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Ramesh T, Wozniak GD, Yu H. County-Level Disparities in Heat-Related Emergencies. JAMA Netw Open 2024; 7:e242845. [PMID: 38502129 PMCID: PMC10951733 DOI: 10.1001/jamanetworkopen.2024.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/25/2024] [Indexed: 03/20/2024] Open
Abstract
This cross-sectional study examines the distribution of emergency medical service activation across US countries during the heat wave in July 2023.
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Affiliation(s)
- Tarun Ramesh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Khan T, Tsipas S, Wozniak GD, Kirley K, Mainous AG. Health Care Costs Following COVID-19 Hospitalization Prior to Vaccine Availability. J Am Board Fam Med 2024; 36:883-891. [PMID: 37857443 DOI: 10.3122/jabfm.2023.230069r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Postacute sequelae of coronavirus (PASC) disease of 2019 (COVID-19) include morbidity and mortality, but little is known of the impact on medical expenditures. This study measures patients' health care costs after COVID hospitalization before vaccinations. METHODS The Merative MarketScan database is used to track trends in medical expenditures for commercially insured patients hospitalized for COVID-19 (case subjects) compared with COVID-19 patients not hospitalized (control subjects) using a propensity score matching model. Medical expenditures were estimated from 30-, 60-, and 120-day clean periods after an initial COVID-19 encounter through the end of 2020. RESULTS Average total medical expenditures were 96% higher for individuals hospitalized for COVID-19 starting 30 days after initial COVID-19 encounter and almost 70% higher 120 days after based on the propensity score matching. The average spending differential was $11,242 30 days after and $4959 120 days after. This effect is highest for inpatient admissions and services 60 days after at $56,862 and lowest among pharmaceuticals 120 days after at $329. The magnitude of the difference is greater for those with hypertension or diabetes where total expenditures is $14,958 30 days after, and $5962 120 days after compared with those without these chronic conditions. DISCUSSION The results suggest both health and economic implications for COVID-19 hospitalization and supports the use of vaccinations to help mitigate these implications. PASC includes increased health care costs for hospitalized patients, particularly for those with chronic conditions. Preventing COVID-19 hospitalization has economic value in terms of reduced medical spending in addition to health benefits associated with reduced morbidity and mortality.
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Affiliation(s)
- Tamkeen Khan
- From the American Medical Association, Chicago, IL (TK, ST, GDW, KK); University of Florida, Gainesville, FL (AGM). )
| | - Stavros Tsipas
- From the American Medical Association, Chicago, IL (TK, ST, GDW, KK); University of Florida, Gainesville, FL (AGM)
| | - Gregory D Wozniak
- From the American Medical Association, Chicago, IL (TK, ST, GDW, KK); University of Florida, Gainesville, FL (AGM)
| | - Kate Kirley
- From the American Medical Association, Chicago, IL (TK, ST, GDW, KK); University of Florida, Gainesville, FL (AGM)
| | - Arch G Mainous
- From the American Medical Association, Chicago, IL (TK, ST, GDW, KK); University of Florida, Gainesville, FL (AGM)
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Ramesh T, Brotherton SE, Wozniak GD, Yu H. Evaluation of the Conrad 30 Waiver Program's Success in Attracting International Medical Graduates to Underserved Areas. JAMA Health Forum 2023; 4:e232021. [PMID: 37505491 PMCID: PMC10383001 DOI: 10.1001/jamahealthforum.2023.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Tarun Ramesh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Escarce JJ, Wozniak GD, Tsipas S, Pane JD, Ma Y, Brotherton SE, Yu H. The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists. Med Care 2022; 60:342-350. [PMID: 35250020 PMCID: PMC8989636 DOI: 10.1097/mlr.0000000000001703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them. OBJECTIVE The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them. RESEARCH DESIGN We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion. SUBJECTS A total of 32,102 new general internists. RESULTS Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states. CONCLUSIONS States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.
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Affiliation(s)
- José J. Escarce
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, CA
| | | | | | | | - Yanlei Ma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Egan BM, Yang J, Rakotz MK, Sutherland SE, Jamerson KA, Wright JT, Ferdinand KC, Wozniak GD. Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines. Hypertension 2021; 79:338-348. [PMID: 34784722 DOI: 10.1161/hypertensionaha.121.17102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for β-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P=0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P=0.204), although CCB monotherapy increased (29.5% versus 21.0%, P=0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P=0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.
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Affiliation(s)
- Brent M Egan
- Improving Health Outcomes, American Medical Association, Greenville, SC (B.M.E., S.E.S.)
| | - Jianing Yang
- Improving Health Outcomes, American Medical Association, Chicago, IL (J.Y., M.K.R., G.D.W.)
| | - Michael K Rakotz
- Improving Health Outcomes, American Medical Association, Chicago, IL (J.Y., M.K.R., G.D.W.)
| | - Susan E Sutherland
- Improving Health Outcomes, American Medical Association, Greenville, SC (B.M.E., S.E.S.)
| | - Kenneth A Jamerson
- Department of Medicine, University of Michigan Medical Center, Ann Arbor (K.A.J.)
| | - Jackson T Wright
- Department of Medicine, Case Western Reserve, Cleveland, OH (J.T.W.)
| | - Keith C Ferdinand
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA (K.C.F.)
| | - Gregory D Wozniak
- Improving Health Outcomes, American Medical Association, Chicago, IL (J.Y., M.K.R., G.D.W.)
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Escarce JJ, Wozniak GD, Tsipas S, Pane JD, Brotherton SE, Yu H. Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States. Med Care 2021; 59:653-660. [PMID: 33956413 PMCID: PMC8191468 DOI: 10.1097/mlr.0000000000001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand. OBJECTIVE The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices. RESEARCH DESIGN Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation. SUBJECTS The sample consisted of 160,842 physicians in 8 specialty groups. RESULTS Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states. CONCLUSIONS The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.
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Affiliation(s)
- José J. Escarce
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, CA
| | | | | | | | | | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Egan BM, Li J, Sutherland SE, Rakotz MK, Wozniak GD. Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups. Hypertension 2021; 78:578-587. [PMID: 34120453 DOI: 10.1161/hypertensionaha.120.16418] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Brent M Egan
- American Medical Association, Improving Health Outcomes, Greenville, SC (B.M.E., S.E.S.)
| | - Jiexiang Li
- Department of Mathematics, College of Charleston, SC (J.L.)
| | - Susan E Sutherland
- American Medical Association, Improving Health Outcomes, Greenville, SC (B.M.E., S.E.S.)
| | - Michael K Rakotz
- American Medical Association, Improving Health Outcomes, Chicago, IL (M.K.R., G.D.W.)
| | - Gregory D Wozniak
- American Medical Association, Improving Health Outcomes, Chicago, IL (M.K.R., G.D.W.)
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Yang PK, Ritchey MD, Tsipas S, Loustalot F, Wozniak GD. State and Regional Variation in Prescription- and Payment-Related Promoters of Adherence to Blood Pressure Medication. Prev Chronic Dis 2020; 17:E112. [PMID: 32975508 PMCID: PMC7553210 DOI: 10.5888/pcd17.190440] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction Medication adherence can improve hypertension management. How blood pressure medications are prescribed and purchased can promote or impede adherence. Methods We used comprehensive dispensing data on prescription blood pressure medication from Symphony Health’s 2017 Integrated Dataverse to assess how prescription- and payment-related factors that promote medication adherence (ie, fixed-dose combinations, generic formulations, mail order, low-cost or no-copay medications) vary across US states and census regions and across the market segments (grouped by patient age, prescriber type, and payer type) responsible for the greatest number of blood pressure medication fills. Results In 2017, 706.5 million prescriptions for blood pressure medication were filled, accounting for $29.0 billion in total spending (17.0% incurred by patients). As a proportion of all fills, factors that promoted adherence varied by state: fixed-dose combinations (from 5.8% in Maine to 17.9% in Mississippi); generic formulations (from 95.2% in New Jersey to 98.4% in Minnesota); mail order (from 4.7% in Rhode Island to 14.5% in Delaware); and lower or no copayment (from 56.6% in Utah to 72.8% in California). Furthermore, mean days’ supply per fill (from 43.1 in Arkansas to 63.8 in Maine) and patient spending per therapy year (from $38 in Hawaii to $76 in Georgia) varied. Concentration of adherence factors differed by market segment. Patients aged 18 to 64 with a primary care physician prescriber and Medicaid coverage had the lowest concentration of fixed-dose combination fills, mean days’ supply per fill, and patient spending per therapy year. Patients aged 65 years or older with a primary care physician prescriber and commercial insurance had the highest concentration of fixed-dose combinations fills and mail order fills. Conclusion Addressing regional and market segment variation in factors promoting blood pressure medication adherence may increase adherence and improve hypertension management.
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Affiliation(s)
- Peter K Yang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail Stop S107-7, Atlanta, GA 30341. .,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Matthew D Ritchey
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stavros Tsipas
- Improving Health Outcomes Group, American Medical Association, Chicago, Illinois
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory D Wozniak
- Improving Health Outcomes Group, American Medical Association, Chicago, Illinois
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Casey DE, Thomas RJ, Bhalla V, Commodore-Mensah Y, Heidenreich PA, Kolte D, Muntner P, Smith SC, Spertus JA, Windle JR, Wozniak GD, Ziaeian B. 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes 2019; 12:e000057. [PMID: 31714813 DOI: 10.1161/hcq.0000000000000057] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Khan T, Wozniak GD, Kirley K. An assessment of medical students' knowledge of prediabetes and diabetes prevention. BMC Med Educ 2019; 19:285. [PMID: 31357985 PMCID: PMC6664721 DOI: 10.1186/s12909-019-1721-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The United States has 84 million adults with prediabetes, putting them at a higher risk than the general population for developing type 2 diabetes. Missed opportunities among primary care providers in diagnosing and managing patients with prediabetes represent a gap in care, suggesting there is a need to educate practicing physicians and medical students about diabetes prevention. The purpose of this study is to assess medical students' basic knowledge of prediabetes and diabetes prevention, identify potential educational needs, and target areas for improvement in undergraduate medical education curricula. METHODS A cross-sectional study to assess medical students' preclinical and clinical management knowledge of prediabetes and diabetes prevention. Medical students attending the 2016 American Medical Association's annual meeting took a 6-item knowledge questionnaire using a mobile application or a paper version. Scores were reported for the full sample of respondents, by year in medical school, by topic area, and by mode of survey response. RESULTS The average student answered fewer than half of the questionnaire questions correctly. Scores on some items addressing preclinical content were higher among third- and fourth-year students compared to first- and second-year students (p = 0.039 and effect size = 0.363). Average scores on the items addressing clinical management were not significantly different by year in medical school, but the item measuring effectiveness of metformin to a lifestyle change program had 41.9% correct answers among the mobile application respondents compared to 21.5% among paper test respondents (p = 0.003 and effect size = 0.463). CONCLUSIONS Medical student performance on the prediabetes knowledge questionnaire was low. Students' year in medical school had a slight impact on overall performance, but only for certain questions. The results suggest the need for improvements in current medical school curricula for increasing the awareness of screening for prediabetes as well as the benefits of the lifestyle change programs in the National Diabetes Prevention Program.
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Affiliation(s)
- Tamkeen Khan
- Improving Health Outcome, American Medical Association, 330 N. Wabash Avenue, Suite 39300, Chicago, IL 60611 USA
| | - Gregory D. Wozniak
- Improving Health Outcome, American Medical Association, 330 N. Wabash Avenue, Suite 39300, Chicago, IL 60611 USA
| | - Kate Kirley
- Improving Health Outcome, American Medical Association, 330 N. Wabash Avenue, Suite 39300, Chicago, IL 60611 USA
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Rakotz MK, Townsend RR, Yang J, Alpert BS, Heneghan KA, Wynia M, Wozniak GD. Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge. J Clin Hypertens (Greenwich) 2017; 19:614-619. [PMID: 28452119 PMCID: PMC5488302 DOI: 10.1111/jch.13018] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 01/24/2017] [Accepted: 02/12/2017] [Indexed: 12/03/2022]
Abstract
Blood pressure (BP) measurement is the most common procedure performed in clinical practice. Accurate BP measurement is critical if patient care is to be delivered with the highest quality, as stressed in published guidelines. Physician training in BP measurement is often limited to a brief demonstration during medical school without retraining in residency, fellowship, or clinical practice to maintain skills. One hundred fifty‐nine students from medical schools in 37 states attending the American Medical Association's House of Delegates Meeting in June 2015 were assessed on an 11‐element skillset on BP measurement. Only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1. The findings suggest that changes in medical school curriculum emphasizing BP measurement are needed for medical students to become, and remain, proficient in BP measurement. Measuring BP correctly should be taught and reinforced throughout medical school, residency, and the entire career of clinicians.
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Affiliation(s)
| | | | | | - Bruce S Alpert
- University of Tennessee Health Sciences Center, Memphis, TN, USA
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Palmisano DJ, Emmons DW, Wozniak GD. Expanding insurance coverage through tax credits, consumer choice, and market enhancements: the American Medical Association proposal for health insurance reform. JAMA 2004; 291:2237-42. [PMID: 15138246 DOI: 10.1001/jama.291.18.2237] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Recent reports showing an increase in the number of uninsured individuals in the United States have given heightened attention to increasing health insurance coverage. The American Medical Association (AMA) has proposed a system of tax credits for the purchase of individually owned health insurance and enhancements to individual and group health insurance markets as a means of expanding coverage. Individually owned insurance would enable people to maintain coverage without disruption to existing patient-physician relationships, regardless of changes in employers or in work status. The AMA's plan would empower individuals to choose their health plan and give patients and their physicians more control over health care choices. Employers could continue to offer employment-based coverage, but employees would not be limited to the health plans offered by their employer. With a tax credit large enough to make coverage affordable and the ability to choose their own coverage, consumers would dramatically transform the individual and group health insurance markets. Health insurers would respond to the demands of individual consumers and be more cautious about increasing premiums. Insurers would also tailor benefit packages and develop new forms of coverage to better match the preferences of individuals and families. The AMA supports the development of new health insurance markets through legislative and regulatory changes to foster a wider array of high-quality, affordable plans.
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Abstract
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.
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Affiliation(s)
- Daniel Polsky
- University of Pennsylvania, Division of General Internal Medicine, Philadelphia 19104, USA
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Kletke PR, Polsky D, Wozniak GD, Escarce JJ. The effect of HMO penetration on physician retirement. Health Serv Res 2000; 35:17-31. [PMID: 16148949 PMCID: PMC1383592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
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.
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Escarce JJ, Polsky D, Wozniak GD, Kletke PR. HMO growth and the geographical redistribution of generalist and specialist physicians, 1987-1997. Health Serv Res 2000; 35:825-48. [PMID: 11055451 PMCID: PMC1089155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
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.
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Affiliation(s)
- J J Escarce
- Dept. of Medicine, University of Pennsylvania, and the Leonard Davis Institute of Health Economics, USA
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Abstract
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.
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Affiliation(s)
- D Polsky
- Department of Medicine, University of Pennsylvania, Philadelphia, USA
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Shea JA, Kletke PR, Wozniak GD, Polsky D, Escarce JJ. Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association. Med Care 1999; 37:333-8. [PMID: 10213014 DOI: 10.1097/00005650-199904000-00003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- J A Shea
- Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, USA
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Escarce JJ, Polsky D, Wozniak GD, Pauly MV, Kletke PR. Health maintenance organization penetration and the practice location choices of new physicians: a study of large metropolitan areas in the United States. Med Care 1998; 36:1555-66. [PMID: 9821943 DOI: 10.1097/00005650-199811000-00005] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.
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Affiliation(s)
- J J Escarce
- RAND Health Program, Santa Monica, CA 90401, USA
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Emmons DW, Wozniak GD, Otten RD, Baker NA. Data on employee physician profiling. J Health Hosp Law 1993; 26:73-82. [PMID: 10127074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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