Managed care, access to specialists, and outcomes among primary care patients with pain

Integrated Care for Complicated Patients: A Role for Combined Training and Practice

Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.

Managed Care and Patient-Rated Quality of Care from Primary Physicians

The aim is to determine the associations between managed care controls and patient-rated quality of care from primary physicians. In a prospective cohort study, 17,187 patients were screened in the waiting rooms of 261 primary care physicians in the Seattle metropolitan area (1996-1997) to identify 2,850 English-speaking adult patients with depressive symptoms and/or selected pain problems. Patients completed 6-month follow-ups to rate the quality of care from their primary physicians. The intensity of managed care was measured for each patient’s health plan, primary care office, and physician. Regression analyses revealed that patients in more managed plans and offices had lower ratings of the quality of care from their primary physicians. Managed care controls targeting physicians were generally not associated with patient ratings.

Physician-reported barriers to referring cancer patients to specialists: prevalence, factors, and association with career satisfaction

BACKGROUND

Quality care for patients with cancer often requires access to specialty providers, but little is known about barriers to referring cancer patients for specialized care. Referral barriers may also lessen physician career satisfaction. The study was aimed at determining what factors are associated with these barriers and whether greater barriers are associated with low career satisfaction.

METHODS

This cross-sectional study examined 1562 primary care physicians (PCPs) and 2144 specialists responding to the multiregional Cancer Care Outcomes Research and Surveillance Consortium physician survey. The prevalence of physician-reported barriers to referring cancer patients for more specialized care (restricted provider networks, preauthorization requirements, patient inability to pay, lack of surgical subspecialists, and excessive patient travel time) was assessed. The 5 items were averaged to calculate a barrier score. A multivariate linear regression was used to determine physician and practice setting characteristics associated with the barrier score, and a multivariate logistic regression was used to analyze the association of the barrier score with physician career satisfaction.

RESULTS

Three in 5 physicians reported always, usually, or sometimes encountering any barrier to cancer patient specialty referrals. In adjusted analyses of PCPs and specialists, international medical graduates, physicians practicing in solo or government-owned practices, and physicians with <90% of their patients in managed care plans had higher barrier scores than others (P < .05). High barrier scores were associated with lower physician career satisfaction among PCPs and specialists (P < .05).

CONCLUSIONS

Many physicians experience barriers to specialty referral for cancer patients. Uniform systems for providing and tracking timely referrals may enhance care and promote physician career satisfaction.

Predictors of postpartum depression

OBJECTIVE

To examine sociodemographic factors, pregnancy-associated psychosocial stress and depression, health risk behaviors, prepregnancy medical and psychiatric illness, pregnancy-related illnesses, and birth outcomes as risk factors for post-partum depression (PPD).

METHODS

A prospective cohort study screened women at 4 and 8 months of pregnancy and used hierarchical logistic regression analyses to examine predictors of PPD. The study sample include 1,423 pregnant women at a university-based high risk obstetrics clinic. A score of ≥10 on the Patient Health Questionnaire-9 (PHQ-9) indicated clinically significant depressive symptoms.

RESULTS

Compared with women without significant postpartum depressive symptoms, women with PPD were significantly younger (p<0.0001), more likely to be unemployed (p=0.04), had more pregnancy associated depressive symptoms (p<0.0001) and psychosocial stress (p<0.0001), were more likely to be smokers (p<0.0001), were more likely to be taking antidepressants (ADs) during pregnancy (p=0.002), were less likely to drink any alcohol during pregnancy (p=0.02), and were more likely to have prepregnancy medical illnesses, including diabetes (p=0.02) and neurologic conditions (p=0.02).

CONCLUSION

Specific sociodemographic and clinical risk factors for PPD were identified that could help physicians target depression case finding for pregnant women.

[Do gatekeeping programs increase equality of health care in Germany? A comparison of the health care situation of participants and nonparticipants]

This article compares the health care situation of participants in programs of general practitioner-centered health care (gatekeeping) in Germany (participants) with that of statutory health insurance holders who are not participating in such programs (nonparticipants). Because a key objective of the general practitioner model is to reduce the number of visits to specialists, the article also examines factors influencing frequent utilization of specialists in both groups. The analysis draws on a survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, 2010) based on a sample representative of the German population. In this context, 5,232 holders of statutory health insurance aged between 18 and 79 years were interviewed on health care policy issues. The results show that regulating the utilization of specialists through the gatekeeping function of general practitioners succeeds in facilitating similar utilization rates across educational levels, between cities and towns, and between men and women. Thus, gatekeeping programs contribute to the reduction of health care inequalities.

Corporatization of pain medicine: implications for widening pain care disparities

The current health care system in the United States is structured in a way that ensures that more opportunity and resources flow to the wealthy and socially advantaged. The values intrinsic to the current profit-oriented culture are directly antithetical to the idea of equitable access. A large body of literature points to disparities in pain treatment and pain outcomes among vulnerable groups. These disparities range from the presence of disproportionately higher numbers and magnitude of risk factors for developing disabling pain, lack of access to primary care providers, analgesics and interventions, lack of referral to pain specialists, longer wait times to receive care, receipt of poor quality of pain care, and lack of geographical access to pharmacies that carry opioids. This article examines the manner in which the profit-oriented culture in medicine has directly and indirectly structured access to pain care, thereby widening pain treatment disparities among vulnerable groups. Specifically, the author argues that the corporatization of pain medicine amplifies disparities in pain outcomes in two ways: 1) directly through driving up the cost of pain care, rendering it inaccessible to the financially vulnerable; and 2) indirectly through an interface with corporate loss-aversion/risk management culture that draws upon irrelevant social characteristics, thus worsening disparities for certain populations. Thus, while financial vulnerability is the core reason for lack of access, it does not fully explain the implications of corporate microculture regarding access. The effect of corporatization on pain medicine must be conceptualized in terms of overt access to facilities, providers, pharmaceuticals, specialty services, and interventions, but also in terms of the indirect or covert effect of corporate culture in shaping clinical interactions and outcomes.

Measuring patients' experiences with individual specialist physicians and their practices

This study assesses the reliability of patient-reported information about care received by individual specialist physicians. A patient questionnaire that included core composites from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey was administered to random samples of patients visiting 1315 physicians from 14 specialties in California during 2005-2006 (n = 68 406 respondents). The quality of specialist-patient interaction and organizational access composites achieved adequate physician-level reliability (alpha(MD) = 0.70) with 30 or fewer patients per specialist, but the care coordination and health promotion support composites were generally less reliable. Patients reporting consult-based relationships with specialists reported worse care experiences across measures (P < .001). The results indicate that reliable patient-reported information can be obtained about specialist physicians with patient sample size requirements comparable to primary care physicians. In order to promote equitable performance measurement in specialty care, future research should clarify the contribution of consult-based specialist-patient relationships to performance differences.

Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms

BACKGROUND

Managed care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.

METHODS

A prospective cohort study design was conducted in the offices of 261 primary physicians in private practice in Seattle in 1997. Patients (N = 17,187) were screened in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms. Patients (n = 1,995) completed a 6-month follow-up survey. Of these, 691 patients received specialty care for pain, and 356 patients saw mental health specialists. For each patient, managed care was measured by the intensity of managed care controls in the patient's health plan and primary care office. Quality of specialty care at follow-up was measured by patient rating of care provided by the specialists. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days.

RESULTS

The intensity of managed care controls in health plans and primary care offices was generally not associated with patient ratings of the quality of specialty care. However, pain patients in more-managed primary care offices had lower ratings of the quality of specialty care from physician specialists and ancillary providers.

CONCLUSION

For primary care patients with pain or depressive symptoms and who see specialists, managed care controls may influence ratings of specialty care for patients with pain but not patients with depressive symptoms.

Primary care physician specialty referral decision making: patient, physician, and health care system determinants

PURPOSE

To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making.

METHODS

Physicians (n=142) and their practices (n=83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n=34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist.

RESULTS

Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gate-keeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice.

CONCLUSIONS

PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

Economic efficiency of gate-keeping compared with fee for service plans: a Swiss example

STUDY OBJECTIVE

The impact of isolated gate-keeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gate-keeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection.

DESIGN

Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two-part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non-zero costs. Complementary data sources were used to identify selection effects.

SETTING

A gate-keeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland.

PARTICIPANTS

Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans.

MAIN RESULTS

The characteristics of gate-keeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr 231 (8%) lower in the gate-keeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gate-keeping in the source population amounted to Sw fr 403-517 (15%-19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non-detected selection effects cannot be ruled out.

CONCLUSIONS

This study hints at substantial cost savings through gate-keeping that are not attributable to mere risk selection.

Managed care, physician job satisfaction, and the quality of primary care

OBJECTIVE

To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms.

DESIGN

Prospective cohort study.

SETTING

Offices of 261 primary physicians in private practice in Seattle.

PATIENTS

We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey.

MEASUREMENTS AND RESULTS

For each patient, managed care was measured by the intensity of managed care controls in the patient's primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes.

CONCLUSIONS

For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.

The case for pain medicine

Pain Medicine has its roots in multiple primary specialties and has developed into a discrete specialty with disparate practice styles. Its identity is in flux and is threatened by forces that may fragment this new field before it can set firm roots. The public health crisis of under treated pain parallels medicine's struggle to adequately classify Pain Medicine as a specialty. We review the case for Pain Medicine as a discrete discipline, with specialized knowledge, treatments, training and education. Without recognition of the specialty of Pain Medicine, and resolution of the fragmentation of the field throughout healthcare, medicine's approach to the current problem of under treated pain is likely to continue to be inadequate.