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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> &gt; <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> &gt; <a href="." class="crumb_link">December 1996</a> </span></p>
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<td><h1><a name="h1" id="h1"></a>Healthcare Costs and Financing </h1>
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<td><div id="centerContent"><div class="headnote">
<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
<a name="head1"></a>
<a name="head2"></a><h2>Insurance reimbursement levels greatly affect
use of chiropractic services </h2>
<p>About 7 percent of persons in the United States visit
chiropractors, the third largest group of health professionals
after medical doctors and dentists. An increasing number of
health insurance plans are covering chiropractic services. But
the amount the plan reimburses a patient for these services
greatly affects their use, according to a recent study supported
in part by the Agency for Health Care Policy and Research
(HS06920). It shows that when patients have to share 25 percent
or more of the cost, they decrease their chiropractic expenses by
half.</p><p>
This pattern makes chiropractic care more sensitive to cost than
overall health and dental care and about as sensitive as
outpatient mental health services, concludes Paul G. Shekelle,
M.D., Ph.D., of RAND, principal investigator of the study. The
researchers analyzed data from the RAND Health Insurance
Experiment, a randomized controlled trial on the effects of cost
sharing on use of health services. Families in six U.S. sites
(Dayton, OH, Seattle, WA, Fitchburg and Franklin County, MA, and
Charleston and Georgetown County, SC) were randomized to receive
fee-for-service (FFS) care that was free or required one of
several levels of cost sharing, or to receive care from a health
maintenance organization. Families were followed for 3 or 5
years, and chiropractic use among persons in the HMO and FFS
plans was compared.</p>
<p>In the fee-for-service plans, persons who had to pay coinsurance
of 25 percent or more decreased chiropractic expenditures by
about half. Access to free chiropractic care among HMO enrollees
increased chiropractic use nine-fold, compared with a
contemporaneous sample of HMO enrollees who faced 95 percent cost
sharing for chiropractic care. Among this latter group, access to
free medical care in the HMO decreased by over 50 percent their
use of chiropractic care relative to persons who faced 95 percent
cost sharing for both medical and chiropractic care. This
suggests that there is a substitution of medical care for
chiropractic care, depending on price.</p><p>
See "The effect of cost sharing on the use of chiropractic
services," by Dr. Shekelle, William H. Rogers, PH.D., and
Joseph P. Newhouse, Ph.D., in <em>Medical Care</em> 34(9), pp. 863-872,
1996.</p>
<a name="head3"></a><h2> Medicaid providers vary in cost and
efficiency in managing chronic illnesses </h2>
<p>Medicaid providers vary in how efficiently they manage patients
who have hypertension, diabetes, or asthma, all chronic diseases
for which quality outpatient management can reduce costly
hospitalizations and emergency room visits. In a study supported
by the Agency for Health Care Policy and Research (HS06170),
researchers from Johns Hopkins University developed and applied a
claims-data-based approach to study the performance of Medicaid
providers who deliver ambulatory care to chronically ill persons
with diabetes, hypertension, and asthma in the State of Maryland.
They found that a large degree of misclassification on cost
performance can occur unless allowances are made for the severity
of illness of a provider's patients (casemix adjustment) and that
providers are not equally efficient in managing all chronic
illnesses.</p> <p>
According to lead author Neil R. Powe, M.D., M.P.H., M.B.A., and
his colleagues, this study uncovered inconsistencies in the
association of cost performance with clinical performance&#8212;that
is, patients whose usual source of care is a high-cost
office-based physician are more likely to spend time in the
hospital than patients of lower cost physicians. On the other
hand, high-cost providers were not consistently more likely than
others to provide their patients with better followup care after
hospital discharge and to have fewer instances of repetitive
emergency room use.</p>
<p>The researchers point out, however, that without casemix
adjustment, up to half of providers would be misclassified
according to costs. For instance, the severity of illness of a
provider's mix of patients explained 22 percent, 33 percent, and
36 percent of the variation in total payments for patients with
hypertension, diabetes, and asthma, respectively. After adjusting
for physicians' casemix, nearly 20 percent of 211 providers who
treated all three illnesses were in the same cost group for all
three illnesses and 43 percent of 223 providers who treated two
of the three illnesses were in the same cost group for both
illnesses. These findings were based on a cross-sectional analysis of Medicaid beneficiaries in Maryland with these three conditions, who were treated on an ambulatory basis by
hospital-based outpatient departments, physician office-based
providers, and community health centers during 1987 and 1988.
These results may be useful to State Medicaid programs in
structuring, guiding, and evaluating the care of their recipients
with chronic illnesses and to other payers and providers who wish
to profile the care of patients with these illnesses, conclude
the researchers.</p><p>
For more information, see "Systemwide provider performance in a
Medicaid program," by Dr. Powe, Jonathan P. Weiner, Dr.P.H.,
Barbara Starfield, M.D., M.P.H., and others, in <em>Medical
Care</em> 34(8), pp. 798-810.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head4"></a><h1>HIV/AIDS Research </h1>
<a name="head5"></a><h2>Expected toxicity should guide choice of
treatment for mild
to moderate PCP </h2>
<p>Despite the advent of medications to prevent Pneumocystis carinii
pneumonia (PCP), one of the most serious AIDS-related illnesses,
over 15,000 cases of PCP were reported in 1994. A recent study
recommends that oral treatment for mild to moderate PCP in AIDS
patients should be based on expected toxicity, since the three
standard oral treatments for the condition are equally effective.
The study, supported in part by the Agency for Health Care Policy
and Research (HS07824), examined the toxicity and effectiveness
of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and
clindamycin-primaquine in 181 patients at 24 U.S. medical centers
who were randomly assigned to receive one of the three treatments
for 21 days. Albert Wu, M.D., M.P.H., of The Johns Hopkins
Schools of Public Health and Medicine, and his colleagues also
assessed the effects of these treatments on patient-reported
health status measures, such as fatigue, symptoms, physical
functioning, and disability.</p><p>
One week following treatment, patients treated with
clindamycin-primaquine reported the most improved health status,
particularly in reduced pulmonary symptoms and disability,
compared with patients treated with the other two regimens.
However, 3 weeks after treatment, all patients reported further
improvement in health status, and differences among groups were
less evident. These health status outcomes were more sensitive
than survival, treatment failure, and toxic effects to
differences among treatment groups. They further supported the
finding that the most common regimen, trimethoprim
sulfamethoxazole, was not superior to the two alternative
treatments, notes Dr. Wu.</p>
<p>All three medications were similarly effective, with about 9
percent of each group experiencing failure of their medication to
reduce symptoms or correct the condition. However, one-fourth to
one-third of patients in all treatment groups had to discontinue
therapy because of one or more toxic reactions (36 percent for
trimethoprim-sulfamethoxazole, 24 percent for dapsone
trimethoprim, and 33 percent for clindamycin-primaquine). Drug
toxicities varied, ranging from rash and nausea to liver damage
(trimethoprim-sulfamethoxazole) and severe anemia
(clindamycin-primaquine). Evidence of a patient's liver
insufficiency at the beginning of therapy should prompt the
clinician to consider a regimen other than
trimethoprim-sulfamethoxazole, and severe bone marrow suppression
may suggest a regimen other than clindamycin-primaquine.</p><p>
Details are in "Comparison of three regimens for treatment of
mild to moderate Pneumocystis carinii pneumonia in patients with
AIDS," by Sharon Safrin, M.D., Dianne M. Finkelstein, Ph.D.,
Judith Feinberg, M.D., and others, in the <em>Annals of Internal
Medicine</em> 124(9), pp. 792-802, 1996. </p>
<a name="head6"></a><h2>Low CD4 count signals the need to screen
HIV/AIDS patients
for CMV retinitis </h2>
<p>Cytomegalovirus retinitis (CMV-R) is a major cause of blindness
in persons infected with the human immunodeficiency virus (HIV)
that causes AIDS. Nearly one in five persons with end-stage HIV
disease (CD4 count below 100, normal is about 1,000) will develop
this condition, according to a Multicenter AIDS Cohort Study
(MACS), which is supported in part through an interagency
agreement between the Agency for Health Care Policy and Research
and the National Institute of Allergy and Infectious Diseases.</p><p>
CMV-R can be diagnosed and treated through early screening and
might be prevented through prophylactic medication, explains the
study's lead author, Donald R. Hoover, Ph.D., of The Johns
Hopkins University School of Public Health. Dr. Hoover and his
colleagues at Johns Hopkins and other MACS centers recommend
periodic ophthalmologic exams for CMV-R when a patient's CD4
count falls below 100 and intensified screening when the count
falls below 50. </p>
<p>The researchers evaluated the prevalence of CMV-R in 367
HIV-infected men who were receiving zidovudine and Pneumocystis
carinii pneumonia (PCP) prophylaxis and had CD4 cell counts below
100. They found that during a median 3-year period, 103 of the
367 men developed CMV disease, which caused retinitis in 71
percent, gastrointestinal disorders (mostly colitis) in 20
percent, pneumonitis in 8 percent, esophagitis in 12 percent, and
nervous system disorders in 4 percent. Once a person's CD4 count
fell below 50, the risk of developing CMV-R increased
three-fold.</p><p>
With a CD4 count of 100 as the starting point, the onset of CMV-R
was associated with nearly a two-fold increase in the risk of
death. Most progression to CMV-R and/or death occurred within 4
years after CD4 cell counts fell below 100, at which time only 11
percent of men were alive and free of retinitis. During these 4
years, almost 25 percent of the men had been diagnosed as having
CMV-R.</p>
<p>The researchers point out that the ability to predict when
initial manifestations of CMV-R will appear is important for
planning long-range screening programs or entry into treatment
studies for these individuals. For example, this study shows that
7 percent of HIV-infected homosexual men with a current CD4 count
of 100 will need to be treated within 1.5 to 2 years for an
initial clinical manifestation of CMV-R.</p><p>
More details are in "Occurrence of cytomegalovirus retinitis
after human immunodeficiency virus immunosuppression," by Dr.
Hoover, Yun Peng, M.S., Alfred Saah, M.D., and others, in the
July 1996 <em>Archives of Ophthalmology</em> 114, pp. 821-827.</p>
<a name="head7"></a><h2> Problems with HIV-related medications are
common, but few
patients require hospitalization </h2>
<p>Current standard treatment for persons infected with the human
immunodeficiency virus (HIV) that causes AIDS consists of
antiretroviral drugs to reduce the amount of HIV in the blood and
other medication to prevent Pneumocystis carinii pneumonia (PCP),
a common and serious HIV-related infection. Adverse reactions to
both types of medications are common, but few are severe enough
to require hospitalization. HIV-infected persons whose CD4
lymphocyte cell counts decline to less than 100 cells/mm3 are
more likely to have problems tolerating these medications than
others whose immune systems are stronger. And, sex and race
appear to be related to poor reactions to certain drugs,
according to a study supported in part by the Agency for Health
Care Policy and Research (HS07809). These adverse reactions can
lead to dosage reduction, discontinuation of therapy, or the need
to treat problems arising from the medication itself, explains
Richard D. Moore, M.D., M.H.Sc., the study's principal
investigator.</p><p>
Dr. Moore and colleagues at The Johns Hopkins University School
of Medicine calculated rates of adverse drug reactions to
zidovudine, didanosine, zalcitabine, cotrimoxazole, and dapsone
in 1,450 HIV-infected patients with CD4 counts of 500 cells/mm3
(approximately 1,000 cells/mm3 is normal) being seen at an urban,
university-based HIV clinic from 1989 through 1994. Adverse drug
reactions were 16 per 100 person years for dapsone, 24 for
didanosine, 26 for zidovudine, 26 for cotrimoxazole, and 37 for
zalcitabine. In addition, women were nearly three times more
likely than men to have an adverse reaction to didanosine and 1.5
times more likely to react poorly to cotrimoxazole. Whites were
1.6 times more likely than blacks to have a bad reaction to
cotrimoxazole. Finally, only 6 percent of adverse reactions to
these medications required hospitalization, and none resulted in
death.</p>
<p>Patient age or injecting drug use did not influence the rate of
adverse drug reactions. For all of the drugs studied except
dapsone, the risk of adverse reactions increased progressively as
the person's CD4 count declined. Depending on the drug, reactions
ranged from blood, kidney, and nervous system disorders to
gastrointestinal problems, pancreatitis, and rashes.</p><p>
Details are in "Adverse events from drug therapy for human
immunodeficiency virus disease," by Dr. Moore, IIana Fortgang,
A.B., Jeanne Keruly, B.S.N., and Richard E. Chaisson, M.D., in
<em>The American Journal of Medicine</em> 101, pp. 34-40, 1996. </p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head8"></a><h1> AHCPR News and Notes </h1>
<a name="head9"></a><h2> AHCPR's Administrator announces
resignation </h2>
<p>Clifton R. Gaus, Sc.D., Administrator of the Agency for Health
Care Policy and Research, has announced his resignation. He
released the following statement on December 2, 1996.</p><p>
"It has been my privilege to lead AHCPR at a critical juncture in
its history and at a time of dramatic change in the American
health care system. Now that the goals that I have set forth for
AHCPR have been achieved through the hard work and dedication of
its staff, it is time for me to return to the private sector.</p>
<p>"I am confident that I leave an AHCPR that is strategically
positioned to better help clinicians, health plans, consumers,
and policymakers improve the quality of health care services and
achieve value in health care spending. To ensure a smooth
transition, I will be staying on until HHS Secretary Donna
Shalala names a successor."</p>
<a name="head10"></a><h2> AHCPR and Kaiser examine consumers' use of
quality
information </h2>
<p>Health care consumers value quality-related information, but
currently they do not use it to make key decisions. Instead, they
rely on personal recommendations from people they know and trust,
according to a national poll co-sponsored by AHCPR and the Kaiser
Family Foundation. The results of the poll, which were released
at a national conference held in Washington, DC, on October
29-30, are significant because they provide the first national,
quantitative snapshot of how quality affects consumer
decisions.</p>
<p>For example, in choosing a health plan, quality of care is more
of a concern (42 percent) than low costs (18 percent), a wide
choice of doctors (17 percent) and a range of benefits (14
percent). However, consumers' ultimate selections actually are
based on information they receive from their personal physicians
(59 percent) and their family and friends (57 percent).</p><p>
If they need to find a new doctor, Americans also are more likely
to turn to someone they know for a recommendation. Fifty-seven
percent would ask their current doctor, and 51 percent would
consult friends and family. When selecting a physician, those
surveyed said they are more concerned with how well a doctor
communicates with patients and if he or she shows a caring
attitude (84 percent) and whether the doctor is board certified
(71 percent). By contrast, only 25 percent were concerned with
whether a doctor has been highly rated by an independent
organization.</p>
<p>Consumers' views on selecting a hospital continue these trends.
When choosing a hospital, an individual's regular doctor has the
most influence (65 percent), followed by friends or family (60
percent), and then patient surveys (43 percent). In choosing
between two hospitals, a majority of consumers (72 percent) would
choose the hospital that is familiar to them over the hospital
rated higher in quality by experts.</p><p>
Americans' lukewarm reception to quality information produced by
independent organizations could reflect their lack of familiarity
with such information; only 39 percent said they had seen quality
comparisons within the last year. In addition, seven out of ten
(69 percent) of those surveyed regard their family and friends as
"good" sources of information about health plans because they
share common concerns. For the same reasons, patient satisfaction
surveys were valued as quality sources of information for those
polled. When asked to name a "very believable" source about
quality of care, family and friends were considered the most
believable (50 percent), followed by patient surveys (34 percent)
and individual doctors (29 percent). Respondents consistently
considered patient satisfaction surveys to be an influential
source of information, after personal doctor and family and
friends, in choosing a health plan (45 percent) and a doctor (37
percent).</p>
<p>The vast majority of those surveyed say specific quality-of-care
information is "very important" to know when choosing a health
plan. The quality-of-care indicators considered very important
were: how well a plan cares for members who have health problems
(90 percent), how easy it is to get needed care (88 percent), how
successfully early disease is detected (87 percent), and how well
a health plan keeps its members as healthy as possible (79
percent).</p><p>
Most Americans (88 percent) believe there is a role for the
Government in the quality of health care arena. A majority (52
percent) think the Government should both monitor health
providers to ensure a minimum standard of quality and make sure
information about quality is available to the public. Another 24
percent think the Government should only make sure information is
available so people can make judgments about quality themselves,
and 12 percent say the Government's only role should be to
monitor for a minimum standard of quality of care.</p>
<p>"Americans as Health Care Consumers: The Role of Quality
Information," is a nationally representative telephone survey of
2,006 adults conducted between July 26 and September 5, 1996. The
margin of error is plus or minus three percentage points. The
survey was designed by the Kaiser Family Foundation, AHCPR, and
Princeton Survey Research Associates.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="ra3.htm">Proceed to Next Section</a></p>
<div class="footnote">
<p> The information on this page is archived and provided for reference purposes only.</p></div>
<p>&nbsp;</p>
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