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<title>Research Activities, May 1996: Primary Care/Managed Care</title>
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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">May 1996</a>
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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">
<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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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>
<h2>U.S. military experience with managed care questions its
cost-saving potential</h2>
<p>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.</p><p>
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.</p>
<p>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.</p><p>
Details are in "Managed care as a public cost-containment
mechanism," by Dr. Goldman, in the <em>RAND Journal of
Economics</em> 26(2), pp. 277-295, 1995.</p>
<a name="head2"></a>
<h2>A sustained doctor/patient partnership is key to improved
primary care</h2>
<p>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.</p><p>
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.</p>
<p>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.</p><p>
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&#8212;the patient's
trust of his or her physician and the patient's perception that
the doctor knows the patient as a "whole person"&#8212;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.</p>
<p>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.</p><p>
Details are in "Sustained partnership in primary care," by Ms.
Leopold and Drs. Cooper and Clancy, in the February 1996 issue of
<em>The Journal of Family Practice</em> 42(2), pp. 129-137.</p>
<a name="head3"></a>
<h2>Higher use of dental services found among African
Americans within an elderly, low-income population</h2>
<p>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.</p><p>
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.</p>
<p>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.</p><p>
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 <em>HSR: Health Services
Research</em> 30(6), pp. 809-825.</p>
<a name="head4"></a>
<h2>Vouchers fill primary care gaps for migrant farm workers</h2>
<p>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.</p><p>
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.</p>
<p>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).</p><p>
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.</p>
<p>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 <em>Public
Health Reports</em> 111, pp. 57-62.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="dept2.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>
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