Consequences of cost-sharing for children's health

Do children whose families bear a percentage of their health care costs reduce their use of ambulatory care compared with those families who receive free care? If so, does the reduction affect their health? To answer these questions, 1,844 children aged 0 to 13 years were randomly assigned (for a period of 3 or 5 years) to one of 14 insurance plans. The plans differed in the percentage of their medical bills that families paid. One plan provided free care. The others required up to 95% coinsurance subject to a +1,000 maximum. Children whose families paid a percentage of costs reduced use by up to one third. For the typical child in the study, this reduction caused no significant difference in either parental perceptions of their child's health or in physiologic measures of health. Confidence intervals are sufficiently narrow for most measures to rule out the possibility that large true differences went undetected. Nor were statistically significant differences observed for children at risk of disease. Wider confidence intervals for these comparisons, however, mean that clinically meaningful differences, if present, could have been undetected in certain subgroups.

Expanding patient involvement in care. Effects on patient outcomes

An intervention was developed to increase patient involvement in care. Using a treatment algorithm as a guide, patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit. In a randomized controlled trial we compared this intervention with a standard educational session of equal length in a clinic for patients with ulcer disease. Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities (p less than 0.05), preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians (p less than 0.05). Results of the intervention included increased involvement in the interaction with the physician, fewer limitations imposed by the disease on patients' functional ability, and increased preference for active involvement in medical decision-making.

Adherence to health care regimens among elderly women

This study examined selected components of nurse practitioners' care to determine which contributed most to the intent to adhere to the care plan. High and low levels of components of care (technical quality, psychosocial, and patient participation) were depicted by videotapes of a patient visit to a nurse practitioner. The videotapes were randomly selected and shown in 26 senior citizen nutrition centers in a metropolitan area. Elderly women indicated how likely they would be to adhere if they had been the patient in the tape. High psychosocial care was the only component significantly related to intent to adhere; however, the significance did not hold in an analysis of covariance when individual characteristics were controlled. Individual characteristics related to high intent to adhere were widowed marital status, religion, perceived importance of the examination, social network, and preexisting satisfaction with health care.

Do physicians preach what they practice? A study of physicians' health habits and counseling practices

We examined the relation of physicians' clinical specialty, personal health habits, and health-related beliefs to their practices in counseling about smoking, weight, exercise, and alcohol. We surveyed a random sample of members of a county medical society in selected specialties. Physicians with better personal health habits and more positive attitudes toward counseling counsel a broader range of patients and counsel more aggressively. Surgeons counsel less than nonsurgeons, even after controlling for differences in health-related attitudes and personal habits.

The sensitivity of mental health care use and cost estimates to methods effects

The authors determined the sensitivity of estimates of the use and cost of outpatient mental health care to two methods effects: the definition of a mental health visit and strategies for allocating mental health care costs. They use data from the Rand Health Insurance Study, which has a random sample of the nonaged noninstitutionalized civilian population in six United States sites. Estimates of the use of mental health specialists are insensitive to alternative methods. However, estimates of the use and cost of the mental health care delivered by nonpsychiatrist physicians (e.g., internists) are quite sensitive to methods effects. Nevertheless, the cost of care from nonpsychiatrist physicians is so low that the total cost of outpatient mental health care is not meaningfully affected by methods effects.

Methodology in behavioral and psychosocial cancer research. Conceptualizing disease impact and treatment outcomes

The focus of assessment of disease impact is moving beyond survival and biomedical outcomes to include a comprehensive set of health status and quality of life concepts. We have discussed four socially relevant concepts that can be thought of as dimensions of health status or well being: physiologic status, personal (physical) functioning, mental health, and social well-being. Quality of life was also discussed briefly as a very global concept encompassing these health status dimensions and a broader set of concepts including finances, housing, and employment. Five categories of measures based on manifest content were also discussed, including measures of disease/diagnostic status, personal functioning, mental health, general health perceptions, and social/role functioning. The physiologic dimension of health is very heterogeneous and includes many concepts and measures that vary largely independently of each other and that differ in terms of their impact on the other dimensions of health status. The physical, mental, and social dimensions of health and well-being also can be measured many different ways, and each can be broken down into distinct concepts that may vary in importance from one study to another. Of these three concepts, social well-being is the most heterogeneous. To assist investigators searching for valid measures of specific health status and quality of life concepts, we recommended formal estimations of measurement models. A preliminary model of 15 health status measures was presented to illustrate the usefulness of such a model.

Physicians' attitudes in counseling patients about smoking

Attitudes of physicians toward counseling patients about their smoking habits may influence whether and how counseling occurs. In this paper, the authors develop and test a conceptual model of these attitudes. The model includes four attitude dimensions: physicians' motivations to counsel, perceived health risk of smoking, perceived skills in counseling, and perceived costs and benefits to the physician of counseling. A self-report questionnaire including a 40-item measure of these attitudes was delivered to a random sample of male general practitioners, internists, surgeons, and obstetrician-gynecologists who were members of a western county medical society in 1978. The response rate was 76%. Based on factor analyses, 10 subscales and 3 global scales were formed by summing items. The item contents of scales are consistent with the authors' model, and reliability and item-discriminant validity are excellent. The authors' model may be useful in understanding the factors that affect the process and outcomes of physician counseling about smoking.

Physicians' practices in counseling patients about health habits

The authors developed and tested a model of two dimensions of physicians' behavior in counseling patients about four health habits (smoking, weight control, alcohol consumption, and regular exercise). The two dimensions are the indications for routine counseling and the aggressiveness of counseling style. To test these dimensions, a questionnaire was administered to a random sample of members of a Western County Medical Society in 1978. The response rate was 76%. Indications and Aggressiveness subscales were developed for each habit. Reliability and discriminant validity for all subscales was excellent. Descriptive results were consistent with expectations, e.g., physicians counseled more about smoking and weight control than about alcohol and exercise. The results support the dimensions and suggest that the questionnaire will be useful for future research on counseling behavior.

Does free care improve adults' health? Results from a randomized controlled trial

Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost? In an effort to answer this question, we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been randomly assigned to a set of insurance plans for three or five years. One plan provided free care; the others required enrollees to pay a share of their medical bills. As previously reported, patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often. For persons with poor vision and for low-income persons with high blood pressure, free care brought an improvement (vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3 mm Hg); better control of blood pressure reduced the calculated risk of early death among those at high risk. For the average participant, as well as for subgroups differing in income and initial health status, no significant effects were detected on eight other measures of health status and health habits. Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence, favorable or adverse, of free care for the average participant. For some measures of health in subgroups of the population, however, the broader confidence intervals make this conclusion less certain.

Patient satisfaction and change in medical care provider: a longitudinal study

Longitudinal data from The Rand Corporation's Health Insurance Experiment were used to test the hypothesis that provider continuity can be modeled as one behavioral consequence of patient satisfaction. Bivariate and multivariate analyses (controlling for sociodemographic characteristics, prior use of services, health status, and health insurance plan) supported our hypotheses. A multivariate linear probability function indicated that a 1-point decrease on a general satisfaction scale was associated with a 3.4 percentage-point increase in the probability of provider change. The relationship between satisfaction scores and continuity during the following year appears to be roughly linear; we observed no "threshold" satisfaction level at which the probability of provider change increased markedly. We discuss needed improvements in the measurement of provider continuity and the need for further study of other behavioral consequences of patient satisfaction.

Defining and measuring patient satisfaction with medical care

This paper describes the development of Form II of the Patient Satisfaction Questionnaire (PSQ), a self-administered survey instrument designed for use in general population studies. The PSQ contains 55 Likert-type items that measure attitudes toward the more salient characteristics of doctors and medical care services (technical and interpersonal skills of providers, waiting time for appointments, office waits, emergency care, costs of care, insurance coverage, availability of hospitals, and other resources) and satisfaction with care in general. Scales are balanced to control for acquiescent response set. Scoring rules for 18 multi-item subscales and eight global scales were standardized following replication of item analyses in four field tests. Internal-consistency and test-retest estimates indicate satisfactory reliability for studies involving group comparisons. The PSQ well represents the content of characteristics of providers and services described most often in the literature and in response to open-ended questions. Empirical tests of validity have also produced generally favorable results.

Behavioral consequences of consumer dissatisfaction with medical care

The effects of consumer dissatisfaction with doctors and medical care services on intentions to seek care and subsequent behavior were estimated using data from four general population studies. Satisfaction was linked to reported intentions regarding care-seeking behavior (choices between self-care and seeking care from a regular doctor or emergency room) in response to both minor and serious medical problems. These results were replicated in two populations with diverse sociodemographic characteristics. Satisfaction scales also predicted subsequent changes in medical care providers and disenrollments from prepaid health plans independent field tests. These results suggest that the behavioral consequences of individual differences in satisfaction with doctors and health care services are noteworthy from both clinical and social perspectives.

Psychosocial problems in chronically ill children: physician concern, parent satisfaction, and the validity of medical records

This study concerns the psychosocial aspects of treatment for chronically ill children. The English-speaking parents of 44 children 5-13 years of age being seen at five specialty clinics at a large county hospital in Los Angeles, and their attending physicians, were the subjects in this study. The parents were interviewed concerning their expectations for the current visit, and the doctor-patient interaction was tape-recorded. Identical categories of information were abstracted from the tape recording and from a chart review of the patients' medical records. Although parents expected 76% of the psychosocial aspects of care to be covered by the doctor, only one fourth were actually discussed in the visit. These unfulfilled expectations were associated with lower satisfaction with medical care received (r = .47, p less than 0.01). Finally, while doctors recorded about 80% of discussions of symptoms and physical examinations in the patient's medical record, they recorded only 25% of discussion of psychosocial problems.

Effects of physical and mental health on health-state preferences

Studies concerned with measuring values and preferences for health states and health status components have typically employed "direct" scaling techniques that require conclusions to be based on definition. Problems and limitations of direct scaling are discussed. The algebraic modeling approach is new to health services research; it emphasizes testing models of how respondents combine stimulus information. The model specifies the causal relationship between the stimulus information and the responses. Subjective stimulus and response scales are derived from the model when the data satisfy the model's predictions. Thus, the validity of the subjective scale values rests on the validity of the model. In the present research, university students judged preferences between health states, each described by a physical (degree of physical activity) and mental (level of happiness/depression) component. The object of the research was to determine the subjective trade-offs between physical and mental health values in these preference judgments. For all respondents, preference judgments were consistent with the predictions of a preference model that yielded interval scales of the health states. Also, there were systematic interactions between physical and mental values, so that when a health state was bad on one component (e.g., poor physical health), the other component had less of an effect. However, results revealed individual differences in emphasis placed on the physical and mental health components. Advantages of replacing presently used measurement techniques with the algebraic modeling approach in general population studies are discussed.

Choosing measures of health status for individuals in general populations

This paper offers suggestions to adi the selection of appropriate instruments and data gathering methods for studies that require measures of personal health status applicable in general populations. Before selecting measures, the reason for studying health status must be identified. Next, definitional issues arise when attempting to specify the components of health that are to be studied. Evidence supports restriction of the definition of personal health status to its physical and mental components, rather than including social circumstances as well. In evaluating the suitability of available measures, three features must be considered: 1) practicality in terms of administration, respondent burden, and analysis; 2) reliability in terms of the study design and group or individual comparisons; 3) validity, in terms of providing information about the particular health components of interest to the study. Evaluating validity will be difficult for most available measures; careful attention to item content will be helpful in choosing appropriate measures. Despite problems in development and interpretation, overall health status indicators will prove useful to many studies and should be considered, as should both subjective and objective measures of health status. Given that the reasons to measure health have been identified, the aspects of health to be measured specified, and attention paid to their suitability, appropriate measures may often be found among those now available.

Advances in the measurement of functional status: construction of aggregate indexes

This article summarizes tests of the appropriateness of aggregating specific categories of physical capacities and limitations into aggregate functional status indexes. Self-administered questionnaires were used to gather data from 4,603 people between 14 and 66 years of age. Cumulative indexes defining ranked levels of functional status were derived for two global constructs of functioning (personal and role functioning). Each index is scored to define chronic limitations and those of shorter duration. Personal functioning includes self-care, mobility and physical activity categories. Role functioning includes role and general activity categories. An index that aggregated personal and role limitations did not satisfy the assumptions of cumulative scaling.