Primary Care/Managed Care

U.S. military experience with managed care questions its cost-saving potential

Large and diffuse managed care networks may not be the answer for containing health care costs, according to a study supported by the Agency for Health Care Policy and Research (HS07490 and T32 HS00028). It shows that in a recent Department of Defense demonstration project, managed care beneficiaries of the CHAMPUS health insurance plan for U.S. military personnel and their dependents used 20 percent more outpatient care than enrollees who chose either the preferred provider organization (PPO) option or the fee-for-service (FFS) option. Unlike the private-sector's experience with managed care, aggressive utilization review did not significantly curtail hospital stays. This suggests that geographically diffuse managed care networks may not reliably contain public-sector health costs, explains Dana P. Goldman, Ph.D., of the RAND Corporation, author of the study.

The results are based on a survey of the socioeconomic status, health status, and medical service use of randomly chosen military households from geographic regions near 22 military bases around the country. Half of the sites instituted the CHAMPUS Reform Initiative (CRI), with PPO and HMO options; the other sites offered CHAMPUS enrollees only the FFS option. Most of the increased outpatient use by HMO enrollees was due to more individuals accessing the system rather than to an increase in the number of visits by particular users. Some evidence suggests that the HMO managed to control the number of visits once a beneficiary had entered the system, a "gatekeeper" effect that reflects the central role of primary care providers in referral decisions.

Enrollment in an HMO increased the probability of a hospital admission but decreased the length of stay. HMOs and PPOs that keep costs down often do so by avoiding inpatient admissions rather than shortening lengths of stay, according to Dr. Goldman, who notes that the lack of a clear reduction in hospitalizations suggests the physicians exerted much more control over the admissions process than did the CRI HMO. The CRI experience indicates that large networks of physicians may require stronger financial incentives to induce significant reductions in inpatient use. It is doubtful such incentives can be found in large independent practice associations, concludes Dr. Goldman.

Details are in "Managed care as a public cost-containment mechanism," by Dr. Goldman, in the RAND Journal of Economics 26(2), pp. 277-295, 1995.

A sustained doctor/patient partnership is key to improved primary care

A person's long-term partnership with his or her primary care doctor may be a bond of trust that can be healing in and of itself and one that is essential when guiding patients through the health system, according to the Institute of Medicine's Committee on the Future of Primary Care. In fact, this partnership may be one way to improve the quality of primary care, notes Carolyn Clancy, M.D., director of the Center for Primary Care Research, Agency for Health Care Policy and Research. She and AHCPR researcher James Cooper, M.D., and former AHCPR researcher Nancy Leopold, M.B.A., M.H.S., have developed a conceptual model of sustained partnership in primary care that has the potential to improve patient satisfaction and outcomes and reduce malpractice suits and health care costs.

Their model focuses on the whole person. The clinician attends to all health-related problems, either directly or through collaboration with other health professionals. In addition to the patient's medical history, the clinician also knows the patient's personal history, family life, and work situation, as well as his or her preferences, values, and beliefs about health care and decisionmaking. The clinician is caring and empathetic toward the patient, and inspires the patient's trust. The clinician appropriately tailors treatment recommendations to reflect the patient's goals and expectations and encourages the patient to participate in all aspects of care, including decisions about treatment and referrals to other providers.

Achieving this clinician-patient partnership could improve physician and patient satisfaction, decrease the risk of malpractice claims, and reduce unnecessary health service use and costs, according to the researchers. Few studies have evaluated the benefits of a sustained primary care partnership, in part because of the lack of a definition, which this model provides.

Preliminary results from an AHCPR-supported study, led by Dana Safran, Sc.D., of New England Medical Center, which were presented at the June 1996 Association for Health Services Research meeting in Atlanta, GA, suggest that "sustained partnership" can be measured. Two domains—the patient's trust of his or her physician and the patient's perception that the doctor knows the patient as a "whole person"—predicted a substantial amount of variation in overall satisfaction with care and the probability that the patient would adhere to the physician's recommendations regarding changes in behavior or lifestyle.

Whether achievement of a sustained partnership between clinician and patient remains a philosophical ideal or becomes the basis for primary care performance measures remains an unanswered but important question, concludes Dr. Clancy.

Details are in "Sustained partnership in primary care," by Ms. Leopold and Drs. Cooper and Clancy, in the February 1996 issue of The Journal of Family Practice 42(2), pp. 129-137.

Higher use of dental services found among African Americans within an elderly, low-income population

A recent study shows that about three of five low-income elderly persons using health services in Cincinnati, OH, used free dental care provided by a Municipal Health Service Program in their neighborhoods. Contrary to results of previous studies showing that white elderly persons use dental care twice as much as black elderly persons, in this study black elderly persons visited the dentist significantly more often than their white counterparts.

According to researchers at Ohio State University, it may be that the African-American population has a better social network to let others know about the program. An alternative explanation may be that the substantially greater use of medical services by the whites "crowded out" dental use, they gave higher priority to their medical problems, or dealing with their medical problems left them too little time or energy to seek dental care.

The researchers, who were supported in part by the Agency for Health Care Policy and Research (AHCPR grant HS07661), used Medicare Part B claims data from 1983 to 1993 to examine the use of no-cost dental services provided for Cincinnati's senior citizens at a community health center in a predominantly black neighborhood and a city health clinic in a predominantly white neighborhood. Over the 10-year period, nearly 3,500 Medicare patients were seen for at least one health service at these two facilities.

For more information, see "Determinants of dental user groups among an elderly, low-income population," by Raymond A. Kuthy, D.D.S., M.P.H., Michael S. Strayer, D.D.S., M.S., and Robert J. Caswell, Ph.D., in the February 1996 HSR: Health Services Research 30(6), pp. 809-825.

Vouchers fill primary care gaps for migrant farm workers

Migrant workers, who made up 6 percent of the paid farm labor force in 1985, rank among the most disadvantaged, medically underserved populations in the United States. Few have private health insurance, and they rarely stay in one State or county long enough to satisfy the 30-day residency requirement for State medical assistance programs. As a result, a federally funded system has evolved to subsidize migrant health care. Once registered at a migrant health clinic, the workers can obtain vouchers for physician visits and prescriptions when they are away from the clinic or for services not provided at the clinic.

University of Wisconsin-Madison researchers, Doris P. Slesinger, Ph.D., and Cynthia Ofstead, M.S., analyzed how Family Health-La Clinica, which is located in the heart of Wisconsin's farmland, allocated the Federal voucher funds it received for fiscal year 1992. Once issued, the vouchers were valid for 15 days and for one visit (for which the provider was paid less than the normal charge) or one prescription.

During FY 1992, La Clinica vouchers paid $83,833 toward health care provider fees, paying an average of 60 percent of each bill. As expected, hospital bills and associated payments tended to be the largest, and payments for pharmacy bills were the lowest. Dentists received the highest proportion (70 percent) of the amounts they billed, and clinics and medical groups received the lowest (42 percent).

Although the program was designed to improve access to health care for migrant workers outside of the primary service area, La Clinica issued almost 80 percent of the vouchers for medical care within that area. The number of vouchers issued has increased each year, as migrant workers and health care providers have become more familiar with the program. The researchers point out, however, that it is unclear whether the voucher program can overcome traditional barriers to health care encountered by migrant workers, such as illiteracy, lack of fluency in English, and transportation problems.

This study was supported by the Agency for Health Care Policy and Research (HS06524). Details are in "Using a voucher system to extend health services to migrant farmworkers," by Dr. Slesinger and Ms. Ofstead, in the January/February 1996 issue of Public Health Reports 111, pp. 57-62.

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