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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> > <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> > <a href="." class="crumb_link">July/August 1996</a>
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<tr>
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<td><h1><a name="h1" id="h1"></a> Primary Care/Managed Care</h1>
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<td><div id="centerContent"><div class="headnote">
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<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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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>
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<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
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<a name="head1"></a><h2>Making vaccines free to providers may not
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improve
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childhood immunization rates</h2>
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<p>Since 1983, provider costs for purchasing one full series of
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vaccine for a child (all doses of standard vaccines up to age 2
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years) have increased 10-fold. Some believe that Federal
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initiatives that would lessen provider vaccine costs would
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increase the number of children with up-to-date immunizations.
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However, a new study, supported in part by the Agency for Health
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Care Policy and Research (HS07286), suggests that this may not be
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the case.</p><p>
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Led by Gary L. Freed, M.D., University of North Carolina
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researchers calculated patient charges for
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diphtheria-tetanus-pertussis (DTP), measles-mumps-rubella (MMR),
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<em>Haemophilus influenzae</em> type b (Hib), and combined
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(DTP-Hib)
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vaccines, as well as the charges for well-child visits in three
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States with varying vaccine financing systems. Results showed
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that in Massachusetts, which supplies providers with free
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vaccines and limits physicians to a "reasonable administration
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fee," average patient vaccine charges were 10 percent lower, but
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well-child visits averaged $10 to $13 more than such visits in
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North Carolina and Texas. Neither regional variation in cost of
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living nor Medicaid reimbursement rates explained this
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difference.</p>
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<p>It was not clear whether Massachusetts physicians shifted vaccine
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costs to other preventive services to compensate for lower
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allowable immunization charges. If such cost shifting occurs,
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current Federal immunization initiatives to lower or eliminate
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provider vaccine costs may not provide increased access to
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preventive health services. In effect, lowering charges for
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immunizations may not lower a family's overall outlay for health
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care because well-child visits do not always include
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immunizations, conclude the researchers.</p><p>
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For more information, see "Variation in patient charges for
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vaccines and well-child care," by Dr. Freed, Sarah J. Clark,
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M.P.H., Thomas R. Konrad, Ph.D., and Donald E. Pathman, M.D.,
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M.P.H., in the April 1996 <em>Archives of Pediatric and Adolescent
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Medicine</em> 150, pp. 421-426. </p>
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<a name="head2"></a><h2>Conference focuses on the changing interface
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of primary and specialty care</h2>
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<p>About 4.5 percent of patient contacts with primary care providers
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result in referral to a specialist. Rates of referral vary widely
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however, and there is great uncertainty about appropriate
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referral practices. Managed care organizations (MCOs) often use
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the primary care physician as a gatekeeper to reduce unnecessary
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referrals and save costs.</p><p>
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It has been argued but not proven that health outcomes and
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patient satisfaction can be jeopardized in the process of
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referral and that for some complex conditions, such as diabetes,
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care for that condition provided by a specialist might be more
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appropriate. To tackle some of these issues, the Agency for
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Health Care Policy and Research convened a conference in
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September 1995 entitled, "Research at the Interface of Primary
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and Specialty Care."</p>
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<p>The purpose of the conference was two-fold: to assess the current
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state of research related to integration of primary and specialty
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health care services, including practices of referral and
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consultation; and to elicit suggested topics for future research
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in this area. Speakers at the AHCPR conference noted that until
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such information is available, efforts to develop referral
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guidelines will be premature. There is an urgent need for
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information that can lead to more science-based decisions about
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when and how to refer patients, point out AHCPR staff members
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David C. Lanier, M.D., and Carolyn M. Clancy, M.D. Dr. Clancy is
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Director of AHCPR's Center for Primary Care Research.</p><p>
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For an overview of the conference, see "The changing interface of
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primary and specialty care," by Drs. Lanier and Clancy, in the
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March 1996 issue of <em>The Journal of Family Practice</em> 42(3),
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pp. 303-305.</p>
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<p>The full text of the Conference Summary Report (AHCPR Pub. No.
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96-0034) is available from the AHCPR Publications Clearinghouse; call toll free 800-358-9295. Online <a
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href="/research/interovr.htm">highlights of the
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Conference
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Summary Report</a> are also available.</p>
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<a name="head3"></a><h2>"Medical necessity" is an imprecise term</h2>
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<p>The term "medical necessity" has been used by health insurance
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plans for 30 years to define the limits of their benefits
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coverage, despite widespread disagreement about its meaning. Over
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the years, the term has evolved from an insurance concept
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controlled for the most part by practicing physicians to a
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rationale used by health plan administrators and medical
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directors to control the use of scarce resources, according to
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Linda A. Bergthold, Ph.D., of the Lewin Group. In a presentation
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at a 1995 symposium on medical necessity, cosponsored by the
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Agency for Health Care Policy and Research, she discussed the
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historical and current use of the term and its impact on national
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health care debates.</p><p>
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Dr. Bergthold suggests that several factors have contributed to
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the redefining of medical necessity. These include the growth of
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managed care, shifts in the health care delivery system away from
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the traditional insurance model for which the term "medical
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necessity" was devised, a lack of consensus within the medical
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community on treatment options, and a paucity of clinical
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evidence about the merits of one treatment over another for the
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same condition.</p>
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<p>In a recent paper summarizing her presentation, Dr. Bergthold
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calls for a new definition of medical necessity—one that
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would remove the vagueness inherent in the term—and
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processes for applying it that are clearer and more
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collaborative. A redefinition becomes particularly important,
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notes Dr. Bergthold, as the population ages, new technology
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continues to press its findings upon the medical consumer, and
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the ability to pay for wonder drugs and treatments becomes
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further constrained.</p><p>
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Details are in "Medical necessity: Do we need it?" by Dr.
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Bergthold, in the Winter 1995 issue of <em>Health Affairs</em>
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14(4), pp. 180-189. </p>
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<p class="size2"><a href=".">Return to Contents</a><br />
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<a href="dept6.htm">Proceed to Next Section</a></p>
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<div class="footnote">
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<p> The information on this page is archived and provided for reference purposes only.</p></div>
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<p> </p>
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