The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

Sensitivity S of film-screen systems and mode of operation of different automatic exposure systems in general practice conditions. II: Automatic exposure systems

Antipsychotic agents, such as clozapine and risperidone, have been reported to be beneficial in the treatment of some bipolar patients. Many bipolar patients experience 'breakthrough episodes' of mood disorder, with mania or depression recurring despite adequate ongoing levels of one or more mood-stabilizing medications. There are no controlled studies of breakthrough episodes, and there is little open experience to guide clinicians in pharmacotherapy of breakthrough episodes. This report describes the outcome of adjunctive risperidone treatment in breakthrough episodes of bipolar disorder. We assessed the outcome of openly adding risperidone to the medication regimen of 12 outpatients with bipolar disorder, type I, who suffered breakthrough episodes despite adequate maintenance medication (lithium, valproate, or carbamazepine, or a combination of these). Prospective ratings were made at each clinical visit using the Clinical Global Impressions and Global Assessment of Functioning scales. Patients received risperidone for a mean of 6.0 months (23.96 weeks, range 0.5-72 weeks) at a mean dose of 2.75 mg/day (range 1-4.5 mg/day). Four patients discontinued medication (two because of lack of efficacy at weeks 6 and 64, and two because of adverse events at weeks 0.5 and 23). Among the remaining eight patients, four experienced a 10-25 point improvement in Global Assessment of Functioning scores and were rated much better on the Clinical Global Impression-Improvement scale. Although one patient suffered a major depressive recurrence (at week 22), no patient experienced worsening of mania. This small open series suggests a subgroup of bipolar patients with breakthrough episodes may benefit from treatment with risperidone.     

Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial.

Recently hospitalized bipolar, manic patients (N=53) were randomly assigned to a 9-month, manual-based, family-focused psychoeducational therapy (n=28) or to an individually focused patient treatment (n=25). All patients received concurrent treatment with mood-stabilizing medications. Structured follow-up assessments were conducted at 3-month intervals for a 1-year period of active treatment and a 1-year period of posttreatment follow-up. Compared with patients in individual therapy, those in family-focused treatment were less likely to be rehospitalized during the 2-year study period. Patients in family treatment also experienced fewer mood disorder relapses over the 2 years, although they did not differ from patients in individual treatment in their likelihood of a first relapse. Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of payor/provider type on health care use and expenditures among the frail elderly

OBJECTIVES: This study examined whether health care expenditures and usage by the frail elderly differ under three payor/provider types: Medicare fee for service, Medicare health maintenance organization (HMO), and dual Medicare-Medicaid enrollment. METHODS: In-home interviews were conducted among 450 frail elderly patients of a San Diego, Calif, health care system. Cost and use data were collected from providers. RESULTS: Analyses revealed no difference in total expenditures between fee-for-service and HMO enrollees, but Medicare-Medicaid beneficiaries' expenditures were 46.8% higher than those for HMO enrollees and 52.2% higher than those for the fee-for-service group. Fee-for-service participants were less than half as likely as HMO enrollees to have two or more hospital admissions, but hospital usage rates between those two payor/provider groups did not differ. Not were there payor/provider differences in access to home health care, but HMO home health care users received significantly fewer services than the others. CONCLUSIONS: The care provided to these HMO beneficiaries resulted in a combination of restricted home health use and higher multiple hospitalizations. This raises compelling questions for future research. For the dually enrolled, stronger cost containment may be required.     

Changes in health plans serving Medicaid, 1993-1996

To better understand the Medicaid managed care market during a period of rapid change, we developed a new data set that links Medicaid enrollment data with health maintenance organization (HMO) industry data for 1993-1996 to analyze Medicaid enrollment in full-risk health plans. Nearly half of the Medicaid enrollees in a fully capitated managed care arrangement were in plans in which Medicaid makes up at least 75 percent of the total enrollment. In addition, the number of Medicaid-only plans has more than doubled since 1993. Commercial-based plans participated increasingly in Medicaid managed care during the period, yet more than half of the plans entering the Medicaid market were newly formed.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

How do HMOs achieve savings? The effectiveness of one organization's strategies

OBJECTIVE: To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. DATA SOURCES/STUDY SETTING: A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic's procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible. STUDY DESIGN: Using an explanatory case design, we first compared HMO and FFS rates of resource utilization, in standardized dollars, which measured the impact of organizational strategies to influence patient and provider behavior. We then examined the effect of HMO insurance and organizational measures to explain total outpatient use. Key variables were standardized charges for all outpatient services and the HMO's strategies. PRINCIPAL FINDINGS: Patient and provider behavior responded to organizational strategies designed to achieve savings for HMO patients; for instance, HMO patients used midlevel providers and generalists more often and ER and specialists less often. Overall HMO savings, adjusted for case mix, were explained by the specialty of the physicians the patients first visited and appeared to affect patients with average health more than others. CONCLUSION: Organizational strategies, without resort to differential financial incentives to each provider, resulted in lower rates of outpatient services for HMO patients. Savings from outpatient use, especially for common diseases that rarely require hospitalization, can be substantial.     

Managed behavioral health services for children under carve-out contracts

OBJECTIVE: Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults. METHODS: Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization. RESULTS: Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children). CONCLUSIONS: The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.     

Health maintenance organizations and children with special health needs. A suitable match?

OBJECTIVE: To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans. DESIGN: A cross-sectional survey. MEASUREMENTS/MAIN RESULTS: Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. PARTICIPANTS: Individual HMO plans. SELECTION PROCEDURE: A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. INTERVENTIONS: None. CONCLUSIONS: Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

Lamotrigine in rapid-cycling bipolar disorder

BACKGROUND: We evaluated the antidepressant and mood-stabilizing effects of lamotrigine, a novel anticonvulsant, in a group of rapid-cycling bipolar patients. Most were already nonresponders or poor partial responders to other conventional mood-stabilizing agents. METHODS: This open, naturalistic, and prospective study was conducted with five rapid-cycling bipolar patients (DSM-IV). Each received lamotrigine titrated to a minimum dose of 150 mg/day as monotherapy or in combination with other psychotropic agents. Patients were assessed with the Global Assessment Scale (GAS), Beck Depression Inventory (BDI), and Young Mania Rating Scale (YMRS) for evidence of cycling mood. RESULTS: Lamotrigine was used at a mean +/- SD dose of 185.0 +/- 33.5 mg/day for 225.8 +/- 28.0 days. Random regression modeling of data showed significant dose- and time-dependent improvements in depressive symptoms and social function of patients taking lamotrigine (Dose: z = 2.17, p < .03 for BDI, z = 4.44, p < .001 for GAS; Time: z = -3.79, p < .001 for BDI, z = 2.16, p < .03 for GAS). Further random regression modeling analysis of change over time in symptoms prior to lamotrigine compared with symptoms during lamotrigine treatment showed a significant treatment by time effect for GAS (z = 2.40, p < .016) and a trend for BDI scores (z = -1.79, p < .073). No significant time or dosage effect or time by treatment effect was observed for YMRS. Finally, t statistics showed a significant reduction in mean BDI scores following treatment with lamotrigine (t = -5.26, p < .006). Lamotrigine was well tolerated by all patients; only one patient experienced several side effects, which were probably due to interaction between several psychotropic medications. CONCLUSION: Lamotrigine augmentation therapy and monotherapy appeared to have mood-stabilizing and antidepressant efficacy in the treatment of five rapid-cycling bipolar patients. The effect persisted for an average of 7.5 months.     

Ambulatory health care visits by children: principal diagnosis and place of visit

OBJECTIVES: This report presents national estimates of ambulatory health care use by children under 15 years of age according to principal diagnosis, place of visit (physician office, hospital outpatient department, and hospital emergency department), and patient characteristics (age, sex, and race). METHODS: Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Data were from 1993-95. RESULTS: In 1993-95 children under 15 years of age made 165.3 million visits per year (289 visits per 100 children). Visit rates were highest among infants and varied inversely with age. Visit rates were 43 percent higher among white children than black children. Three-quarters of ambulatory visits occurred in physician offices, 8 percent in hospital outpatient departments, and 14 percent in hospital emergency departments. Visits by white children were more likely to occur in physician offices than visits by black children (81 percent and 54 percent). Conversely, visits by black children were more likely to occur in hospital outpatient departments (19 percent and 7 percent) and hospital emergency departments (28 percent and 12 percent) than visits by white children. The following principal diagnoses accounted for almost 40 percent of visits: well-child visit, 15 percent; middle ear infection, 12 percent; and injury, 10 percent. Rates for well-child visits were almost 80 percent higher among white infants than black infants. Continued monitoring of these differences in use of ambulatory care among children are needed, particularly in view of the possible impact of changes in the health care system on these differences.     

Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory.

It often is difficult clinically to differentiate bipolar disorder from other mental health conditions in young people. This study evaluated a parent report measure of depressive and hypomanic/biphasic symptoms. Parents of 196 youths, who were 5 to 17 years old and presented at an outpatient research center, completed an adapted General Behavior Inventory (GBI). Factor analyses suggested two dimensions, depression and biphasic/hypornania. Logistic regressions using these scales discriminated mood disorder versus disruptive behavior disorder or no diagnosis, unipolar versus bipolar disorder, and bipolar versus disruptive behavior disorder based on structured interviews. Classification rates exceeded 80%, and receiver operating characteristic analyses showed good diagnostic efficiency for the scales, with areas under the curve greater than .80. Results indicate that clinicians can use the parent-completed GBI to derive clinically meaningful information about mood disorders in youths. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mood stabilizers: shared mechanisms of action at postsynaptic signal-transduction and kindling processes

Several distinct classes of agents have demonstrated efficacy as mood stabilizers in patients with bipolar disorder. It may be reasonable to assume that these agents share one or more common mechanisms of action. This paper will explore the hypothesis that all effective mood stabilizers exert their actions through inhibition of postsynaptic signal-transduction and kindling processes. A literature search was performed for all currently used mood stabilizers to identify reports of mood-stabilizer action in postreceptor cell-signaling and kindling processes. Most effective mood stabilizers appear to inhibit intracellular calcium mobilization through several distinct mechanisms. In addition, several mood stabilizers appear to diminish generation of second-messenger molecules from the membrane phospholipids phosphatidylinositol and phosphatidylcholine, inhibit the activity of protein kinases, and directly inhibit activity of G-proteins. Finally, all established mood stabilizers also exhibit antikindling effects. All of these mechanisms of action could dampen excessive intracellular and intercellular signaling, which may be a core feature of the pathophysiology of bipolar disorder. The observation that all effective mood stabilizers inhibit both kindling and signal-transduction pathways suggests that these processes are intimately linked. We hypothesize that an effective mood stabilizer must possess some specific minimum inhibitory effects at postsynaptic signal-transduction and kindling processes. If this hypothesis is correct, then a rational search for safer and more effective mood-stabilizing agents can begin.     

Experiences of African American adolescent fathers

This study examines 1993 Medicare expenditures for enrollees in 63 managed care plans that were reimbursed on a cost basis. We find that government spending for enrollees in cost-reimbursed plans in 1993 was substantially greater than it would have been had these enrollees instead received care in traditional fee-for-service Medicare or in a Medicare risk plan. The increase was due entirely to the much higher expenditures for Part B services under cost reimbursement. The findings suggest that Medicare cost reimbursement of health plans should be eliminated or significantly modified.     

Effects of toothbrush design and brushing proficiency on plaque removal

BACKGROUND: Primary care physicians frequently use antibiotics for nonindicated conditions and conditions for which antibiotics have not been shown to be effective. The intention of this study was to determine whether shifting the costs from the insurer to physicians in a staff model health maintenance organization (HMO) influenced antibiotic prescribing. METHODS: A random sample of patients in whom upper respiratory infections (URIs) (n = 334) or acute bronchitis (n = 218) were diagnosed within a 12-month period was selected from a large multispecialty group practice whose population was predominantly fee-for-service (FFS) and from a staff model HMO. Detailed chart reviews were performed to verify the diagnosis and note secondary diagnoses, identify whether an antibiotic or other medication was prescribed, assess whether diagnostic testing was performed, and determine the specialty of the clinician. RESULTS: After excluding patients seen with sinusitis, otitis media, or streptococcal pharyngitis, 334 patients with URIs and 218 patients with acute bronchitis remained for analysis. For URIs, antibiotic prescribing was higher in the HMO population than in the FFS group (31% vs 20%, P = .02). In patients with acute bronchitis, HMO patients were also more likely to have an antibiotic prescribed, but the difference was not statistically significant (82% vs 73%, P = .11). Further analyses showed that while HMO physicians were more likely to prescribe antibiotics, they were less likely to prescribe other medications for acute bronchitis or use diagnostic tests for evaluation of patients with URIs or bronchitis. CONCLUSIONS: Shifting costs from insurer to physicians through managed care appears to reduce diagnostic testing for URIs and acute bronchitis, but does not decrease excessive use of antibiotics and may actually increase antibiotic use for URIs.