Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices

We have identified a new, slightly unstable alpha chain hemoglobin variant, present in a Mexican-American family. Amino acid sequencing and mass spectral analysis of the aberrant peptide (alpha T-9) of the variant revealed that the aspartic acid is deleted either at position 74 or 75 of one of the alpha-globin chains. Sequencing of the amplified alpha 2- or alpha 1-globin genes revealed a trinucleotide deletion (GAC) at codon 74 or 74 of the alpha 2 gene. Although the aspartic acid residues of 74 and 75 of the alpha chain are neither a heme nor an inter chain contact, the slight instability of Hb Watts may be due to disturbance of the central cavity of hemoglobin by the deletion of an aspartic acid residue in the EF helix. Hb Watts is the first example of a trinucleotide deletion in the alpha 2-globin gene.     

Race, prostate cancer survival, and membership in a large health maintenance organization

BACKGROUND: Population-based cancer registry data have shown that black men with prostate cancer have poorer stage-specific survival than white men, while studies in equal-access health care systems have not found racial differences in stage-specific survival. This study was designed to test the hypothesis that black men and white men with prostate cancer have equal stage-specific survival in equal-access health care systems. METHODS: We conducted a cohort study using cancer registry data from all incident cases of prostate cancer occurring in a five-county San Francisco Bay Area region. Incident cases occurred among members (5263 cases, from January 1973 through June 1995) and nonmembers (16,019 cases, from January 1973 through December 1992) of the Kaiser Permanente Medical Care Program, a large health maintenance organization. Death rate ratios (DRRs, black men versus white men) for Kaiser members and nonmembers were computed for all stages combined (adjusting for age and stage) and for each stage (adjusting for age). RESULTS: Among Kaiser members, adjusted DRRs comparing black men with white men were as follows: all stages combined, 1.28 (95% confidence interval [CI] = 1.14-1.44); local stage, 1.23 (95% CI = 1.01-1.51); regional stage, 1.30 (95% CI = 0.97-1.75); and distant stage, 1.27 (95% CI = 1.07-1.50). Corresponding DRRs for nonmembers were as follows: all stages combined, 1.22 (95% CI = 1.14-1.30); local stage, 1.24 (95% CI = 1.09-1.41); regional stage, 1.48 (95% CI = 1.29-1.68); and distant stage, 1.01 (95% CI = 0.91-1.12). CONCLUSIONS: These results show poorer prostate cancer survival for black men compared with white men in an equal-access medical care setting. The findings are most consistent with the hypothesis of increased tumor virulence in blacks.     

Community disasters: Primary prevention and treatment in a health maintenance organization.

In March 1977, members of the Hanafi Muslim sect seized and held hostages at three sites in Washington, D. C. The greatest number, over 100 persons, were held in the B'Nai B'rith National Headquarters for 39 hours. Many of these hostages suffered emotional aftereffects from this ordeal. The mental health staff of a Washington area health maintenance organization (HMO), to which many of the B'Nai B'rith hostages belonged, made its services available to all these men and women, regardless of their health insurance coverage. The symptoms covered a wide spectrum of modalities and ranged in severity and persistence. The case example of a 42-year-old female employee is presented. Treatment interventions followed a primary prevention model using a broad-spectrum behavioral group approach. This article advocates a primary prevention model for the delivery of services in crisis situations. Such a model is also advisable for services provided in an HMO. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol consumption and utilization of health services in a health maintenance organization

OBJECTIVES: This study examined the relation between alcohol use and utilization of health services during a 3-year period in a sample of 4,264 adult respondents to a member health survey in a health maintenance organization. METHODS: Respondents were categorized as abstainers (no drinks in the past year, n = 1,139), lighter drinkers (less than seven drinks/week, n = 2,330), moderate drinkers (seven to 13 drinks/week, n = 498), and heavier drinkers (> or =14 drinks/week, n = 297). Each drinker group was compared with abstainers on outpatient visits, hospital days, and number of hospitalizations controlling for age, race, and health plan membership. RESULTS: The mean number of outpatient visits was inversely related to the amount of alcohol consumed. Significant differences also were found for mean number of hospitalizations and mean days hospitalized per year. Compared with the three drinker groups, abstainers were significantly higher on both inpatient measures. CONCLUSIONS: These results might be explained by the inclusion in the abstainer group of exdrinkers who quit because of illness, inattention to health problems by heavier drinkers, or lower rates of illness among drinkers. The findings underscore the importance of replicating our study in other cohorts in which problem drinkers can be identified and compared with non-problem drinkers and in which lifelong abstainers can be separated from exdrinkers in the analysis.     

Couple therapy in a health maintenance organization (HMO).

Presents case examples of treatment for a 25-yr-old couple with a commitment impasse and a married couple with anxiety about becoming parents in a health maintenance organization setting. Such treatment requires conceptualizing the problem within a developmental framework, prompt identification of a focal issue, and emphasis on the couple's part in bringing about desired changes. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Costs of acid-related disorders to a health maintenance organization

BACKGROUND: Little is known about the economic impact of the acid-related disorders (ARDs), which include dyspepsia, gastritis, gastroesophageal reflux disease (GERD), and peptic ulcer disease (PUD), in managed care patient populations. OBJECTIVES: To describe the prevalence of medically attended ARDs, and their direct medical costs from the perspective of a large health maintenance organization (HMO). METHODS: A total of 1,550 ARDs subjects (age > or = 18 years), were randomly sampled from outpatient diagnosis and pharmacy databases of the Kaiser Permanente Medical Care Program of Northern California and verified by chart review. Five age- and gender-matched controls were identified per subject. One-year prevalence, excess annual costs, and initial 6-month costs for incident cases were estimated using the HMO cost accounting system. RESULTS: Total ARDs prevalence (5.8%) increases with advancing age. GERD is the most common ARD (2.9% overall prevalence). Annual per person attributable costs were $1,183, $471, and $431 respectively for PUD, GERD, and gastritis/dyspepsia. Excess inpatient costs for PUD explain its higher costs. Outpatient costs were somewhat higher for GERD ($279) than for PUD or gastritis/dyspepsia. Pharmacy costs were relatively low for each condition, in part because many patients were treated with generic cimetidine. Total annual HMO expenditures for ARDs were $59.4 million, with 40.6%, 36.8%, and 22.6% respectively for GERD, PUD, and gastritis/dyspepsia. CONCLUSIONS: Acid-related disorders, particularly GERD and PUD, contribute substantially to the direct costs of medical care in this managed care population.     

Short-term group therapy for couples in a health maintenance organization.

Describes a 15-session group treatment program for couples in a health maintenance organization (HMO). The program demonstrates principles of efficiency, economy, integration of services, and prevention in an HMO. It is argued that the location of the program in a comprehensive organized health care setting enhances the efficacy of the treatment. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Base rates of postconcussive symptoms in health maintenance organization patients and controls.

This study was intended to provide a normative comparison for determining the base rates of postconcussive syndrome (PCS) symptoms in patients from 4 medical departments of a health maintenance organization (HMO) and in people without acute medical or psychological complaints (controls). Recent research suggests that both neurologic and psychosocial factors influence these symptoms. Participants were 1,116 individuals who were surveyed regarding various symptoms, including those reported to be common in the PCS. Endorsement rates are presented for each PCS symptom for controls, each medical sample, and those people with a recent history of being knocked unconscious (2.3%), bumping their heads without losing consciousness (7.4%), and lawsuit involvement (6.8%), which were independently related to most PCS symptoms. The data indicate that neurologic, psychological, and environmental variables are related to having PCS complaints, and such factors should be considered before PCS complaints are used as evidence for brain damage. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medical crisis counseling in a health maintenance organization: Preventive intervention.

Mental health clinicians can play a cost-effective role in reducing distressing psychological symptoms accompanying diagnosis of chronic illness. Medical crisis counseling (MCC) is a focal short-term intervention directly addressing illness-related psychosocial problems. A randomized clinical trial tested the effectiveness of MCC. Counseling was offered to patients who had cancer that was newly diagnosed, 1st heart attacks, or adult-onset diabetes and was contrasted with a control group receiving an HMO's standard mental health care. Significant reductions in distress attributable to MCC were noted in some patient groups. No increases in overall medical costs and some decreased mental health utilization and costs were noted with MCC use. Practitioners can easily apply MCC to improving patients' quality of life and mental health, without adding to health care costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Temporal trends in hospital-based episodes of asthma care in a health maintenance organization

Studies reporting increased asthma hospitalizations and mortality in the United States and abroad have heightened concern about the changing epidemiology of asthma. We studied 20-yr patterns of acute asthma care occurring at two large community hospitals among members of a large health maintenance organization. The presentation focuses on the conceptualization and operationalization of an "episode" of asthma care, defined as a collection of encounters (emergency room visits, urgency care visits, and hospital admissions) that cluster in time, as well as on changes in episode rates over time. We found a statistically significant increase in asthma episodes among boys younger than 5 yr of age that continued unabated from 1967 to 1987 despite a drop in asthma hospitalization rates starting in 1985. We hypothesize that this difference may reflect a change in emergency room management practices and not a true change in the underlying epidemiology of asthma. The concept of an episode of acute asthma care has not been studied in the literature and represents a potentially useful methodologic innovation. Particularly in the context of managed health care systems, studies of such episodes may be less sensitive than studies of hospital admissions to changes in the organization and delivery of acute asthma care, and thus may be better suited for studying changes in the epidemiology of asthma.     

Results of a radiology performance report for a health maintenance organization

PURPOSE: To present results with a radiology performance report to help evaluate utilization of radiologic examinations by primary-care practices (family practice, internal medicine, or pediatrics) in an independent practice association health maintenance organization (HMO). MATERIALS AND METHODS: Utilization reports for primary-care-physician practices (n = 5,000) over a 12-month period (July 1, 1993 through June 30, 1994) were derived from administrative data collected from claim and encounter forms submitted by radiologic practices. Data were divided into 22 measures to help define practice utilization. five overall measures helped evaluate procedures performed by HMO member or nonmember practices per 1,000 members. Twelve specific measures helped evaluate patterns of use of frequently ordered imaging procedures (eg, computed tomography, magnetic resonance imaging, bone scanning, cardiovascular nuclear imaging, nonobstetric ultrasound, and plain radiography). Five quality measures helped evaluate utilization of screening mammography in women aged 50-64 years (as a percentage of all women in the HMO aged 50-64 years) and of low-yield examinations (ie, sinus, rib, and skull radiography per 1,000 adult members). RESULTS: Individual practice utilisation mean results were compared with overall HMO mean results adjusted for practice type and age and sex of members. CONCLUSION: Utilization data are an integral part of evaluation of HMOs and their providers, and these results helped establish a baseline level of performance.     

Variations in mental health needs and fee-for-service reimbursement for physicians in Ontario

In order to evaluate the intracellular function of glia maturation factor (GMF), we overexpressed GMF in C6 rat glioma cells using two methods: stable transfection using the pcDNA3 plasmid, and transient transfection using replication-defective human adenovirus. With both methods, C6 cells transfected with GMF and overexpressing the protein exhibit a lower saturation density in culture compared to non-transfected or vector alone controls. Transfected cells also exhibit morphological differentiation as shown by the outgrowth of cell processes. When inoculated into nude mice, transfected cells are less tumorigenic than controls, and express the mature astrocytic marker glial fibrillary acidic protein. In tissue culture, transfected cells show a 3.5-fold increase in CuZn-dependent superoxide dismutase (CuZnSOD) activity. Western blot analysis reveals a 3.5-fold increase in CuZnSOD protein, suggesting an induction of the enzyme. In view of recent findings that reactive oxygen species (ROS) and the antioxidant enzymes are intricately involved in key physiologic processes such as proliferation, differentiation and apoptosis, the study raises the possibility that CuZnSOD may be a mediator of GMF function.     

Antidepressant pharmacotherapy: economic evaluation of fluoxetine, paroxetine and sertraline in a health maintenance organization

The present study was designed to compare direct health service expenditures, for the treatment of depression, among patients enrolled in a health maintenance organization, and prescribed one of three selective serotonin reuptake inhibitors, fluoxetine, paroxetine or sertraline. Information regarding depression-related health service use was derived from the computer archive of a network-model health maintenance organization system serving 700,000 beneficiaries. A total of 744 health maintenance organization beneficiaries were found to satisfy the study selection criteria. Multivariate regression analysis was used to determine the incremental influence of selected demographic, clinical, financial and provider characteristics on health service expenditures related to the treatment of depression (ICD-9-CM, or DSM-IV code 296.2) 1 year after the start of antidepressant pharmacotherapy. Multivariate findings indicate that treatment with paroxetine increases average expenditures for physician visits ($31.93; P < or = 0.05), psychiatric visits ($19.33; NS), laboratory tests ($2.35; P < or = 0.05), hospitalizations ($85.33; P < or = 0.05), psychiatric hospitalizations ($82.01; P < or = 0.05), and antidepressant pharmacotherapy ($63.72; P < or = 0.05), for a total per capita increase in health service use of $284.68 (P < or = 0.05), compared with treatment with fluoxetine. Sertraline treatment increases average expenditures for physician visits ($21.74; P < or = 0.05), psychiatric visits ($56.79; P < or = 0.05), laboratory tests ($1.21; P < or = 0.05), hospitalizations ($70.59; P < or = 0.05), psychiatric hospitalizations ($95.75; P < or = 0.05), and antidepressant pharmacotherapy ($69.85; P < or = 0.05), for a total per capita increase in health service use of $315.96 (P < or = 0.05), compared with treatment with fluoxetine. Economic comparisons between paroxetine and sertraline did not demonstrate any significant differences in expenditures for the health services examined.     

Psychotherapy in a staff model health maintenance organization: Providing and assuring quality care in the future.

Discusses characteristics of effective health maintenance organization therapy. These characteristics include a problem-solving orientation, crisis intervention preparedness, clear definition of patient and therapist responsibilities, flexible and creative use of time, interdisciplinary cooperative treatments, use of multiple formats and modalities, a family practitioner model that allows for intermittent treatment throughout the life cycle, and quality assurance and utilization review procedures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acceptability of a substitution of estrogen replacement therapy to women enrolled in a health maintenance organization

This research examines the implications of an aging society on the demand for prehospital emergency medical services (EMS). Using a large comprehensive set of population-based EMS utilization data (N = 73874) and population data from the 1990 Census for the City of Dallas, Texas, rates of utilization for eight age groups were computed for total EMS incidents, incidents requiring transport services, and a sub-category of transport services for individuals requiring services for life-threatening conditions. The pattern of utilization associated with age was found to be tri-modal with rates rising geometrically with age for individuals aged 65 and over. Compared to the age group 45 to 64 years of age, rates of utilization for those aged 85 years and older were 3.4 times higher (P < 0.001) for total EMS incidents, 4.5 times higher (P < 0.001) for emergency transports and 5.2 times higher (P < 0.001) for incidents of a life-threatening nature. A broad categorization of all EMS incidents by reason for requiring services indicates that the observed age-associated increase in utilization is due primarily to medical conditions rather than incidents arising from trauma. Finally, gender and racial/ethnic differences in utilization are briefly considered.     

Breast carcinoma survival analysis for African American and white women in an equal-access health care system

BACKGROUND: This retrospective review of breast carcinoma cases in the Department of Defense (DoD) Central Tumor Registry evaluated differences in survival patterns between African American and white women treated in U.S. military health care facilities. The study examined the effects of age, stage of cancer, tumor size, grade, lymph node involvement, waiting time between diagnosis and first treatment, marital status, military dependent status, alcohol usage, tobacco usage, and family history of cancer. METHODS: Researchers reviewed the tumor registry records of 6577 women (5879 whites and 698 African Americans) diagnosed with breast carcinoma. The patients, ages 19-97 years, were diagnosed between 1975 and 1994. A hazard ratio (relative risk of mortality) model compared African American and white patients, adjusting for various combinations of covariates; impact of independent variables on the risk of death; prognostic factors significantly associated with survival; disease free and overall survival times; effects of ethnicity, stage, and age on survival; and trends in stage at diagnosis. A P value (2-sided) of less than 0.05 was considered statistically significant. RESULTS: After adjustment for age, the risk of death was 1.45 (95% confidence interval [CI], 1.20-1.76) times greater for African American women than for white women. Adjustment for stage reduced the risk to 1.41 (95% CI, 1.16-1.70); further adjustment for demographic variables and most clinical variables had no effect. Still, African American women treated in the military health care facilities had a better survival rate than African American women represented in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. In our study, the 5-year risk of death, from any cause, was 1.37 for African American women with breast carcinoma; in other words, the mortality rate for African American women was 24.77% compared with 18.08% for white women. In the latest SEER data, the 5-year relative risk of death for African American women compared with white women is 1.86. The mortality rate in SEER is 34.2% for African American women and 18.4% for white women. The survival rate for white DoD beneficiaries is comparable to that for white women in SEER. CONCLUSIONS: These observations suggest that ready access to medical facilities and the full complement of treatment options that are standard for all DoD patients improve survival rates for African American women. However, a significant unexplained difference in survival still exists between African American and white military beneficiaries.