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<td><h1><a name="h1" id="h1"></a> Feature Story </h1>
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<a name="head1"></a><h2>Adjusting capitation rates may not prevent discrimination against
chronically ill children</h2>
<p>Some Medicaid and other health insurance programs use capitation
payment rates to pay managed care plans and providers on a
predetermined per capita basis. If a plan or provider is paid the
same rate for a patient with chronic health problems as for a
generally healthy patient, however, there is a financial
incentive to discriminate against patients with more serious
illness, so-called selection bias.</p>
<p>
Capitation or risk-adjustment methods, which adjust capitated
rates to compensate plans for increased costs associated with
chronic medical problems, are one approach to eliminating the
incentive to discriminate against children with chronic
conditions. Patient sociodemographic characteristics, functional
health status, clinical indicators, self-reported health status,
and prior health system use are all factors that have been used
to adjust capitation rates.</p>
<p>However, children with chronic health problems&#8212;such as
asthma
and diabetes&#8212;would probably remain at risk for
discrimination in
a competitive health care market even under risk-adjusted rates,
according to a study conducted by Elizabeth J. Fowler, Ph.D., of
HealthSystem Minnesota, and Gerard F. Anderson, Ph.D., of Johns
Hopkins University. Regardless of the capitation adjustment
method used, this study found significant underpayment to
providers of care to high-risk children.</p>
<p>
Drs. Fowler and Anderson tested current claims-based
risk-adjustment methods on two pediatric populations based on
data from 1990 and 1991. They tested five models at the
individual and group level, using both randomly selected and
nonrandom groups: a demographic model, ambulatory care groups,
ambulatory diagnostic groups, diagnostic cost groups, and payment
amounts for capitated systems. The researchers employed health
care use and expenditure data for children enrolled in the
Maryland Medicaid program and a private nonprofit health
maintenance organization in Minnesota. One of the nonrandom
groups represented children with chronic conditions.
</p>
<p>The findings of this study indicate that the disincentive to
enroll children with costly conditions and special health care
needs would not be eliminated by any of the capitation methods
tested. Although each of the alternative methods offers an
improvement over a demographic model, significant underpayment
remained for high-risk children. The authors call for further
research in the area of pediatric capitation adjustment methods
to address the limitations associated with current alternatives.</p>
<p>
This study was supported by the Agency for Health Care Policy and
Research (HS08441). For more information, see "Capitation
adjustment for pediatric populations," by Drs. Fowler and
Anderson, which appears in the July 1996 issue of
<em>Pediatrics</em> 98(1), pp. 10-17.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head2"></a><h1>Hospital Use/Quality of Care</h1>
<a name="head3"></a><h2>Researchers find quality of care for asthma
affects pediatric hospitalization rates in three Northeastern
communities</h2>
<p>Pediatric hospitalizations account for almost 50 percent of total
pediatric health care expenditures. Many of these
hospitalizations&#8212;for example, for conditions such as
asthma&#8212;can
be prevented by good primary care, including the use of effective
preventive therapies such as medications. The following two
studies&#8212;conducted by researchers from Children's Hospital,
Boston, Massachusetts General Hospital, Harvard University, Yale
University, and the University of Rochester&#8212;examined the
effects
of quality of care on hospitalization rates for childhood asthma
in Boston, MA, Rochester, NY, and New Haven, CT; and the effects
of primary care involvement before and during a hospital episode
for children in the same three communities.</p>
<p>
The following studies were supported by the Agency for Health
Care Policy and Research (HS06060).
</p>
<p><strong>Homer, C.J., Szilagyi, P., Rodewald, L., and others (1996,
July). "Does quality of care affect rates of hospitalization for
childhood asthma?" <em>Pediatrics</em> 98(1), pp. 18-23.</strong></p>
<p>
Use of effective medications may prevent many children with
asthma, even children who have severe asthma, from being
hospitalized for the condition, according to these researchers.
Use of inhaled rather than oral bronchodilators (beta-agonists
that open up constricted airways to improve oxygen flow),
long-term anti-inflammatory therapy (inhaled cromolyn sodium or
corticosteroids) for children with moderate to severe disease,
and short-term anti-inflammatory therapy as soon as an acute
episode becomes worse frequently prevents a child's asthma from
progressing to the point at which hospitalization becomes
necessary.
</p>
<p>The researchers reviewed the medical charts of a random sample of
614 children (2 to 12 years of age) diagnosed with asthma,
pneumonia, or bronchitis, who were discharged from hospitals in
Boston, Rochester, and New Haven from 1988 through 1990. They
found that Boston had the highest rate of hospitalizations for
pediatric asthma and multiple deficiencies in asthma care
compared with the other communities. Only 11 percent of Boston
children had received maintenance anti-inflammatory therapy with
either cromolyn or inhaled corticosteroids during the month prior
to hospitalization, compared with 19 percent of New Haven and 33
percent of Rochester children. Only 30 percent of Boston children
had received inhaled beta-agonist therapy during the month before
admission compared with 51 percent of New Haven and 58 percent of
Rochester children. About 5 percent of Boston children had
received oral corticosteroids for acute asthma exacerbations,
while 20 percent of New Haven and 14 percent of Rochester
children had been treated with this therapy. Differences in
patient characteristics, illness, and source of care did not
fully explain these differences, according to the authors.</p>
<p>
Boston pediatric patients, who were more often cared for at
health centers, were less likely to be cared for by their primary
care doctor while they were hospitalized. This finding suggests
that a problem in integration of community-based primary care and
tertiary hospital care may hinder communication between
specialists and generalist physicians and interfere with the
rapid introduction of new asthma treatments at the community
level, conclude the researchers.
</p>
<p><strong>Perrin, J.M., Greenspan, P., Bloom, S.R., and others (1996).
"Primary care involvement among hospitalized children.<em>"
Archives
of Pediatric and Adolescent Medicine</em> 150, pp. 479-486.</strong></p>
<p>
This study found a lower rate of pediatric hospitalizations in
communities in which primary care physicians are more involved in
the care of children before and during hospitalization. In
contrast to physicians who may not have seen the child prior to
hospitalization, the primary care physicians often had examined
the child prior to admission, referred the child to the emergency
department, and served as the child's attending physician during
the hospitalization.
</p>
<p>The researchers reviewed the medical records of children admitted
to all hospitals in Boston, New Haven, and Rochester during 1988
through 1990 for asthma, abdominal pain, meningitis, toxic
ingestions, and head injury. The rate of hospitalization was
nearly three times higher for children in Boston than children in
Rochester (16 vs. 5.5 admissions per 1,000 children per year for
the specified conditions) and twice as high as the rate for
children in New Haven (16 vs. 8.4 admissions per 1,000). Children
in Rochester had the highest likelihood of previous medical
visits (59 percent vs. about 49 percent in Boston and New Haven),
and once hospitalized, 81.5 percent of children in Rochester were
attended by a familiar physician, compared with 50.2 percent for
children in New Haven and 35.1 percent for children in Boston.</p>
<p>
However, sources of care performed differently in each city.
Private physicians in Boston were much less likely to be involved
in the children's care than those in Rochester. Neighborhood
health centers in New Haven had substantially closer ties to
their patients during the admissions process than did Boston or
Rochester health centers.
</p>
<p>These findings indicate higher rates of hospitalization in
communities with less primary care attachment and suggest that
restructuring the components of primary care might diminish
reliance on hospital care. However, the substantial variation by
source of care and city suggests that different strategies may be
needed in different settings to enhance primary care, conclude
the authors. </p>
<a name="head4"></a><h2>Computer reminders fail to improve preventive care for
hospitalized patients</h2>
<p>Computer reminders do not improve preventive care&#8212;such as
immunization against influenza and cholesterol
screening&#8212;during
hospitalization, according to a study supported by the Agency for
Health Care Policy and Research (HS05626 and HS07719). These
reminders have improved preventive care in outpatient settings.
However, the fact that physicians providing care to hospitalized
patients often are not their primary care physicians proved to be
an important barrier to preventive care in the hospital,
according to researchers at the Indiana University School of
Medicine, the Regenstrief Institute for Health Care, and the VA
Medical Center, Indianapolis.</p>
<p>
The researchers analyzed physicians' responses to computer
reminders on general medicine wards of a university-affiliated
public hospital during 6 months in 1992. They randomized 12
rotating teams of physicians and medical students to receive the
guideline-based, computer-generated reminders while 12 teams did
not (a total of 78 house staff). Reminders about preventive care
for which individual patients were eligible were printed on daily
rounds reports, and suggested orders for preventive care were
provided through the physicians' workstations.
</p>
<p>Doctors who received the reminders failed to comply with
preventive care guidelines at the same rate as doctors who did
not receive the reminders (23 vs. 24 percent). This was despite
the fact that most physicians were in favor of providing most
kinds of preventive care for hospitalized patients.</p>
<p>
About half of the staff felt that patients would prefer long-term
preventive care treatments (for example, aspirin to prevent heart
attack) to be started by their primary care physician in the
clinic, and 60 percent thought that preventive care was best left
to the primary care physician. On the other hand, 62 percent of
physicians said they would like other physicians to provide their
hospitalized patients with preventive care. Perhaps the most
important barrier is embedded in incentives faced by physician
teams to shorten stays and lower costs, suggest the researchers.
Thus, providing preventive care for patients who are not their
own carried only risk of more work and more responsibility.
</p>
<p>Requiring physicians to respond to recommendations for preventive
care (for example, saying why a recommendation is inappropriate
for a particular patient) or requiring them to treat these care
measures as "standing orders," unless the physician explicitly
countermands them, might increase preventive care for
hospitalized patients, conclude the researchers.</p>
<p>
See "Computer reminders to implement preventive care guidelines
for hospitalized patients," by J. Marc Overhage, M.D., Ph.D.,
William M. Tierney, M.D., and Clement J. McDonald, M.D., in the
July 22, 1996, <em>Archives of Internal Medicine</em> 156, pp.
1551-1556. </p>
<a name="head5"></a><h2>Emergency department clinicians often
experience conflicted relationships with patients who are
"regulars"</h2>
<p>Clinicians who practice in the emergency department (ED) setting
often have ambivalent feelings about caring for heavy ED users,
who may visit the ED as often as every week. These patients
commonly have chronic, relatively intractable medical problems,
including mental illness and substance abuse, which may be
compounded by social problems such as homelessness or
estrangement from families. Such characteristics&#8212;when
encountered in an environment of urgency such as the ED&#8212;can
contribute to feelings of futility and withdrawal on the part of
ED clinicians from the patients they know best. A study supported
in part by the Agency for Health Care Policy and Research
(HS08412) suggests that clinicians need to distinguish between
care and control in their expectations for and understanding of
these patients.</p>
<p>
The ED environment pushes clinicians toward a focus on control
rather than a focus on care, explains Ruth E. Malone, R.N.,
Ph.D., CEN, of the University of California, San Francisco,
author of the study. This is due to the legitimate need to treat
patients quickly and clear space for new arrivals, but the kinds
of chronic problems most of these patients experience are not
amenable to the "quick fix" approach offered in the ED.
Clinicians may feel they are doing nothing for such patients
except treating symptoms.
</p>
<p>However, observations and interviews at two inner-city trauma
center EDs suggest that, for some patients who utilize these
facilities most heavily, EDs are places to seek not only medical
care but also reassurance of inclusion in the human
community&#8212;often in the absence of other safe places in which
to
seek such recognition. Basic caring practices such as recognizing
the patient on sight, inquiring about family, or referring to the
patient by a familiar nickname were meaningful to patients, who
frequently alluded to being "known" in the ED setting. Interviews
with these "frequent flyer" patients suggest that such basic
recognition practices might have more value in establishing trust
and encouraging medically indicated behavior changes (such as
reductions in substance use) than the typical practice of rapid
medical stabilization and discharge with instructions to "stop."</p>
<p>
See "Almost 'like family': emergency nurses and 'frequent
flyers'," by Dr. Malone, which appears in the June 1996
<em>Journal
of Emergency Nursing</em> 22(3), pp. 176-183. </p>
<p>Health maintenance organizations typically require patients to
contact their primary care physician first for any new medical
problem, with that physician deciding whether referral to a
specialist is necessary. This first-contact approach to health
care can save more than half of outpatient health care
expenditures, conclude Christopher B. Forrest, M.D., Ph.D., and
Barbara Starfield, M.D., M.P.H., of the Johns Hopkins School of
Public Health. Their study, supported by the Agency for Health
Care Policy and Research (National Research Service Award
fellowship F32 HS00070 and training grant T32 HS00029), used data
from the 1987 National Medical Expenditure Survey of a sample of
noninstitutionalized persons in the United States to assess the
impact of first-contact care on outpatient health expenditures.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head6"></a><h1>Health Care
Costs and Financing</h1>
<a name="head7"></a><h2> Costs of outpatient care are cut in half
when a
patient sees a primary care physician first</h2>
<p>Analysis showed that nearly half (49 percent) of all episodes of
care for 24 acute (not chronic) conditions&#8212;ranging from
respiratory and ear infections to preventive care, sprains, and
burns&#8212;began with a visit to the primary care clinician. This
first-contact use of the primary care clinician was significantly
associated with a 53 percent reduction in expenditures for all
types of episodes except fatigue ($63 vs. $134), 62 percent for
acute illness episodes ($62 vs. $164), and 20 percent for
preventive care episodes ($64 vs. $80). Acute-care episodes that
began with a visit to the emergency room were about four times
more expensive than those that began with a visit to a primary
care clinician ($255 vs. $63).</p>
<p>
Increasing the current level of first-contact care just 10
percent would save at least $1.1 billion per year (1993 dollars)
for the U.S. health care system, according to the researchers.
They attribute the bulk of the cost savings of first-contact care
to lower payments for primary care physician services, less
resource-intensive practice styles of generalists compared with
specialists, lower severity of illness, and lower reimbursement
for established rather than new patients.
</p>
<p>Details are in "The effect of first-contact care with primary
care clinicians on ambulatory health care expenditures," by Drs.
Forrest and Starfield, in the July 1996 issue of <em>The Journal
of
Family Practice</em> 43(1), pp. 40-48.</p>
<a name="head8"></a><h2>Nonclinical factors may determine whether
depressed patients receive specialty care</h2>
<p>Prepaid health insurance plans tend to rely less on psychiatrists
to treat depressed patients and more on nonphysician mental
health specialists than traditional fee-for-service (FFS) plans.
The sicker a patient is, the more likely he or she will receive
specialty care in both systems, but income, patient education,
and ethnicity also influence the likelihood of seeing a
psychiatrist, according to a study supported in part by the
Agency for Health Care Policy and Research (HS06802).</p>
<p>
Psychiatrists are more costly than generalists, but they
typically provide more appropriate antidepressant medication and
counseling than general physicians. This specialty care could be
better targeted to patients most likely to benefit from it in
both systems, notes Kenneth B. Wells, M.D., M.P.H., of RAND and
the University of California, Los Angeles, the study's principal
investigator. Dr. Wells and colleagues Roland Sturm, Ph.D., and
Lisa S. Meredith, Ph.D., also of RAND, analyzed data on adult
patients with depression and other health problems in alternative
systems of care in three cities.
</p>
<p>The researchers found that only 10 percent of depressed patients
in prepaid plans considered a psychiatrist to be their main
source of care, less than half the rate found among FFS patients
(22 percent). And, prepaid patients were more likely to receive
care from a nonphysician mental-health specialist or therapist
than FFS patients (20 percent vs. 15 percent). In both payment
systems, the majority of depressed patients received care from a
general medical provider (63 percent in FFS, 70 percent in
prepaid plans).</p>
<p>
Worse psychological health increased the probability of obtaining
care from a mental health specialist and worse physical health
increased the probability of obtaining care from a general
medical provider in both systems. Depressed individuals with
higher incomes and better education were more likely to have a
mental health specialist as their main provider. However, these
factors were less predictive of specialty care than worse
psychological health, regardless of payment system. Minorities
were significantly less likely to see either type of mental
health specialist in both payment systems.
</p>
<p>Drs. Sturm, Meredith, and Wells point out that continuity of care
may be particularly important for patients with depression
because depression can be chronic and recurrent. They found that
the duration of a patient-provider relationship is significantly
shorter in prepaid than in fee-for-service plans for patients of
psychiatrists and primary care physicians. In both types of
plans, the duration of the patient-provider relationship was
shorter for nonphysician therapists than for psychiatrists or
primary care physicians.</p>
<p>
The authors explored whether the end of a patient-provider
relationship could have implications for quality of care because
many patients in this sample were chronically depressed and could
have benefited from long-term treatment. Focusing on patients
receiving effective antidepressant medication at baseline, they
found that the end of a patient-provider relationship is usually
associated with discontinuing antidepressant medication. The
authors conclude, therefore, that careful consideration of how
new health care policies affect patient-provider relationships
over time will be especially important.
</p>
<p>More details are in "Provider choice and continuity for the
treatment of depression," by Drs. Sturm, Meredith, and Wells, in
<em>Medical Care</em> 34(7), pp. 723-734. </p>
<a name="head9"></a><h2>Recognizing depression in primary care can
avoid unnecessary tests and referrals and save money</h2>
<p>Missed depression diagnoses can lead to unnecessary and costly
tests to uncover the cause of vague physical complaints such as
headache and fatigue, which frequently mask depression.
Physicians in training often do not recognize when a patient is
depressed, according to a recent study. Improving physicians'
recognition of depression could improve quality of care for these
patients and save health care costs, conclude researchers at the
University of California at Davis.</p>
<p>
In a study supported by the Agency for Health Care Policy and
Research (HS06167 and HS08029), Edward J. Callahan, Ph.D., and
Klea D. Bertakis, M.D., M.P.H., and their colleagues found that
when physicians did recognize depression, they treated patients
differently. They spent less time chatting and taking a physical
history and more time on counseling, as well as more overall time
with the patient. Physicians who did not recognize depression
spent significantly more time taking medical histories, perhaps
to clarify confusing data in an effort to explain the patients'
symptoms. This additional time may mark the beginning of
expensive efforts to diagnose patients using more laboratory
tests, more return visits, and more referrals to subspecialists
for diagnostic testing, all of which increase depression-related
cost of care, according to the researchers.
</p>
<p>They videotaped the physician visits of 508 new adult patients
randomly assigned to 105 third-year resident primary care
providers. The patients had previously taken the Beck Depression
Inventory (BDI), a 13-item questionnaire to detect depression,
but results were not revealed to their physicians. The physicians
identified only 15 percent of patients as depressed, while 26
percent of patients had a BDI score of 9 or greater indicating
moderate to severe depression by this test. Whether the patients
actually had depression was not confirmed.</p>
<p>
More details are in "The influence of depression on
physician-patient interaction in primary care," by Drs. Callahan
and Bertakis, Rahman Azari, Ph.D., and others, in the May 1996
issue of <em>Family Medicine</em> 28(5), pp. 346-351.
</p>
<a name="head10"></a><h2>High social costs found for home-based care
of ventilator-assisted individuals</h2>
<p>Pressure to contain costs is prompting hospitals to discharge a
growing number of ventilator-assisted individuals (VAIs) to be
cared for at home. However, studies that demonstrate the
cost-effectiveness of home care do not take into consideration
many of the economic burdens assumed by the families of VAIs who
return home. A recent study, supported in part by the Agency for
Health Care Policy and Research, examined the extent to which
home care resulted in a shift of costs from the hospital to the
family, rather than a true reduction in the total cost of care.
This study, one of the first to measure the social costs
associated with home-based care for VAIs, was conducted by Mary
Ann Sevick, Sc.D., R.N., of Bowman-Gray School of Medicine at
Wake Forest University (National Research Service Award
fellowship F32 HS00054).</p>
<p>
Dr. Sevick and her colleagues surveyed 277 primary family
caregivers of VAIs residing in 37 States. They found that family
members cared for VAIs an average of 12 hours per day, had done
so for an average of 8 years, and reported a loss of 4 to 5 hours
of daily leisure since becoming a caregiver. About half of
respondents adjusted their work schedules to accommodate their
caregiving activities. Of those adjusting their employment,
nearly 50 percent stopped working, 33.6 percent decreased their
working hours, 14.5 percent changed jobs, and 2.7 percent
increased their working hours. These employment changes resulted
in a median loss of $400 in monthly earnings.
</p>
<p>The total direct and indirect costs of home care for health
personnel, equipment rental, oxygen, medications, supplies,
ambulance transport, cost of one-time purchases and/or home
remodeling, physician and hospital costs, and lost wages averaged
$7,642 to $8,596 per month. This is significantly lower than the
estimated monthly cost of long-term-care facility placement found
in other studies, which ranges from $13,578 to $27,133 (in 1995
dollars). However, as Dr. Sevick points out, the figures derived
in this study do not take into consideration intangible costs
such as the value of the caregivers' lost leisure time and the
impact of caregiving on quality of life.</p>
<p>
Previous studies have found that caregivers do not perceive their
experience to be a negative one, and many are unwilling to
consider alternative living arrangements for their family member.
The development of policies and programs to support the growing
number of VAIs being discharged home requires additional
investigation regarding the cost-effectiveness of home placement,
as well as the ability and/or willingness of families to accept
the cost and responsibility of home care, conclude the
researchers.</p>
<p>For more information, see "Economic cost of home-based care for
ventilator-assisted individuals," by Dr. Sevick, Mark S. Kamlet,
Ph.D., Leslie A. Hoffman, Ph.D., R.N., and Ian Rawson, Ph.D., in
the June 1996 issue of <em>Chest</em> 109(6), pp. 1597-1606. </p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head11"></a><h1>Patient Outcomes/Effectiveness
Research</h1>
<a name="head12"></a><h2>Increased risk of preterm birth among
pregnant black women may be due in part to a higher rate of
vaginal infections</h2>
<p>Black women have two to three times more preterm births than
white women, and the gap appears to be increasing. A recent study
suggests that pregnant black women are far more likely to have
vaginal infections that have been associated with preterm births
than other women.</p>
<p>
This multivariate analysis, conducted by Robert L. Goldenberg,
M.D., of the University of Alabama at Birmingham, principal
investigator of the Low Birthweight Patient Outcomes Research
Team (PORT), and colleagues, was supported in part by the Agency
for Health Care Policy and Research (PORT contract 282-92-0055).
Data for the analysis were derived from a computerized database
containing the results of vaginal cultures for various types of
bacteria in 13,747 pregnant women (23 to 26 weeks' gestation) of
low socioeconomic status from various ethnic groups at seven
urban medical centers from 1984 to 1989.
</p>
<p>Results showed that black women were two to six times more likely
than white women to have vaginal infections: Chlamydia
trachomatis (16 percent vs. 5 percent), Neisseria gonorrhoeae
(2.5 percent vs. 0.4 percent), Bacteroides sp. (25 percent vs. 14
percent), and bacterial vaginosis (23 percent vs. 9 percent), as
well as four other organisms. Infection rates in Hispanic women
were higher than in white and Asian-Pacific Islander women but
lower than in black women. Asian-Pacific Islander women had the
lowest rates of vaginal infections.</p>
<p>
Differences in socioeconomic and health status, medical
conditions, health behaviors (for example, number of sexual
partners or smoking or alcohol use during pregnancy), and
psychological characteristics do not explain the great disparity
in pregnancy outcomes between black and other women, according to
the authors.
</p>
<p>For the various organisms evaluated in this study, when black and
white women of similar incomes are compared, black women still
have a two-fold greater preterm delivery rate, according to Dr.
Goldenberg. The authors also note that Hispanic
women&#8212;especially
those of Mexican origin&#8212;have one of the lowest rates of low
birthweight, despite average income levels that are lower than
many other ethnic groups. The presence of bacterial vaginosis in
more than 20 percent of the black women studied suggests a
significant association with the risk of preterm birth. Vaginal
infections during pregnancy may well provide a new explanation
for the disparity in preterm delivery rates between black and
other women, concludes Dr. Goldenberg.</p>
<p>
Details are in "Bacterial colonization of the vagina during
pregnancy in four ethnic groups," by Dr. Goldenberg, Mark A.
Klebenoff, M.D., Robert Nugent, Ph.D., and others, in the May
1996 <em>American Journal of Obstetrics and Gynecology</em> 174(5),
pp.
1618-1621. </p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="ra2.htm">Proceed to Next Section</a></p>
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