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PubMedDate not supplied

Physicians and prepaid group practices.

Prepaid group practices (PGPs) are complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. PGPs' ability to manage their physician staffing efficiently must be placed in context with the cost and quality of their care. It seems unlikely that PGPs or their use of staff will proliferate. With increased integration of care through disease management programs and use of clinical information technology, it should be possible for the United States as a whole to come closer to achieving the care delivery goals that PGPs have set in the past.

Costs and Cost Analysis↗
PubMed1977

National dermatology manpower requirements: the experience of prepaid group practices.

Ten prepaid group health plans across the country were surveyed as part of an effort to estimate the need for dermatologists in the United States. Although generalizing the experiences of prepaid group practices to the general population is at best an imprecise approach, the dramatic shortage suggested by the data cannot be completely ascribed to the method used. Whereas the average ratio in the surveyed plans was 2.8 dermatologists per 100,00 subscribers, there are only about 1.9 dermatologists providing patient care per 100,000 persons in the general population. The difference between prepaid plan subscribers and the general population in annual visits to dermatologists is even more dramatic: 193 per 1,000 subscribers compared to 84 per 1,000 population.

Dermatology↗
PubMed1990

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↗
PubMed1984

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↗
PubMed1985

Satisfaction with children's medical care in six different ambulatory settings.

This article compares mothers' satisfaction with children's medical care in six widely varying settings: fee-for-service solo and group practices, prepaid group practice, public clinics, hospital outpatient departments, and emergency rooms. Data are from a household survey representing 700 children in Washington, D.C. Satisfaction with the physician's friendliness, competence, and personal care, as well as waiting time, atmosphere, and cost were examined, comparing how satisfaction levels varied in relation to patient attributes and also among medical settings. Findings revealed significant differences across settings, even controlling statistically for multiple patient characteristics. Satisfaction with interpersonal items was highest in fee-for-service settings, especially solo practice, whereas satisfaction with cost was highest in the public clinics, followed by the prepaid group practice. Previously published comparisons of utilization and health outcomes in the same settings revealed entirely different rankings. Together, these findings illustrate the multifaceted and paradoxical nature of health system performance.

Age Factors↗
PubMed1979

The effect of length of membership upon the utilization of ambulatory care services. A comparison of disadvantaged and general membership populations in a prepaid group practice.

The relationships between duration of membership and the use of outpatient medical care services for disadvantaged and general membership groups in a prepaid group practice were analyzed. The effects of duration of membership upon utilization rates during a six-year study period were estimated by retrospective cohort analyses. Rates were computed for successive three-month intervals. There were no significant start-up effects on use for new enrollees in either study population. This finding is in contrast to what has been reported in other studies. New HMOs or existing HMOs with many new members may not require the additional resources previously thought necessary. Average cohort utilization rates were higher for the disadvantaged cohorts, with the exception of young males 0 to 14 years old. We also examined the persistence of utilization patterns over time. Consistently high users and nonusers were found in both populations. In general, these findings suggest that length of time does not affect ambulatory care use. Age, sex, socioeconomic background and health status are more important than duration of membership in accounting for differences in utilization.

Adolescent↗
PubMed1976

Time utilization of a population of general surgeons in a prepaid group practice.

Seven general surgeons in a prepaid group practice previously shown to have a mean operative work load of 9.2 hernia equivalents (HE) per week were found to have a standardized mean daytime working week of 56.2 hours, exclusive of evening activities of which 50.7 hours were devoted to professional activities. The surgeons also devoted a mean of 6.7 evening hours per week to professional activities for a mean net professional week of 57.4 hours. Comparisons with a population of previously studied community surgeons revealed that the prepaid group surgeons were able to produce a surgical output more than double that of the community surgeons while devoting only one and a half as much time to professional activities. Economies in the utilization of surgical manpower in the prepaid group appear to stem from: 1) restriction of practice setting to a single geographic location, 2) restriction of patients to surgical patients, 3) reduced surgeon waiting time in the office, and 4) the utilization of paraprofessional personnel for selected operative assisting. These economies were achieved while the prepaid group surgeons were observed to average more time per patient visit both on rounds and in the office than the community surgeons.

Adult↗
PubMed1979

Mental health services: utilization by low income enrollees in a prepaid group practice plan and in an independent practice plan.

Mental health services were included in a comprehensive package of benefits available to low income enrollees in a prepaid group practice plan (PGP) and in an independent practice plan (IPP) under the Seattle Prepaid Health Care Project. There were no out-of-pocket costs for enrollees. Utilization of services was studied for four years under conditions that might simulate universal entitlement. The analyses indicated that females used substantially more mental health services than males and that enrollees aged 20-44 used more services than those in other age groups. The prepaid group practice generally experienced higher utilization than the prepaid independent plan. Significant racial differences were evident with whites using more services than blacks and black males using strikingly few services. The prepaid independent plan was oriented toward physician providers and emphasized individual psychotherapy while the prepaid group practice employed a diversity of practitioners and therapeutic modalities. The data indicated that the per cent of enrollees using any mental health services was twice as great in the PGP as in the IPP. However, once access to the provider system was achieved, the number of services utilized was greater in the PGP. Inpatient services were also examined. A significantly higher proportion of IPP enrollees were admitted for inpatient care as compared to PGP enrollees. Finally, the cost of mental health services was less than ten per cent of total health service costs in both plans.

Adolescent↗
PubMed1980

The use of prenatal cytogenetic diagnosis: a comparison of rates in prepaid group practices and the general population.

To determine whether the reduction in services associated with prepaid group practice is indiscriminate or limited to medically "discretionary" services, the author compared the utilization rates for prenatal cytogenetic diagnosis (a medically indicated service for women aged 35 and older) in prepaid group practices and the geographically corresponding populations-at-large in four settings. The utilization rates by members of the prepaid group practices were equal to rate calculated for the geographically correspondings populations-at-large in two settings, and 2.3 times greater in the other settings. Whatever factors which may be responsible for the reduction of discretionary services delivered to members of prepaid group practices do not appear to interfere with the delivery of a strongly indicated service, prenatal cytogenetic diagnosis, in the population at risk.

California↗
PubMed1976

The effect of prepaid group practice on physicians' utilization behavior.

The study is concerned with the practice of physicians in a prepaid group practice setting. Specifically, it is concerned 1) with investigating the extent of variation in physician behavior concerning use of clinical resources, that is, office visits and telephone calls, and technical resources, that is, x-rays and laboratory procedures, and 2) with determining the factors that account for such variation. The universe of this study consists of all internists practicing in 1970 in the prepaid group setting of Kaiser Permanente at Portland, Oregon, a total of 34. The overall framework for the study is based on the belief that medical training and the setting in which physicians work are significant determinants of their use of clinical and technical resources in different disease situations. Specifically, the framework posits that different sets of organizational variables are important in determining use of resources for acute and undiagnosed conditions. The findings reported in the study suggest that while the teaching environment in which a physician is trained is important in shaping his clinical personality, the setting in which he actually works contains its own source of influence over his professional activity. These results also provide supportive evidence for the widely held notion that prepaid group practice, through changing the nature of the incentives to physicians and introducing professional regulation, leads to a more efficient way of providing medical care by reducing the use of costly resources.

Consumer Behavior↗
PubMed1981

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↗
PubMed1979

The relative emphasis upon physician practice and organizational affairs of a consumer council in a prepaid group practice health plan.

This paper examines the topics of interest to a consumer advisory council in the Health Insurance Plan of Greater New York, a prepaid group practice. Data are derived from observations of consumer council meetings. Topics considered by the council dealt with (a) health plan services, (b) health plan structure, and (c) consumer council structure, process, and organizational role. The council was primarily interested in retaining and expanding existing services, facilitating utilization of services by enrollees, and achieving broader enrollee representation on the board of directors. These interests are directed toward the organizational context within which care is provided and do not relate to physician-patient encounters. Individual enrollees in prepaid group practice may be concerned with the physician-client relationship but consumer representatives are concerned only with the organization-client relationship.

Community Participation↗
PubMed1980

A comparison of surgical assisting in a prepaid group practice and a community hospital.

Previous studies of the work loads and time utilization of general surgeons in two different practice settings suggested that paraprofessional surgical assistants (SAs) could reduce surgeon assisting time and perhaps increase productivity. In order to further assess the potential advantage of using SAs as surgical assistants, the present study examines assisting patterns in a prepaid group practice where SAs are used and in a community hospital where only physicians are available to assist. In the prepaid group practice, 87 per cent of general surgical procedures were performed with an assistant; in the c ommunity hospital, 67 per cent of general surgical procedures were performed with an assistant. General practitioners also were found to assist in the community hospital; family practice residents, medical students and "others" also assisted in prepaid group. In both settings, the propensity to use an assistant was positively correlated with operative complexity. On operations of greatest complexity, surgeons were most likely to act as first assistants. The use of SAs was not usually associated with operative sessions longer than when surgeons assisted, except on operations of high complexity. In the prepaid group, SAs also frequently assisted on orthopedic surgery, neurosurgery and obstetrics-gynecology, only occasionally on otolaryngology and plastic surgery, and never on ophthalmology. It appears that in organizations such as a prepaid group practice, where mechanisms for sharing resources exist and incentives are provided to minimize the total cost of surgery, the utilization of SAs might be associated with cost savings. At present, organizational and financial barriers exist to the introduction of paraprofessionals as surgical assistants. It is difficult to advocate the modification of these barriers to facilitate the training and large-scale introduction of this new group of paraprofessionals in the current surgical market where there may already be an excess supply of surgeons.

General Surgery↗
PubMed1996

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↗
PubMed1975

Factors affecting the choice between prepaid group practice and alternative insurance programs.

This paper examines the basis for the selection of prepaid group practice in a dual-choice situation, and the social, attitudinal, and health characteristics of populations choosing prepaid programs in contrast to other plans. When asked in an open-ended way why they made the decisions they did, those selecting prepaid group practice most frequently referred to the more comprehensive coverage provided and to the fact that at the time of choice they lacked a continuing or adequate relationship with a physician. Enrollees in the prepaid program were better educated and, contrary to previous research, more likely to be unmarried. There was little evidence that enrollees in the prepaid plan brought with them distinctive kinds of attitudes and orientations toward illness and medical care. Enrollees in the prepaid program were also comparable to those retaining an alternative health insurance option on a number of indicators of health status. However, prepaid practice enrollees tended to report more chronic conditions than persons who declined to enroll in the prepaid program. Although the overrepresentation of persons with chronic illnesses is not large, data drawn from a related study suggests that persons with several chronic conditions tend to be heavy users of medical services.

Adult↗