Service mix in the hospital outpatient department: implications for Medicare payment reform

OBJECTIVE

To determine if implementation of a PPS for Medicare hospital outpatient department (HOPD) services will have distributional consequences across hospital types and regions, this analysis assesses variation in service mix and the provision of high-technology services in the HOPD.

DATA

HCFA's 1990 claims file for a 5 percent random sample of Medicare beneficiaries using the HOPD was merged, by hospital provider number, with various HCFA hospital characteristic files.

STUDY DESIGN

Hospital characteristics examined are urban/rural location, teaching status, disproportionate-share status, and bed size. Two analyses of HOPD services are presented: mix of services provided and the provision of high-technology services. The mix of services is measured by the percentage of services in each of 14 type-of-service categories (e.g., medical visits, advanced imaging services, diagnostic testing services). Technology provision is measured by the percentage of hospitals providing selected high-technology services.

FINDINGS/CONCLUSIONS

The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS. HOPDs in major teaching hospitals and hospitals serving a disproportionate share of the poor play an important role in providing routine visits. HOPDs in both major and minor teaching hospitals are important providers of high-technology services. Other findings have implications for the structure of an HOPD PPS as well. First, over half of the services provided in the HOPD are laboratory tests and HOPDs may have limited control over these services since they are often for patients referred from local physician offices. Second, service mix and technology provision vary markedly among regions, suggesting the need for a transition to prospective payment. Third, the organization of service supply in a region may affect service provision in the HOPD suggesting that an HOPD PPS needs to be coordinated with payment policies in competing sites of care (e.g., ambulatory surgical centers).

Influence of hormones on platelet intracellular calcium

The pathophysiology of thromboembolic disease associated with estrogen therapy is poorly understood. There are innumerable calcium-dependent activities involved in platelet function. To determine whether platelet calcium levels are affected by exogenous hormones, intracellular calcium and release were studied in platelets in various hormonal environments and findings were correlated with platelet adhesion and aggregation. Platelet intracellular calcium concentration and release was significantly decreased in women ingesting tamoxifen compared to controls and significantly increased, as was platelet adhesion, in oral contraceptive users. Platelets incubated ex vivo with estradiol had increased intracellular calcium and release but there was decreased adhesion to fibronectin. Intracellular calcium concentration and release were not affected when platelets were incubated with tamoxifen. Adhesion to collagen III was increased in tamoxifen-incubated platelets. Only oral contraceptive users had increased sensitivity to aggregating agents. This data suggests that 17 beta estradiol, progesterone, and tamoxifen likely have a nongenomic effect on platelet intracellular calcium and calcium release and that platelet calcium levels are closely related to the degree of platelet adhesion and aggregation in vivo.

Reassembly of the 66 kD neurofilament protein in vitro following isolation and purification from bovine spinal cord

NF-66, also known as alpha-internexin, has been characterized as a 66 kD mammalian neurofilament (NF) protein whose expression in developing rat brain precedes that of the low molecular weight NF protein (NF-L). NF-66 is thought to assemble into 10 nm diameter intermediate filaments in vitro, although the precise nature of the assembly process remains obscure. Likewise, the ability of NF-66 to polymerize with the low (NF-L), middle (NF-M), and high (NF-H) M(r)NF proteins has not been defined. This investigation describes the reassembly of bovine NF-66 regarding its formation into 10 nm diameter filaments as well as its potential for polymerization with other type IV intermediate filaments. NF-66 and the NF triplet proteins were isolated from bovine spinal cord using established biochemical extraction and isolation procedures (Balin et al., Brain Res 556:181-195, 1991), and purified by a combination of high performance liquid chromatography (HPLC) (DEAE anion exchange and hydroxylapatite column chromatography) and gel elution strategies. In vitro reassembly experiments revealed that NF-66 formed approximately 10 nm diameter filaments of varying length; immunoelectron microscopy demonstrated labeling of these filaments by a monoclonal antibody to intermediate filament antigen (IFA), a polyclonal antibody against rat NF-66 and by a monoclonal antibody generated against the core region of NF-M but cross-reactive with NF-66. This report is the first investigation to look at the in vitro interaction between NF-66 and other type IV intermediate filament proteins (NF-H, -M, and -L) and establishes that NF-66 forms heteropolymeric filaments with these other neurofilament proteins, as confirmed by double immunolabeling. These studies suggest that NF-66 could provide a nucleation site for the polymerization of later-expressed proteins during neuronal development.

Predicting inpatient costs with admitting clinical data

Hospital cost-containment programs should themselves be cost-effective, targeting high-cost physicians (which requires adjusting for case mix) and patients (which requires early identification). In this study, clinical data available within 24 hours of admission from an electronic medical record system were used to develop statistical models to predict hospital costs. In this retrospective analysis of clinical data and diagnosis-related groups (DRGs), study subjects were 2,355 patients admitted for at least 1 day to the medicine service at an urban teaching hospital with sophisticated electronic medical records. Of these 2,355 patients, 1,663 (71%) had one of the 41 most common DRGs. Predictive models were derived on a random subset of two thirds of the patients and were validated on the remaining third. The following patient data were obtained: admission and prior diagnostic test results, diagnoses, vital signs; demographic data; prior inpatient and outpatient visits; tests and treatments ordered within 24 hours of admission (discretionary data); DRGs; and total inpatient costs (estimated from charges). Diagnosis-related groups explained 24% of the variance in total costs in the derivation patient set and 16% in the validation set. When only nondiscretionary data were used, the models retained only clinical laboratory results and prior diagnoses, explaining 20% of the derivation set variance in total costs and 16% in the validation set. Adding DRGs increased the variance explained in the derivation set to 34%, but decreased to 24% in the validation set. Adding discretionary data substantially increased the explained variance in the derivation and validation patient sets. The models' median predicted costs underestimated true costs by 10% to 13%, with the lowest error in the models using all types of variables. Clinical data gathered during routine clinical care can be used to adjust for case mix and identify high-cost patients early in their hospital stays, when they could be targeted by cost-containment interventions.

A comparison of HIV risk between women and men who inject drugs

Although there is growing evidence of differences between women and men who inject drugs (IDUs) in terms of level of risk for HIV infection, very little research has been conducted specifically addressing the risk practices of women IDUs. This study formed part of a national study of HIV infection risks in IDUs and the purpose of the present analysis was an exploration of gender differences in HIV risk practices, focusing on the HIV risk practices of IDU women. 1,245 IDUs from the inner city area of Sydney took part in this study. Of these, 908 were men and 331 were women. Notable results were that female respondents were more likely to report sharing needles, they injected heroin more times in a typical using month and were more likely to have shared with someone they later found out was HIV seropositive. Female respondents also reported more sexual partners than men, were more likely to engage in prostitution, and were more likely to have sexual partners who were themselves IDUs. The results provide support for the proposition that women who inject drugs may be at greater risk of HIV infection through both their drug taking and their sexual practices. Further research is needed to explore the reasons underlying the risk practices of women who inject drugs and an understanding of these factors needs to be incorporated into HIV risk-reduction and drug harm-reduction policies and programs.

Visual and quantitative computerized assessment of disease severity on peripheral angiograms

PURPOSE

This study was designed to determine and compare the intra- and interobserver variability of visual and computerized assessment of peripheral arterial disease (PAD) severity from lower extremity angiograms, and to correlate quantitative angiographic measures with clinical predictors of PAD.

PATIENTS AND METHODS

Peripheral angiograms of 13 segments from the ilio-femoral-popliteal system were evaluated on two separate occasions by nine radiologists and with a quantitative computerized method. In a separate study, images from 18 patients undergoing diagnostic lower extremity angiography were analyzed with use of quantitative angiography and the results were compared with clinical and lipid risk factors.

RESULTS

The data demonstrate that computerized assessment of peripheral angiograms is associated with lower intra- and interobserver variability than visual assessment of the same films. Despite this, there was excellent intraobserver and good interobserver agreement on the presence or absence of a severe lesion with visual assessment. Quantitative computerized measures of disease severity correlate with several known predictors of large vessel PAD.

CONCLUSION

Computerized assessment of peripheral angiograms may be a useful tool in the clinical and investigational evaluation of PAD.

Paradoxical influence of estrogenic hormones on platelet-endothelial cell interactions

Controversies abound in the literature about the safety and efficacy of tamoxifen and estrogen. We studied the effect of these 2 hormonal agents on factors involved in in vitro thrombogenesis: platelets and endothelial cells. Endothelial cells were derived from human umbilical veins and platelets were obtained from premenopausal and postmenopausal women, women on oral contraceptives, postmenopausal women on hormone replacement therapy, men, and patients with breast cancer who had been taking adjuvant tamoxifen for more than 1 year. The interaction of platelets with endothelial cell matrix was measured in 2 systems: 1) in a flow chamber at low shear rate and, 2) with 51Cr labeled platelets in a "static" culture system. In the static system, platelets from women on tamoxifen exhibited decreased platelet adherence to endothelial cell matrix whether they were grown in tamoxifen or control conditions, when compared to platelets from premenopausal women. When flow (25 sec-1) was added these differences were negated. Neither tamoxifen nor 17 beta estradiol had an effect on endothelial cell proliferation or platelet aggregation. Adhesion of platelets at low shear was not altered when platelet rich plasma was incubated with tamoxifen nor when endothelial cells were grown in tamoxifen. In contrast, incubation of platelets in 17 beta estradiol decreased platelet adhesion at low shear rate, however, there was no effect on platelet adhesion when endothelial cells were grown in 17 beta estradiol. We conclude that in early stages of thrombus formation as measured in vitro, tamoxifen may not have a detrimental effect and estrogen may be protective.

Predictors of HIV status among injecting drug users and health promotion

Two consecutive samples one year apart of injecting drug users (n = 754 and n = 345) were collected in Sydney, Australia and analysed for predictors of Human Immunodeficiency Virus (HIV) prevalence. Data indicated that similar variables were associated with HIV infection in both waves of the study. Risks for HIV infection included number of injections in last typical using month, acceptance of used injecting equipment from other injecting drug users (IDUs) who were known to be infected either before or after the sharing occurred, having sex with people known to be infected with HIV, and sexual orientation. It was not possible to determine whether sexual or equipment sharing with known HIV infected people preceded or followed HIV infection. These data confirm that predictors of HIV prevalence in Sydney are similar to those found in overseas studies and that sexual orientation appears to be the most powerful predictor. These data suggest both that sexual contact is an important route of infection in IDUs, and that sexual risks for HIV infection in IDUs need to be emphasised.

Physician profiling. An analysis of inpatient practice patterns in Florida and Oregon

BACKGROUND

Physician profiling is a method of cost control that focuses on patterns of care instead of on specific clinical decisions. It is one cost-control method that takes into account physicians' desire to curb the intrusion of administrative mechanisms into the clinical encounter. To provide a concrete example of profiling, we analyzed the inpatient practice patterns of physicians in Florida and Oregon.

METHODS

Data for 1991 from Medicare's National Claims History File were used to profile 12,720 attending physicians in Florida and 2589 in Oregon. For each attending physician, we determined the total relative value of all physicians' services delivered during each patient's hospital stay. Relative value was measured in relative-value units (RVUs), according to the resource-based relative-value scale used by Medicare in determining payments to physicians. The mean number of RVUs per admission was then adjusted for the physician's case mix according to the patients' assigned diagnosis-related groups. The influence of the physician's specialty and of selected types of services (such as imaging and endoscopy) was also examined.

RESULTS

Florida physicians used markedly more resources, on average, than their colleagues in Oregon (46 vs. 30 case-mix-adjusted RVUs per admission). The difference was apparent for all specialties and all types of service. To illustrate the profiling data potentially available to the medical staffs of individual hospitals, we examined specific data on individual attending physicians and for various types of service for three hospitals' staffs. Despite similar overall profiles that fell below the national mean, each staff had a different practice pattern and would require different efforts to improve efficiency.

CONCLUSIONS

In an effort to encourage further debate, we have described one method of physician profiling. Profiling data help identify and characterize differences in practice style to which individual physicians or hospital staffs can respond. Because profiling is not based on rigid rules, it is a cost-containment strategy that can easily accommodate legitimate exceptions; it is therefore preferable to methods in which the appropriateness of each clinical decision is judged separately.

Bromide pharmacokinetics in cystic fibrosis

OBJECTIVE

Individuals with cystic fibrosis (CF) have altered kinetics for a number of drugs, most often an increased volume of distribution (Vd) per body weight and increased clearance per body weight. To further evaluate those differences, we studied bromide kinetics (Vd, elimination rate constant, and clearance) and body mass index in eight adults with mild-to-moderate forms of CF, 21 obligate carriers of the CF gene, and 21 healthy controls. Bromide distribution approximates the extracellular fluid volume and bromide is excreted unchanged by the kidney.

DESIGN

Individuals were given a single oral dose of bromide (50 mg/kg), and serum bromide concentrations were measured over 4 weeks. Bromide pharmacokinetics (Vd, elimination rate constant, and clearance) were determined using a one-compartment model with first-order kinetics. Body mass index was determined for each individual.

RESULTS

Individuals with CF had a significantly greater lean body mass per kilogram as estimated by body mass index compared with individuals in the obligate carrier and control groups. The mean (+/- SD) Vd per kilogram for the CF group (311 +/- 29 mL/kg) was significantly greater than that of the obligate carrier group (261 +/- 26 mL/kg) and the control group (274 +/- 30 mL/kg). However, the mean (+/- SD) Vd per square meter for the three groups was similar. The mean elimination rate constant for the CF group (3.55 +/- 0.98 x 10(-3)/h) was significantly greater compared with the mean elimination rate constant for the obligate carrier group (2.55 +/- 0.36 x 10(-3)/h) and the control group (2.58 +/- 0.49 x 10(-3)/h). The mean (+/- SD) clearance per kilogram was also significantly greater for the CF group (1095 +/- 283 microL/kg per hour) compared with the obligate carrier group (664 +/- 100 microL/kg per hour) and the control group (700 +/- 115 microL/kg per hour).

CONCLUSIONS

These findings indicate that individuals with CF have a greater Vd per kilogram for bromide and drugs that distribute in the extracellular fluid volume because of their greater lean body mass per kilogram. The findings also suggest that individuals with CF have a greater renal clearance of bromide and presumably of other anionic drugs excreted by the kidney. The results emphasize the importance of body composition in drug disposition.

Statistical prediction of the locus of endoproteolytic cleavage of the nascent polypeptide in glycosylphosphatidylinositol-anchored proteins

Existing methods of identifying the cleavage site of the nascent polypeptide and the C-terminal residue to which the glycosylphosphatidylinositol (GPI) anchor is attached in mature GPI-anchored proteins are technically difficult and labour-intensive. We tested the hypothesis that it was possible to predict this locus using data from the cDNA-deduced amino acid sequence and amino acid composition of GPI-anchored proteins. We employed a statistical approach which allowed repeated chi 2 comparisons between the proportions of residual amino acids in the major body of the cDNA-deduced polypeptide (minus the N-terminal signal peptide) after repeated computer-generated progressive exoproteolysis from its C-terminus one amino acid at a time and the fixed proportion of amino acids obtained from amino acid analysis of the mature GPI-anchored protein. Initial comparison of the two parameters invariably revealed a relatively high chi 2 statistic which progressively lowered to a minimum point at which the amino acid proportions of progressively exoproteolysed polypeptide and fixed endoproteolysed polypeptides of the mature GPI-anchored protein were in closest agreement. This objectively defined and unique minimum point of closest agreement accurately identified the locus of post-translational endoproteolytic cleavage of the nascent polypeptide in several tissue-specific single-gene-encoded GPI-anchored proteins. Thus the C-terminal amino acid to which the GPI anchor is attached can be rapidly identified using data from the cDNA sequence and the amino acid composition of proteins suspected to be GPI-anchored.

Proposals to control high-cost hospital medical staffs

Several health care reform bills would limit Medicare payments to high-cost medical staffs, that is, physicians in hospitals with a high volume of physician services per admission. In a given year, Medicare's payment to the physicians on each hospital's medical staff could not collectively exceed a limit defined as a certain percentage above the national median. Limits of various forms are used in other parts of the Medicare program. This policy would combine cost containment incentives with a clear organizational structure. In addition, medical staffs could be provided with detailed information on their practice styles.

Carboplatin (CBDCA) plus alpha interferon in metastatic non-small cell lung cancer. A Hoosier Oncology Group phase II trial

Interferons have been shown to increase in vitro cytotoxicity of platinum compounds. The Hoosier Oncology Group has conducted a Phase II clinical trial to determine if interferon alpha-2a (IFN-alpha-2a) given in combination with carboplatin (CBDCA) can increase response rates or survival in patients with metastatic or recurrent inoperable non-small-cell lung cancer. Forty-four patients with no prior chemotherapy and high KPS (80-100) were enrolled. CBDCA 400 mg/m2 was given intravenously on day 1 and IFN-alpha-2a 9 million units was given subcutaneously on days 1, 3, and 5. Treatment was administered every 4 weeks until onset of progressive disease or to a maximum of 4 courses: 37 patients (84%) received at least 2 courses, whereas only 16 (36%) received the full 4 courses. Dose-limiting toxicities were leukopenia (27%) and thrombocytopenia (20%) attributable to CBDCA. Grade 2-3 anemia occurred in 32%. Only 4-7% of patients experienced severe fever, fatigue, or flu-like symptoms attributable to interferon administration. Of 41 patients evaluable for response, there were no complete responses and only 3 (7.3%) partial remissions. The overall median survival was 6 months. The combination of CBDCA and IFN-alpha-2a given in this dose and schedule does not appear to have superior activity compared to CBDCA alone in patients with non-small-cell lung cancer.

The analysis of longitudinal polytomous data: generalized estimating equations and connections with weighted least squares

In recent years, methods have been developed for modelling repeated observations of a categorical response obtained over time on the same individual. Although situations in which the repeated response is binary or Poisson have been studied extensively, relatively little attention has been given to polytomous categorical response variable. In this paper, we extend the estimating equations initially developed for clustered discrete data by Liang and Zeger (1986, Biometrika 73, 13-22), and subsequently extended by Prentice (1988, Biometrics 44, 1033-1048), to polytomous response variables. Under certain assumptions, we illustrate that these estimating equations simplify to the weighted least squares (WLS) equations formalized by Koch et al. (1977, Biometrics 33, 133-158). This connection provides a formal framework for obtaining iterated weighted least squares model parameter estimates. Cumulative logit models are developed and applied to a representative longitudinal data set. Simulation results comparing WLS, an iterative form of WLS, and independence estimating equations using a robust estimate of the variance are presented.

Posterior pelvic fixation using a transiliac 4.5-mm reconstruction plate: a clinical and biomechanical study

Operative management of unstable pelvic fractures is directed toward stabilization of the posterior lesion. We describe a technique of posterior pelvic fixation that uses a 4.5-mm reconstruction plate as a transiliac tension band. The plate is inserted through the posterior superior iliac spines with screw fixation to the ilium. Our initial clinical experience was gained using this technique in 15 patients who had unstable pelvic ring injuries with sacral fractures. Stable fixation was achieved in all patients with this low-profile plate. There were no infections, no wound complications, and no failures of fixation. Comparative biomechanical testing using cadaveric and artificial pelvises demonstrated that the strength of the transiliac plate method was equal to that of other techniques of posterior pelvic fixation.

Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols

OBJECTIVE

To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing.

DESIGN

Six-month prospective, randomized, controlled trial.

SETTING

Academic primary care general internal medicine practice.

SUBJECTS

Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols.

INTERVENTION

Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same remainders to which they were required to circle one of four responses: 1) "done/order today," 2) "not applicable to this patient," 3) "patient refused," or 4) "next visit."

RESULTS

Intervention physicians complied more frequently than control physicians with all remainders combined (46% vs 38%, respectively, p = 0.002) and separately with remainders for FOBT (61% vs 49%, p = 0.0007) and mammography (54% vs 47%, p = 0.036) but not cervical Pap testing (21% vs 18%, p = 0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention's effect was greatest for patients > or = 70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patient's electronic medical records) and stated that their patients refused 10% of the time.

CONCLUSIONS

Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians' compliance was the lowest. However, 100% compliance with cancer screening remainders will be unattainable due to incomplete data and patient refusal.

Injecting drug users and HIV/AIDS: risk behaviours and risk perception

This paper reports on the incidence of risk taking behaviours, and the relationship between risk perception and risk behaviours in a sample of 1245 Sydney injecting drug users (IDUs). Almost all respondents reported engaging in behaviours that placed them at risk of HIV infection: 32.9% through unsafe injecting, 84.4% because of unsafe sexual behaviour and 89.2% because of either injecting or sexual behaviour. Injecting and sexual behaviour were poorly correlated. This study also found that risk perception is unrelated to injecting or sexual behaviours, previous history of sexually transmitted diseases, a range of demographic characteristics including age and gender, and the number of times tested for HIV. Social policy and prevention programs should aim to change unsafe injecting and sexual behaviours directly, rather than attempting to achieve change indirectly by changing risk perception.

A comparison of drug use and HIV infection risk behavior between injecting drug users currently in treatment, previously in treatment, and never in treatment

We compared three groups of injecting drug users in a large cross-sectional study on HIV/AIDS and risk behaviors in Sydney, Australia, to determine what differences existed between those who had never been in treatment (n = 458), had previously been in treatment (n = 387), and were currently in treatment (n = 367). Drug use for those currently in treatment was assessed during the last typical using month before treatment. Those previously and currently in treatment were similar in terms of drug use patterns and HIV risk-related injecting behaviors. Those never in treatment were younger, had a lower level of HIV risk-related injecting behaviors, and reported lower drug use and less involvement in the drug subculture. There was little difference between the three groups on HIV risk-related sexual behaviors. These data suggest that those never in treatment are less dysfunctional and possibly less involved in drug-using careers, whereas there appears to be a close relationship between being previously and currently in treatment.

Estimating physician costliness. An empirical Bayes approach

Outpatient data obtained from the general medicine practice of an urban, health care facility are used to provide an application of empirical Bayes techniques in the estimation of physician "costliness." The results illustrate that application of the simplest empirical Bayes estimation procedure can provide more reasonable estimates of physician's utilization of resources than a standard estimation procedure. Empirical Bayes estimates are shown to adjust for potential instability in standard estimates that may arise from either a physician treating a small number of patients or an inappropriate case-mix adjustment. Using simulation, it is demonstrated that the empirical Bayes procedure can provide overall better estimates using fewer data than the standard procedure. This application, although somewhat limited in scope, should provide impetus for increased utilization of the numerous Bayesian and empirical Bayes techniques that currently exist in the statistical literature and pertain to small area estimation techniques.

Geographic variation in expenditures for physicians' services in the United States

BACKGROUND

The national volume-performance standard recently implemented by Medicare does not account for geographic variation in expenditures for physicians' services. To study this variation, we examined expenditures for physicians' services in all metropolitan areas in the United States.

METHODS

We used Medicare claims data for 1989 to measure rates of service use for beneficiaries living in the 317 U.S. metropolitan statistical areas (MSAs). The variables investigated were rates of admission to the hospital, payments to physicians for inpatient care per admission and per beneficiary, payments to physicians for outpatient care per beneficiary, and overall payments to physicians per beneficiary. Expenditures were measured in terms of allowed charges as adjusted to reflect prevailing charges in each MSA. Rates of use were adjusted for age and sex, with the exception of the variable for payments to physicians for inpatient care per admission, which was adjusted for case mix.

RESULTS

Expenditures for the delivery of physicians' services to Medicare beneficiaries varied markedly among MSAs, with those for the areas with the lowest and the highest rates differing at least twofold on each measure. The measures for specific areas varied in parallel: areas with high rates of admission tended to have high levels of payment to physicians for inpatient care per admission, and areas with high payments for inpatient services tended to have high payments for outpatient services. Expenditures were not related to the number of physicians per capita but were lower in MSAs with a high proportion of primary care practitioners. The variation persisted when the 25 largest MSAs were examined; for total payments to physicians per beneficiary, there was a twofold difference between the area with the lowest rate and that with the highest, San Francisco ($872) and Miami ($1,874). The states with the highest overall payments to physicians per beneficiary were Florida, Louisiana, and Michigan.

CONCLUSIONS

The marked variation among metropolitan areas in payments to physicians underscores the lack of consensus among physicians about which services are required. Moreover, the practice style in a given community appears to be influenced not by the aggregate supply of physicians but rather by the mixture of primary care physicians and specialists.

Hypnotic analgesia: dissociated experience or dissociated control?

High-hypnotizable subjects (n = 18) were superior to low-hypnotizable subjects (n = 18) in the extent of pain reduction produced by hypnotic analgesia and by a stress-inoculation procedure. However, stress inoculation but not hypnotic analgesia impaired performance on a cognitively demanding task that competed with pain reduction for cognitive resources. This outcome implies that hypnotic analgesia occurs with little or no cognitive effort to reduce pain and challenges the social psychological model of hypnosis. The findings are also inconsistent with the notion of dissociated experience, which proposes that pain and the cognitive efforts to reduce it are cut off from consciousness by an amnesialike barrier. However, the results do support the notion of dissociated control, which proposes that suggestions for hypnotic analgesia directly activate pain reduction and thereby avert the need for cognitive strategies to reduce pain.