the reduction of esophageal acid exposure were less impressive. Finally, the first results of endoscopic implantation of expandable antireflux prostheses (Gatekeeper Reflux Repair System, Medtronic Europe, Tolochenaz, Switzerland) in the distal esophageal submucosa were reported. SUMMARY: In 2004, new data on available esophageal therapeutic techniques became available. In addition, new information on an old established technique (brachytherapy for malignant dysphagia) and a new device (Gatekeeper system for the prevention of reflux) were presented.

Dilatation↗
PubMed1991

Alternative methods of hospital remuneration in Israel.

The current method of remunerating hospitals by an average per diem fee tends to over-reimburse hospitals that have a concentration of departments whose true costs are less than the average price received. Hospitals with a high concentration of expensive high-technology service departments whose true costs are more than the average price received will be under-reimbursed and are obliged to cover their running deficits by other means, e.g., donations. Reimbursements on a per diem basis provide a 'perverse incentive' for all hospitals to maximize the length of patient stays in order to maximize their income. This paper briefly examines alternative methods to the deficient per diem method of reimbursing hospitals, such as fee for service, historical budgeting, capitation, gatekeeper's fees and diagnosis-related groups (DRGs). Fee for service or historical budgeting shows little or no advantage over the present system. However, a combination of capitation and/or DRG linked with some form of payment via physician gatekeepers appears to provide a favorable option for correcting the distortions of the per diem system. Department-specific DRG weights for each hospital's department admission mix are used to estimate the magnitude of the current distortion in resources allocated to hospitals. The calculation is based on the changes in hospital income were a DRG mechanism introduced instead of a per diem method. Such changes would increase the hospitalization income of hospitals with low lengths of stay and high bed turnover rates up to 39%. Regional hospital centers with high lengths of stays and low bed turnover rates would receive as much as 17% lower income in some cases. Only if DRG weights were available for each individual hospital would it be possible to ascertain whether differences in lengths of stay reflect differing severities of case loads or differing hospital efficiency levels.

Capitation Fee↗
PubMed1991

Cost containment and quality of life. An experiment in compassion for physicians.

A review of emergency department visits during a 2-year period and before and after the liberation of physicians from a requirement of gatekeeping for some patients during the night showed no significant increases in the use or costs of services to our Medicaid enrollees for all but children under 6 years of age between 10 PM and midnight. We recommend that a more humane and practical view be taken of middle-of-the-night gatekeeping requirements for physicians functioning in managed-care environments. We also suggest, as many hospitals have already learned, that the costs of emergency department services for Medicaid patients can be reduced and that care may be enhanced by the offering of 24-hour urgent care services at or near the emergency department.

Adult↗
PubMed1990

The development of a climate for caring: a historical review of premature care in the United States from 1900 to 1979.

The data presented in this review of the history of premature care in the United States is limited to published material available within the local area. Additional manuscripts, records, and oral histories, would provide a more comprehensive perspective. The period from 1900 to the early 1940s represents the beginning of premature care in the United States characterized by efforts to provide an intrauterinelike environment. Energies were focused on the three identified basic needs of temperature support, nutrition, and protection against infection. The idea of caring for prematures in an especially designated area in the hospital evolved, and premature stations or wards were created. Advances in technology resulted in sophisticated systems for providing warmth for infants and some interventions for respiratory support using oxygen and an infant ventilator. The dangers of cold stress during transport were addressed with attempts to provide warmth using an especially designed transport incubator. A revolutionary growth in technology combined with the nationwide coordinated effort for organizing regional care has characterized this past 30-year period of premature care (1950-1980). The infant is now surrounded by sophisticated life-support systems and receives medical care from a much broader knowledge base than was available in the past. The environment for premature care has truly surpassed any expectations that health care professionals of the past may have held when the concept of an incubator emerged. Nursing of premature infants has expanded with the level of sophisticated equipment and the knowledge of the premature infant's physiologic needs. Nurses are no longer the gatekeepers of a sanctuary against infection. They care for the premature and the family by providing support, information, and caring during an emotionally stressful time. As the premature's physiological condition stabilizes, the nurse helps the family learn to care for the infant and thus transfers the responsibility of providing warmth, nutrition, and protection to the parents. Nurses are now gatekeepers of a very special sanctuary--the sanctuary of caring.

History, 20th Century↗
PubMed1988

Determinants of provider selection or assignment in a mandatory case management program and their implications for utilization.

Mandatory managed-care programs for Medicaid beneficiaries typically require enrollees to select the provider who will act as gatekeeper to the medical care system. A substantial number of beneficiaries, however, do not exercise this choice and are assigned a gatekeeper. Using consumer survey data from the Missouri Managed Health Care Project, we examined characteristics and use experiences of assignees compared with selectors. We found that the assignees enjoyed better health than the selectors and were less likely to have had a regular source of care prior to the program. The utilization experience was similar for both groups. We conclude that the basis for not making a choice is one of indifference.

Adult↗
PubMedDate not supplied

Hypertension control through the design of targeted delivery models.

If we discard some of the assumptions upon which curatively oriented medical care is based, we can design models to deliver more effective services for those with chronic diseases. Assumptions to be discarded are--that disease processes can be cured through the delivery of a "magic bullet" rather than controlled through continuous surveillance, -that the physician must be an active decision maker and thus act as gatekeeper and monitor for all disease victims, and -that care for a family of consumers must be provided together. Models for the delivery of services can then be designed to provide continuity of care for those with a specific chronic disease, and paraprofessionals can be used as gatekeepers and monitors, in combination with physicians, rather than physicians alone, to give services. Models can be targeted to reach specific high-risk groups within the population at the workplace, the school, unemployment office, or wherever groups routinely congregate for purposes other than health care. Building targeted models requires extensive knowledge of the specific geographic area and its population as well as knowledge of the natural history of the disease and its treatment. For hypertension programs, goals can be set in terms of numbers of persons whose disease is controlled and the number of new programs initiated as the result of the control efforts.

Comprehensive Health Care↗
PubMed1995

Diverting managed care Medicaid patients from pediatric emergency department use.

OBJECTIVE: To evaluate the health outcomes of managed care Medicaid children with non-emergent conditions who were not authorized to be seen in the Pediatric Emergency Department (PED) by their primary care provider. DESIGN: Consecutive case surveillance from 6/29/92 to 2/2/93. SETTING: University based PED (17,500 visits/year) in inner city Baltimore. PARTICIPANTS: Cases were MAC children denied authorization to be seen for non-emergent conditions in the PED. Age and complaint matched MAC children were selected from the university based Pediatric Ambulatory Center (PAC) and from non-emergent PED visits (PED-seen) in order to compare utilization rates after denial. INTERVENTION: The Maryland Access to Care (MAC) Medicaid program (started in 12/91) emphasizes primary care and appropriate health care utilization by incorporating the following elements of managed care: assignment to primary care provider, gatekeeping, mandatory enrollment and fee for service. METHODS: Consecutive case surveillance from 6/29/92 to 2/2/93 was used to evaluate the health outcomes of MAC children denied authorization for non-emergent care in a university based PED. One week following denial, a pediatric nurse practitioner contacted the patient's caretaker and the MAC provider to ascertain health outcome. Medicaid claims data was used to compare the six month health care utilization of the denied group to age and complaint matched children seen in the PED (PED-seen) or in a primary care clinic (PAC). RESULTS: 216 MAC patients were not authorized for a PED visit by their MAC providers. 123 (57%) saw their MAC provider within one week of the denied PED visit. 40 (18%) were not seen because their presenting complaint had resolved completely. No adverse health outcomes occurred because of delay in health care delivery. The subsequent ER utilization rate of the denied group was the same as the PED-seen comparison group, and significantly higher than that of the PAC group (P = .002). The denied group was hospitalized at a significantly higher rate relative to these comparison groups (P = .003). CONCLUSIONS: Diverting Medicaid children classified as non-emergent in an ER to their MAC providers can be a safe practice short-term. However, denial of a PED visit has no impact on subsequent ER utilization by Medicaid participants and may be associated with higher hospitalization rate. Gatekeeping in this setting does not necessarily change the health care seeking behavior of these patients.

Baltimore↗
PubMedDate not supplied

Help for health decision challenges.

Medical care is becoming more technically challenging and community-based. The majority of patients and family health gatekeepers (the family member who regulates health care services for the family unit) are female, while the majority of physicians are male. Therefore, differences in female versus male methods of decision making add to the difficulty in making health choices. The female patient and family health gatekeeper may need new knowledge, skills and time to help them deal with difficult medical choices. They may benefit from a multidisciplinary, unbiased group of experts in the form of a Community Healthcare Committee. Trained to be responsible for the general health of the community, the primary care practitioner is ideal to take a leadership role in developing such a committee. A Community Healthcare Committee that understands different methods of health decision making could serve as a resource by providing community health education and private case reviews intended to help individuals with health care decisions.

Choice Behavior↗
PubMed1997

Introducing managed care in Switzerland: impact on use of health services.

The objectives of this study were to assess changes in the self-reported use of health care services after gatekeeping by general practitioners and a global budget were introduced in the health insurance plan for students at the University of Geneva, Switzerland, in October 1992. A random sample of 336 members of the University plan answered questions about their use of health care services during the year before (1992) and the year after (1993) the introduction of managed care. Similar data were collected among a random sample of 300 members of a comparison plan. All participants were 18-44 y old in 1992, spoke French and lived in Geneva. The proportion of insurees who visited specialists decreased by 10% in the University plan between 1992 and 1993 and remained unchanged in the comparison group. The proportion of insurees who visited general practitioners increased by 12% in the University plan and remained unchanged in the comparison group. No effects on the total number of health care visits, on hospitalisations or on use of medications were detected. The introduction of gatekeeping and of a global budget managed by physicians was associated with a transfer of patient visits from specialists to general practitioners.

Adolescent↗