Predictors of surgery resident satisfaction with teaching by attendings: a national survey

OBJECTIVE

To identify factors that predict fourth- and fifth-year surgical resident satisfaction of attending teaching quality.

SUMMARY BACKGROUND DATA

With the training of surgical residents undergoing major changes, a key issue facing surgical educators is whether high-quality surgeons can still be produced. Innovative techniques (eg, computer simulation surgery) are being developed to substitute partially for conventional teaching methods. However, an aspect of training that cannot be so easily replaced is the faculty-resident interaction. This study investigates resident perceptions of attending teaching quality and the factors associated with this faculty-resident interaction to identify predictors of resident educational satisfaction.

METHODS

A national survey of clinical fourth- and fifth-year surgery residents in 125 academically affiliated general surgery training programs was performed. The survey contained 67 questions and addressed demographics, hospital, and service characteristics, as well as surgery, education, and clinical care-related factors. Univariate analyses were performed to describe the characteristics of the sample; multivariate analyses were performed to evaluate the factors associated with resident educational satisfaction.

RESULTS

The response rate was 61.5% (n = 756). Average age was 32 years; most were male (79%), white (72%), and married (69%); 42% had children. Ninety-five percent of respondents graduated from U.S. medical schools, and the average debt was $80,307. Of 20 potentially mutable factors, 6 variables had positive associations with resident education satisfaction and 7 had negative associations. Positive factors included the resident being the operating surgeon in major surgeries, substantial citing of evidence-based literature by the attending, attending physicians giving spontaneous or unplanned presentations, increasing the continuity of care, clinical teaching aimed at the chief resident level, and having clinical decisions made together by both the attending and resident. There were 7 negative factors such as overly supervising in surgery, being interrupted so much that teaching was ineffective, and attending physicians being rushed and/or eager to finish rounds.

CONCLUSION

This study identifies several factors that were associated with resident educational satisfaction. It offers the perspective of the learners (ie, residents) and, importantly, highlights mutable factors that surgery faculty (and departments) may consider changing to improve surgery resident education and satisfaction. Improving such satisfaction may help to produce a better product.

Specificity and sensitivity of claims-based algorithms for identifying members of Medicare+Choice health plans that have chronic medical conditions

OBJECTIVE

To examine the effects of varying diagnostic and pharmaceutical criteria on the performance of claims-based algorithms for identifying beneficiaries with hypertension, heart failure, chronic lung disease, arthritis, glaucoma, and diabetes.

STUDY SETTING

Secondary 1999-2000 data from two Medicare+Choice health plans.

STUDY DESIGN

Retrospective analysis of algorithm specificity and sensitivity.

DATA COLLECTION

Physician, facility, and pharmacy claims data were extracted from electronic records for a sample of 3,633 continuously enrolled beneficiaries who responded to an independent survey that included questions about chronic diseases.

PRINCIPAL FINDINGS

Compared to an algorithm that required a single medical claim in a one-year period that listed the diagnosis, either requiring that the diagnosis be listed on two separate claims or that the diagnosis to be listed on one claim for a face-to-face encounter with a health care provider significantly increased specificity for the conditions studied by 0.03 to 0.11. Specificity of algorithms was significantly improved by 0.03 to 0.17 when both a medical claim with a diagnosis and a pharmacy claim for a medication commonly used to treat the condition were required. Sensitivity improved significantly by 0.01 to 0.20 when the algorithm relied on a medical claim with a diagnosis or a pharmacy claim, and by 0.05 to 0.17 when two years rather than one year of claims data were analyzed. Algorithms that had specificity more than 0.95 were found for all six conditions. Sensitivity above 0.90 was not achieved all conditions.

CONCLUSIONS

Varying claims criteria improved the performance of case-finding algorithms for six chronic conditions. Highly specific, and sometimes sensitive, algorithms for identifying members of health plans with several chronic conditions can be developed using claims data.

Changes in racial differences in use of medical procedures and diagnostic tests among elderly persons: 1986-1997

OBJECTIVES

We used 1997 Medicare data to replicate an earlier study that used data from 1986 to examine racial differences in usage of specific medical procedures or tests among elderly persons.

METHODS

We used 1997 physician claims data to obtain a random sample of 5% of Medicare beneficiaries aged 65 years and older. We used this sample to study 30 procedures and tests that were analyzed in the 1986 study, as well as several new procedures that became more widely used in the early 1990s.

RESULTS

Racial differences remain in the rates of use of these procedures; in general, Blacks have lower rates of use than do Whites. Between 1986 and 1997, the ratio of White to Black use moved in favor of Blacks for all but 4 of the established procedures studied.

CONCLUSIONS

The White-Black gap in health care use under Medicare is narrowing.

Socioeconomic disparities in the use of home health services in a medicare managed care population

OBJECTIVE

To investigate socioeconomic disparities in access to home health visits and durable medical equipment by persons enrolled in two Medicare managed care health plans.

DATA SOURCES

A telephone survey of 4,613 Medicare managed care enrollees conducted between April and October of 2000 and linked to administrative claims for a subsequent 12-month period.

STUDY DESIGN

We estimated a series of logistic regression models to determine which socioeconomic factors were related to home health visits and the use of durable medical equipment (DME) among Medicare managed care enrollees.

PRINCIPAL FINDINGS

Controlling for health and demographic differences, Medicare managed care enrollees in the lowest tertile for nonhousing assets had 50 percent greater odds than those in the highest tertile of having one or more home health visits. All else equal, enrollees with less than a high school education had 30 percent lower odds than those who had graduated from high school of using durable medical equipment.

CONCLUSIONS

Medicare managed care enrollees of low socioeconomic status do not appear to have reduced access to home health visits; however, use of durable medical equipment is considerably lower for enrollees with less than a high school education. Physicians and therapists working with Medicare managed care enrollees may want to actively target DME prescriptions to those with educational disadvantages.

Subsidies and the demand for individual health insurance in California

OBJECTIVE

To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population.

DATA SOURCE

Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001.

STUDY DESIGN

A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage.

PRINCIPAL FINDINGS

The elasticity of demand for individual insurance by those without access to group insurance is about -.2 to -.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage.

CONCLUSIONS

Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system.

Sociodemographic differences in use of preventive services by women enrolled in Medicare+Choice plans

BACKGROUND

We examined the effect of sociodemographic factors on the receipt of mammography, colorectal cancer screening, and influenza vaccinations by women enrolled in two Medicare+Choice health plans.

METHODS

Administrative and survey data for 2,698 female health plan members was analyzed using multivariate logistic and ordinal logistic regression to assess the effects of enrollee characteristics on use of preventive services.

RESULTS

Age, race and wealth were associated with the receipt of one or more preventive services. Older women were less likely to receive mammograms, wealthier women were more likely to receive mammograms and CRC screening, and Black women were more likely to receive CRC screening but less likely to receive influenza vaccinations. Wealthier women received a greater number of preventive services, other things equal, while older women received fewer preventive services.

CONCLUSIONS

Race and wealth continue to be important factors in the receipt of preventive services by elderly women, though not always consistent with historical trends. Medicare+Choice plans should consider strategies to further reduce racial and wealth disparities in the use of preventive services.

Predictors for medical students entering a general surgery residency: national survey results

BACKGROUND

The number of general surgery (GS) residency applicants had been decreasing before 2003. This national survey of fourth-year medical students elucidates factors related to the basic surgery clerkship that are associated with the decision to enter a GS residency.

METHODS

A national sample of 2250 fourth-year medical students from all 4-year allopathic US medical schools was surveyed in spring 2002. Multivariate analyses were performed to identify mutable predictors for students entering GS.

RESULTS

Data from 1531 fourth-year medical students from 121 different medical schools (response rate=68%) showed that 5.6% planned to enter GS. In multivariate analyses, the strongest predictor of entering GS was satisfaction with the quality of attending teaching (odds ratio 2.14, P <.01) in surgery clerkships. Several clerkship factors, such as frequency of call nights and total hours worked., were not as strongly associated with entering GS residency, Subsequent analyses showed that predictors of satisfaction with the quality of attending teaching included intraoperative activities (ie, suturing, cutting, and stapling), having attending-led rounds, and performing a history and physical with an attending. Significant negative predictors of satisfaction included observing or retracting only in surgery.

CONCLUSIONS

In this national survey, factors are identified that are significantly associated with students entering a GS residency. Some of these mutable factors may increase the pool of GS residency applicants.

Use of preventive services by men enrolled in Medicare+Choice plans

OBJECTIVES

We examined the effect of demographic and socioeconomic factors on use of preventive services (prostate-specific antigen testing, colorectal cancer screening, and influenza vaccination) among elderly men enrolled in 2 Medicare+Choice health plans.

METHODS

Data were derived from administrative files and a survey of 1915 male enrollees. We used multivariate logistic regression to assess the effects of enrollee characteristics on preventive service use.

RESULTS

Age, marital status, educational attainment, and household wealth were associated with receipt of one or more preventive services. However, the effects of these variables were substantially attenuated relative to earlier studies of Medicare.

CONCLUSIONS

Some Medicare HMOs have been successful in attenuating racial and socioeconomic disparities in the use of preventive services by older men.

Recent Trends and Geographic Variation in the Safety Net

BACKGROUND

Policymakers and researchers are concerned that changes in the healthcare market have stressed and weakened the safety net nationwide.

OBJECTIVES

The objectives of this study were to investigate variations in the safety net across communities and over time and to explore the effect of market changes on the safety net.

MATERIALS AND METHODS

We examined the safety net in all large urban communities from 1993 to 1998. Data from a variety of sources measure uncompensated hospital care, local government spending for health, admissions to safety net hospitals, visits to outpatient departments of safety net hospitals, visits to community health centers, and demographic and market characteristics of the communities. Descriptive analyses examine trends and community variations. Multivariate methods are used to estimate the effect of market structure and of economic factors on the safety net.

RESULTS

The safety net did not erode in urban areas over the study period. There was substantial variation across communities, but the disparity did not increase over time. HMO penetration and hospital competition are not significantly related to variations in the safety net, although demographic and economic factors are.

CONCLUSIONS

Local financing capacity is a factor in variations across communities in the safety net. The economic downturn and pressures on state budgets could lead to future problems.

Updated variable-radius measures of hospital competition

OBJECTIVE

To calculate variable-radius measures of hospital market size and create measures of competition for hospitals' markets.

DATA SOURCES

Discharge abstracts from the 1997 State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) linked with the American Hospital Association (AHA) Annual Survey, Area Resource File (ARF), InterStudy Regional Market Analysis database, and Medicare's Prospective Payment System Impact Files.

STUDY DESIGN

Hospital radii capturing 75 and 90 percent of hospital admissions regressed against hospital and health care market characteristics and other local area characteristics, where the specification was designed to maximize predictive ability. The number of competing hospitals and the Herfindahl-Hirschman index (HHI) of competition were calculated for each hospital's market.

DATA COLLECTION METHODS

Discharge abstracts were used to create actual radii for hospitals in nine states. These data were linked with other data describing hospital, health care market, and other characteristics.

PRINCIPAL FINDINGS

We explained 44.7 and 9.6 percent of the variation among urban and rural hospitals, respectively, in radii that capture 90 percent of patients, and slightly less of the variation in radii that capture 75 percent of patients. Population density; number of other hospitals in the local area; and hospital characteristics such as medical school affiliation, percentage of admissions that are Medicaid, case mix, and service offerings are important correlates of a hospital's market size.

CONCLUSIONS

Predicted radii and associated competition measures were created (matched to AHA hospital identifiers) for all nonfederal, short-term, general medical/surgical hospitals in the continental United States for which complete data were available in 1997 (N=4,806) and are available from the authors.

Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction

OBJECTIVE

To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients.

DATA SOURCES/STUDY SETTING

Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996.

STUDY DESIGN

We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics.

DATA COLLECTION/EXTRACTION METHODS

We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital.

PRINCIPAL FINDINGS

Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets.

CONCLUSIONS

The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

Quantifying income-related inequality in healthcare delivery in the United States

BACKGROUND

Numerous studies have found that high-income Americans use more medical care than their low-income counterparts, irrespective of medical "need." The methods employed in these studies, however, make it difficult to evaluate differences in the degree of income-related inequality in utilization across population subgroups. In this study, we derive a summary index to quantify income-related inequality in need-adjusted medical care expenditures and report values of the index for adults and children in the United States.

METHODS

We used the summary index of income-related inequality in expenditures developed by Wagstaff et al. 1 The source of data for the study was the Household Component of the 1996-1998 Medical Expenditure Panel Survey, which contains person-level data on medical care expenditures, demographic characteristics, household income, and a wide array of health status measures. We used multivariate regression analysis to predict need-adjusted annual medical care expenditures per person by income level and used the predictions to calculate the indices of inequality. Separate indices were calculated for all adults, working-age adults, seniors, and children ages 5 to 17.

RESULTS

For all age groups, predicted expenditures per person, adjusted for medical need, generally increased as income rose. The index of inequality for all adults was +0.087 (95% confidence interval, +0.035, +0.139); for working-age adults, +0.099 (+0.046, +0.152); for seniors, +0.147 (+0.059, +0.235); and for children, +0.067 (+0.006, +0.128).

CONCLUSIONS

There exists income-related inequality in medical care expenditures in the United States, and it favors the wealthy. The inequality is highest among seniors despite Medicare, intermediate among working-age adults, and lowest among children.

Sampling patients within physician practices and health plans: multistage cluster samples in health services research

OBJECTIVE

To better inform study design decisions when sampling patients within health plans and physician practices with multiple analysis goals.

STUDY SETTING

Chronic eye care patients within six health plans across the United States.

STUDY DESIGN

We developed a simulation-based approach for designing multistage samples. We created a range of candidate designs, evaluated them with respect to multiple sampling goals, investigated their tradeoffs, and identified the design that is the best compromise among all goals. This approach recognizes that most data collection efforts have multiple competing goals.

DATA COLLECTION

We constructed a sample frame from all diabetic patients in six health plans with evidence of chronic eye disease (glaucoma and retinopathy).

PRINCIPAL FINDINGS

Simulations of different study designs can uncover efficiency gains as well as inform potential tradeoffs among study goals. Simulations enable us to quantify these efficiency gains and to draw tradeoff curves.

CONCLUSIONS

When designing a complex multistage sample it is desirable to explore the tradeoffs between competing sampling goals via simulation. Simulations enable us to investigate a larger number of candidate designs and are therefore likely to identify more efficient designs.

Methods for using Medicare data to compare procedure rates among Asians, blacks, Hispanics, Native Americans, and whites

OBJECTIVE

Small sample sizes in Asian, Hispanic, and Native American groups and misreporting of race/ethnicity across all groups (including blacks and whites) limit the usefulness of racial/ethnic comparisons based on Medicare data. The objective of this paper is to compare procedure rates for these groups using Medicare data, to assess how small sample size and misreporting affect the validity of comparisons, and to compare rates after correcting for misreporting.

DATA

We use 1997 physician claims data for a 5 percent sample of Medicare beneficiaries aged 65 and older to study cardiac procedures and tests.

STUDY DESIGN

We calculate age and sex-adjusted rates and confidence intervals by race/ethnicity. Confidence intervals are compared among the groups. Out-of-sample data on misreporting of race/ethnicity are used to assess potential bias due to misreporting, and to correct for the bias.

PRINCIPAL FINDINGS

Sample sizes are sufficient to find significant ethnic and racial differences for most procedures studied. Blacks' rates tend to be lower than whites. Asian and Hispanic rates also tend to be lower than whites', and about the same as blacks'. Sample sizes for Native Americans are very small (about .1 percent of the data); nonetheless, some significant differences from whites can still be identified. Biases in rates due to misreporting are small (less than 10 percent) for blacks, Hispanics, and whites. Biases in rates for Asians and Native Americans are greater, and exceed 20 percent for some procedures.

CONCLUSIONS

Sample sizes for Asians, blacks, and Hispanics are generally adequate to permit meaningful comparisons with whites. Implementing a correction for misreporting makes Medicare data useful for all ethnic groups. Misreporting race/ethnicity and small sample sizes do not materially limit the usefulness of Medicare data for comparing rates among racial and ethnic groups.

Practice characteristics and HMO enrollee satisfaction with specialty care: an analysis of patients with glaucoma and diabetic retinopathy

BACKGROUND

The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential.

OBJECTIVE

To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). SUBJECTS/STUDY SETTING: A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices.

STUDY DESIGN

We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction.

PRINCIPAL FINDINGS

Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction.

CONCLUSIONS

Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction.

Patterns of care for open-angle glaucoma in managed care

OBJECTIVES

To describe patterns of care for primary open-angle glaucoma (POAG) and assess conformance with the American Academy of Ophthalmology's Preferred Practice Pattern (PPP).

METHODS

We obtained administrative, survey, and eye care records data on 395 working-age patients with POAG enrolled in 6 managed care plans between 1997 and 1999. We assessed processes of care at the initial and follow-up visits, control of intraocular pressure (IOP), intervals between visits and visual field tests, and adjustments in therapy.

RESULTS

We found high rates of performance on most recommended processes during initial evaluations, although only 53% of patients received an optic nerve head photograph or drawing and only 1% had a target IOP level documented. Recommended processes were performed at 80% to 97% of follow-up visits. Using loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma. Intervals between visits and visual field tests were generally consistent with PPP recommendations. Adjustments in therapy were more likely with worse control of IOP, although adjustments occurred in only half of visits where the IOP was 30 mm Hg or higher.

CONCLUSIONS

Our study suggests that, in many respects, patients with POAG are receiving care that is consistent with the PPP. However, care is falling short on several key aspects, and POAG may be undertreated relative to standards for IOP control established in recent clinical trials.

Participation of patients 65 years of age or older in cancer clinical trials

PURPOSE

Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation.

PATIENTS AND METHODS

We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly.

RESULTS

Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage cancers than in trials for late-stage cancers (P <.001). Furthermore, protocol exclusion criteria on the basis of organ-system abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol exclusions were relaxed, elderly participation in cancer trials would be 60%.

CONCLUSION

The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or requirements, this step may not be sufficient.

Trends And Variability In Individual Insurance Products In California

This paper examines recent trends in benefits and premiums for individual health insurance products purchased by Californians. There is much variability in the coverage available in the individual insurance market, with correspondingly wide variability in premiums. Despite concerns about increased consumer cost sharing, the average share of health spending covered by these products has remained constant between 1997 and 2002. Whether this trend can continue in the face of higher health costs is unclear.

Racial and ethnic differences in public and private medical care expenditures among aged Medicare beneficiaries

This study examines the current allocation of medical care expenditures among non-Hispanic white, non-Hispanic black, and Hispanic seniors who are Medicare beneficiaries. Analyses of both "need-based" and "demand-based" perspectives found that white, black, and Hispanic seniors in similar health had similar total annual expenditures for medical care. The groups did, however, differ substantially in the distribution of expenditures between public and private sources of payment. Notably, racial and ethnic differences in public and private expenditures all but vanished when socioeconomic variables and health insurance coverage were included in the analyses. The findings suggest that public sources of payment for medical care services, especially public supplementary coverage have helped to eliminate racial and ethnic gaps in expenditures.

Characteristics of eye care practices with managed care contracts

OBJECTIVES

To describe the variation in practice structure, financial arrangements, and utilization and quality management systems for eye care practices with managed care contracts.

STUDY DESIGN

Cross-sectional survey of 88 group and 56 solo eye care practices that contract with 6 health plans affiliated with a national managed care organization. The survey contained modules on practice structure, financial arrangements, utilization management, and quality management. The survey response rate was 85%.

RESULTS

Group practices with both ophthalmologists and optometrists were triple the size of ophthalmology-only groups, and 5 times the size of optometry-only groups. Fee-for-service payments were the primary source of group practice revenues, although 60% of groups derived some revenues from capitation payments. Group practices paid their physicians almost exclusively with fee-for-service payments or salary arrangements, with minimal capitation at the individual level. Almost no practices used both capitation and bonuses to compensate providers. Most practices received practice profiles and three fourths were subject to utilization review, which mainly consisted of preauthorization for procedures, tests, or referrals. Nearly all practices used clinical guidelines, protocols, or pathways in managing patients with diabetic retinopathy or glaucoma. Further, nearly all group practices used computerized information systems to assist in delivering care, and most had provider education programs.

CONCLUSIONS

Managed care has affected the way eye care providers organize, finance, and deliver healthcare. In general, our findings paint an optimistic picture of eye care practices that contract with managed care organizations. Few practices bear substantial financial risk, and nearly all practices use quality management tools that could help to improve the quality of care.

Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes

Evidence suggests that social and economic factors are important determinants of health. Yet, despite higher porverty rates, less education, and worse access to health care, health outcomes of many Hispanics living in the United States today are equal to, or better than, those of non-Hispanic whites. This paradox is described in the literature as the epidemiological paradox or Hispanic health paradox. In this paper, the authors selectively review data and research supporting the existence of the epidemiological paradox. They find substantial support for the existence of the epidemiological paradox, particularly among Mexican Americans. Census undercounts of Hispanics, misclassification of Hispanic deaths, and emigration of Hispanics do not fully account for the epidemiological paradox. Identifying protective factors underlying the epidemiological paradox, while improving access to care and the economic conditions among Hispanics, are important research and policy implications of this review.

Employer drug benefit plans and spending on prescription drugs

CONTEXT

With drug spending rising rapidly for working-aged adults, many employers and health insurance providers have changed benefits packages to encourage use of fewer or less expensive drugs. It is unknown how these initiatives affect drug costs.

OBJECTIVE

To examine how innovations in benefits packages, such as those that include multitier formularies and mandatory generic substitution, affect total cost to insurance providers for generic and brand drugs and out-of-pocket payments to beneficiaries.

DESIGN AND PARTICIPANTS

Retrospective study from 1997 to 1999 linking claims data of 420,786 primary beneficiaries aged 18 through 64 years who worked at large firms (n = 25) with health insurance benefits that included outpatient drugs.

MAIN OUTCOME MEASURES

Overall drug costs; generic, single-source brand, and multisource brand costs; and drug expenditures by health insurance providers and out-of-pocket costs for beneficiaries.

RESULTS

For a 1-tier plan with a 5 US dollars co-payment for all drugs, the average annual spending was 725 US dollars per member. Doubling co-payments to 10 US dollars for all drugs reduced the annual average drug cost from 725 US dollars to 563 US dollars per member (22.3%, P<.001). Doubling co-payments in a 2-tier plan from 5 US dollars for generics and $10 for brand drugs to 10 US dollars for generics and 20 US dollars for brand drugs reduced costs from 678 US dollars to 455 US dollars (32.9%, P<.001). Adding an additional co-payment of 30 US dollars for nonpreferred brand drugs to a 2-tier plan (10 US dollars generics; 20 US dollars brand) lowered overall drug spending by 4% (P<.001). Requiring mandatory generic substitution in a 2-tier plan reduced drug spending by 8% (P<.001). Doubling co-payments in a 2-tier plan increased the fraction beneficiaries' paid out-of-pocket from 17.6% to 25.6%.

CONCLUSIONS

Adding an additional level of co-payment, increasing existing co-payments or coinsurance rates, and requiring mandatory generic substitution all reduced plan payments and overall drug spending among working-age enrollees with employer-provided drug coverage. The reduction in drug spending largely benefited health insurance plans because the percentage of drug expenses beneficiaries paid out-of-pocket rose significantly.

Initial practice locations of international medical graduates

OBJECTIVE

To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs.

DATA SOURCES

The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile.

STUDY DESIGN

We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area.

PRINCIPAL FINDINGS

The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group.

CONCLUSIONS

Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.

The determinants of HMOs' contracting with hospitals for bypass surgery

OBJECTIVE

Selective contracting with health care providers is one of the mechanisms HMOs (Health Maintenance Organizations) use to lower health care costs for their enrollees. However, are HMOs compromising quality to lower costs? To address this and other questions we identify factors that influence HMOs' selective contracting for coronary artery bypass surgery (CABG).

STUDY DESIGN

Using a logistic regression analysis, we estimated the effects of hospitals' quality, costliness, and geographic convenience on HMOs' decision to contract with a hospital for CABG services. We also estimated the impact of HMO characteristics and market characteristics on HMOs' contracting decision.

DATA SOURCES

A 1997 survey of a nationally representative sample of 50 HMOs that could have potentially contracted with 447 hospitals.

PRINCIPAL FINDINGS

About 44 percent of the HMO-hospital pairs had a contract. We found that the probability of an HMO contracting with a hospital increased as hospital quality increased and decreased as distance increased. Hospital costliness had a negative but borderline significant (0.10 < p < 0.05) effect on the probability of a contract across all types of HMOs. However, this effect was much larger for IPA (Independent Practice Association)-model HMOs than for either group/staff or network HMOs. An increase in HMO competition increased the probability of a contract while an increase in hospital competition decreased the probability of a contract. HMO penetration did not affect the probability of contracting. HMO characteristics also had significant effects on contracting decisions.

CONCLUSIONS

The results suggest that HMOs value quality, geographic convenience, and costliness, and that the importance of quality and costliness vary with HMO. Greater HMO competition encourages broader hospital networks whereas greater hospital competition leads to more restrictive networks.

Personal choices of health plans by managed care experts

BACKGROUND

Expert opinion has not been used as a basis for comparing different forms of health insurance, in part because this perspective may not be appropriately sensitive to aspects of care that consumers value.

RESEARCH DESIGN

Using a case-control design, managed care experts were surveyed at 17 academic institutions in the United States to determine the type of health plan they chose (fee-for-service, HMO, POS, PPO, or catastrophic). Controls consisted of academicians from other disciplines at these institutions who ostensibly faced the same insurance options. We then compared the choices of physician experts, nonphysician experts and controls using a multinomial logit model that was sensitive to the choice set available at each institution. We also examined the choice behavior of respondents within moderate (< $150,000) and high (> or =$150,000) income levels.

RESULTS

Four hundred thirty-seven experts and 465 controls were surveyed and responses were received from 73.7% and 52.7%, respectively. Physician experts were approximately half as likely (14.9%) as controls (26.6%) or nonphysician experts (27.6%) to enroll in HMO plans. In moderate-income households, both physicians (Relative Risk [RR] = 0.42; P <0.01) and nonphysician experts (RR = 0.71; P <0.1) were less likely than controls to opt for an HMO. Experts' propensity to choose HMO coverage varied little with income, whereas controls' propensity changed dramatically between moderate (39.1% in HMOs) and high (14.0% in HMOs) income categories.

CONCLUSIONS

The aversion of physician experts, and nonphysician experts with moderate income, to HMO plans may be caused by their stronger distaste for the constraints on choice and access that typically accompany HMO coverage. Alternatively, it may be explained by their superior ability to absorb, understand, and use information about available insurance options. Insights into quality in managed care may also play a role.

Compliance among pharmacies in California with a prescription-drug discount program for Medicare beneficiaries

BACKGROUND

Several states have developed prescription-drug discount programs for Medicare beneficiaries. In California, Senate Bill 393, enacted in 1999, requires pharmacies participating in the state Medicaid program (Medi-Cal) to charge customers who present a Medicare card amounts based on Medi-Cal rates. Because Medicare beneficiaries may not be accustomed to presenting their Medicare cards at pharmacies, we assessed the compliance of pharmacies with Senate Bill 393.

METHODS

Fifteen Medicare beneficiaries who received special training and acted as "standardized patients" visited a random sample of pharmacies in the San Francisco Bay area and Los Angeles County in April and May 2001. According to a script, they asked for the prices of three commonly prescribed drugs: rofecoxib, sertraline, and atorvastatin. The script enabled us to determine whether and when, during their interactions with pharmacists or salespeople, the discounts specified in Senate Bill 393 were offered. Pharmacies at which the appropriate discounts were offered were considered compliant.

RESULTS

The patients completed visits to 494 pharmacies. Seventy-five percent of the pharmacies complied with the prescription-drug discount program; at only 45 percent, however, was the discount offered before it was specifically requested. The discount was offered at 91 percent of pharmacies that were part of a chain, as compared with 58 percent of independent pharmacies (P<0.001). Compliance was higher in the San Francisco Bay area than in Los Angeles County (84 percent vs. 72 percent, P=0.004) and was higher in high-income than low-income neighborhoods (81 percent vs. 69 percent, P=0.002). A Medicare beneficiary taking all three drugs would have saved an average of $55.70 per month as compared with retail prices (a savings of 20 percent).

CONCLUSIONS

Discounts required under California's prescription-drug discount program for Medicare beneficiaries offer substantial savings. Many patients, however, especially those who use independent pharmacies or who live in low-income neighborhoods, may not receive the discounts.

Medical care expenditures under gatekeeper and point-of-service arrangements

OBJECTIVE

To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network.

DATA SOURCE/STUDY SETTING

The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services.

STUDY DESIGN

Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables.

PRINCIPAL FINDINGS

Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses.

CONCLUSIONS

Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Measuring the incremental cost of clinical cancer research

PURPOSE

To summarize evidence on the costs of treating patients in clinical trials and to describe the Cost of Cancer Treatment Study, an ongoing effort to produce generalizable estimates of the incremental costs of government-sponsored cancer trials.

METHODS

A retrospective study of costs will be conducted with 1,500 cancer patients recruited from a randomly selected sample of institutions in the United States. Patients accrued to either phase II or phase III National Cancer Institute-sponsored clinical trials during a 15-month period will be asked to participate in a study of their health care utilization (n = 750). Costs will be measured approximately 1 year after their trial enrollment from a combination of billing records, medical records, and an in-person survey questionnaire. Similar data will be collected for a comparable group of cancer patients not in trials (n = 750) to provide an estimate of the incremental cost.

RESULTS

Evidence suggests insurers limit access to trials because of cost concerns. Public and private efforts are underway to change these policies, but their permanent status is unclear. Previous studies found that treatment costs in clinical trials are similar to costs of standard therapy. However, it is difficult to generalize from these studies because of the unique practice settings, insufficient sample sizes, and the exclusion of potentially important costs.

CONCLUSION

Denials of coverage for treatment in a clinical trial limit patient access to trials and could impede clinical research. Preliminary estimates suggest changes to these policies would not be expensive, but these results are not generalizable. The Cost of Cancer Treatment Study is an ongoing effort to provide generalizable estimates of the incremental treatment cost of phase II and phase III cancer trials. The results should be of great interest to insurers and the research community as they consider permanent ways to finance cancer trials.

The effect of HMO penetration on physician retirement

OBJECTIVE

To examine the effect of HMO penetration on physician retirement.

STUDY DESIGN

We linked together historical data from the Physician Masterfile of the American Medical Association for successive years to track changes in physicians' activity status between 1980 and 1997. We used a multivariate discrete-time survival model to examine how the probability of physician retirement was affected by the level of HMO penetration in the physician's market area, controlling for other physician and market characteristics. The study population included all active allopathic patient-care physicians in the United States who reached age 55 between the years of 1980 and 1996. The main outcome measure was physician retirements as reported on the Physician Masterfile.

PRINCIPAL FINDINGS

HMO penetration had a statistically significant positive effect on the retirement probabilities of generalists and medical/surgical specialists, but it s effect on hospital-based specialists and psychiatrists was not significant . For generalists regression-adjusted retirement probabilities were roughly 13 percent greater in high-penetration markets (HMO penetration of 45 percent ) than in low-penetration markets (HMO penetration of 5 percent ). For medical/surgical specialist s regression-adjusted retirement probabilities were roughly 17 percent greater in high-penetration markets than in low-penetration markets.

CONCLUSIONS

Our findings suggest that many older physicians have found it preferable to retire rather than adapt their practices to an environment with a high degree of managed care penetration . Because the number of physicians entering the older age categories will increase rapidly over the next 20 years, the growth of managed care and other influences on physician retirement will play an increasingly important role in determining the size of the physician workforce.

How managed care growth affects where physicians locate their practices

Managed care has had a profound effect on physician practice. It has altered patterns in the use of physician services, and consequently, the practice and employment options available to physicians. But managed care growth has not been uniform across the United States, and has spawned wide geographic disparities in earning opportunities for generalists and specialists. This Issue Brief summarizes new information on how managed care has affected physicians' labor market decisions and the impact of managed care on the number and distribution of physicians across the country.

Visits to primary care physicians and to specialists under gatekeeper and point-of-service arrangements

OBJECTIVE

To assess utilization of ambulatory visits to primary care physicians (PCPs) and to specialists in 2 different managed care models: a closed panel gatekeeper health maintenance organization (HMO) and an open panel point-of-service HMO.

STUDY DESIGN

Retrospective study of patients enrolled in a single managed care organization with 2 distinct product lines: a gatekeeper HMO and a point-of-service HMO. Both plans shared the same physician network.

PATIENTS AND METHODS

The study sample included 16,192 working-age members of the gatekeeper HMO and 36,819 working-age members of the point-of-service HMO. We estimated the number of PCP and specialist visits using negative binomial regression models and predicted the number of visits per year for each person under each HMO type and copayment option.

RESULTS

There were more annual visits to PCPs and a greater number of total physician visits in the gatekeeper HMO than in the point-of-service plan. However, we did not observe higher rates of specialist visits in the point-of-service HMO.

CONCLUSION

We found no evidence that direct patient access to specialists leads to higher rates of specialty visits in plans with modest cost-sharing arrangements.

HMO growth and the geographical redistribution of generalist and specialist physicians, 1987-1997

OBJECTIVE

To assess the impact of the growth in HMO penetration in different metropolitan areas on the change in the number of generalists, specialists, and total physicians, and on the change in the proportion of physicians who are generalists.

DATA SOURCES/STUDY SETTING

The American Medical Association Physician Masterfile, to obtain the number of patient care generalists and specialists in 1987 and in 1997 who were practicing in each of 316 metropolitan areas in the United States. Additional data for each metropolitan area were obtained from a variety of sources, and included HMO penetration in 1986 and 1996.

STUDY DESIGN

We estimated multivariate regression models in which the change in the number of physicians between 1987 and 1997 was a function of HMO penetration in 1986, the change in HMO penetration between 1986 and 1996, population characteristics and physician fees in 1986, and the change in population characteristics and fees between 1986 and 1996. Each model was estimated using ordinary least squares (OLS) and two-stage least squares (TSLS).

PRINCIPAL FINDINGS

HMO penetration did not affect the number of generalist physicians or hospital-based specialists, but faster HMO growth led to smaller increases in the numbers of medical/surgical specialists and total physicians. Faster HMO growth also led to larger increases in the proportion of physicians who were generalists. Our best estimate is that an increase in HMO penetration of .10 between 1986 and 1996 reduced the rate of increase in medical/surgical specialists by 10.3 percent and reduced the rate of increase in total physicians by 7.2 percent.

CONCLUSIONS

The findings of this study support the notion that HMOs reduce the demand for physician services, particularly for specialists' services. The findings also imply that, during the past decade, there has been a redistribution of physicians-especially medical/surgical specialists-from metropolitan areas with high HMO penetration to low-penetration areas.

HMO penetration and the geographic mobility of practicing physicians

In this study, we assessed the influence of changes in health maintenance organization (HMO) penetration on the probability that established patient care physicians relocated their practices or left patient care altogether. For physicians who relocated their practices, we also assessed the impact of HMO penetration on their destination choices. We found that larger increases in HMO penetration decreased the probability that medical/surgical specialists in early career stayed in patient care in the same market, but had no impact on generalists, hospital-based specialists, or mid career medical/surgical specialists. We also found that physicians who relocated their practices were much more likely to choose destination markets with the same level of HMO penetration or lower HMO penetration compared with their origin markets than they were to choose destination markets with higher HMO penetration. The largely negligible impact of changes in HMO penetration on established physicians' decisions to relocate their practices or leave patient care is consistent with high relocation and switching costs. Relocating physicians' attraction to destination markets with the same level of HMO penetration as their origin markets suggests that, while physicians' styles of medical practice may adapt to changes in market conditions, learning new practice styles is costly.

Expenditures for physician services under alternative models of managed care

This study compares expenditures for physician services in a closed panel gatekeeper health maintenance organization (HMO) and an open panel point of service HMO that share the same physician network. The study uses administrative files of the two study HMOs for 1994-1995 to assess differences in spending for primary care physicians' (PCPs') services, specialists' services, and total physician services. When the copayments for PCP visits and PCP-referred specialist visits were $0, total physician expenditures were 4 percent higher in the gatekeeper HMO than in the point of service plan (p < .05). When the copayments for PCP visits and PCP-referred specialist visits were $10, total physician expenditures ranged from equal in both HMOs to 7 percent higher in the gatekeeper HMO (p < .01), depending on the copayment for self-referred visits. Expenditures for specialists' services were not higher in the point of service plan. The authors conclude that direct patient access to specialists does not necessarily result in higher physician or specialist expenditures in HMOs.

Race and sex differences in the management of coronary artery disease

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decision-making appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician awareness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.

Association of dialyzer reuse and hospitalization rates among hemodialysis patients in the US

OBJECTIVES

To determine if reuse of hemodialyzers is associated with higher rates of hospitalization and their resulting costs among end-stage renal disease (ESRD) patients.

METHODS

Noncurrent cohort study of hospitalization rates among 27,264 ESRD patients beginning hemodialysis in the United States in 1986 and 1987.

RESULTS

Dialysis in free-standing facilities reprocessing dialyzers was associated with a greater rate of hospitalization than in facilities not reprocessing (relative rate (RR) = 1.08, 95% confidence interval (CI), 1.02-1.14). This higher rate of hospitalization was observed with dialyzer reuse using peracetic/acetic acids (RR = 1.11, CI 1. 04-1.18) and formaldehyde (RR = 1.07, CI 1.00-1.14), but not glutaraldehyde (p = 0.97). There was no difference among hospitalization rates in hospital-based facilities reprocessing dialyzers with any sterilant and those not reprocessing. Hospitalization for causes other than vascular access morbidity in free-standing facilities reusing dialyzers with formaldehyde was not different from hospitalization in facilities not reusing. However, reuse with peracetic/acetic acids was associated with higher rates of hospitalization than formaldehyde (RR = 1.08, CI 1.03-1.15).

CONCLUSIONS

Dialysis in free-standing facilities reprocessing dialyzers with peracetic/acetic acids or formaldehyde was associated with greater hospitalization than dialysis without dialyzer reprocessing. This greater hospitalization accounts for a large increment in inpatient stays in the USA. These findings raise important concerns about potentially avoidable morbidity among hemodialysis patients.

Equity in managed care for mental disorders

Equity of mental health care relative to general medical care is a long-standing policy issue in the mental health field, which in recent years has been debated as an issue of parity in insurance benefits. The shift toward managed mental health care makes the parity debate less controversial, because feared cost increases are an unlikely consequence under managed care. We argue, however, that managed care also makes benefit parity less relevant to the goals of achieving fairness in the delivery of mental health services. A broader policy perspective is required to encompass concerns about fairness under managed care.

Health maintenance organizations and hospital quality for coronary artery bypass surgery

This study uses hospital discharge data for 1992-1994 to assess differences between HMO and insured non-HMO patients in California and Florida with regard to the quality of the hospitals used for coronary artery bypass graft (CABG) surgery. The authors found that commercially insured HMO patients in California used higher quality hospitals than commercially insured non-HMO patients, controlling for patient distance to the hospital. In contrast, commercially insured HMO and non-HMO patients in Florida were similarly distributed across hospitals of different quality levels, whereas Medicare HMO patients in Florida used lower quality hospitals than patients in the standard Medicare program. The authors conclude that the association between HMO coverage and hospital quality may differ across geographic areas and patient populations, possibly related to the maturity and structure of managed care markets.

Financial incentives and drug spending in managed care

Pharmaceutical costs have been rising dramatically since 1995, growing 16.6% in 1998 alone. This rate of increase is more than four times that of all health care spending. Employers, managed care organizations and consumers are looking anew for ways to stem these rising costs, without denying patients effective care. Therefore, this Issue Brief is especially timely because it investigates how patient copayments and financial incentives for physicians affect drug spending in managed care.

Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association

BACKGROUND

Many internal medicine physicians report both primary and secondary specialties in the American Medical Association (AMA) Physician Masterfile. Usually, those represent combinations of general internal medicine and medical subspecialty practice. Whether reported specialty combinations can be used to assess the contribution of specialists to primary care is unknown.

OBJECTIVES

To examine whether internists' primary and secondary specialties reported in the Masterfile reflect the amount of primary care that they provide, and whether changes over time in internists' reported specialties reflect changes in primary care provision.

DESIGN

The Masterfile was used to identify internists' reported specialties in 1992 and in 1996. A mail questionnaire was used to assess the primary care content of physicians' practices. The association between reported specialties and the amount of primary care provided was evaluated using analysis of variance.

SUBJECTS

A stratified random sample of internists in active clinical practice.

MEASURES

The percentage of visits which were for the general medical care of patients for whom the physicians maintained ongoing responsibility. In addition, how often the physicians initiated the provision of preventive care for their regular patients, provided general medical care to these patients, and organized and coordinated the care received by these patients from other providers.

RESULTS

There was a strong association between the internists' primary and secondary specialties reported in the Masterfile and measures of the primary care content of physicians' practices (P < 0.0001). In contrast, changes over time in internists' reported specialties were not associated with physicians' assessments of changes in the primary care content of their practices.

CONCLUSIONS

Aggregate estimates of the availability of primary care in the US could be adjusted by taking into account the primary and secondary specialties reported by internal medicine physicians in the AMA Physician Masterfile.

Financial incentives and drug spending in managed care

This study estimates the impact of patient financial incentives on the use and cost of prescription drugs in the context of differing physician payment mechanisms. A large data set was developed that covers persons in managed care who pay varying levels of cost sharing and whose physicians are compensated under two different models: independent practice association (IPA)-model and network-model health maintenance organizations (HMOs). Our results indicate that higher patient copayments for prescription drugs are associated with lower drug spending in IPA models (in which physicians are not at risk for drug costs) but have little effect in network models (in which physicians bear financial risk for all prescribing behavior).