Christy Harris Lemak

Expanding the definition of access: it isn't just about health insurance.

Measurement of access to health care services is often limited to such variables as having health insurance or a usual source of care. We argue for an expanded definition of access measuring whether providers accept a particular form of insurance (overall accessibility), ease of contacting providers for appointments (contact accessibility), length of time it takes to get an appointment (appointment accessibility), and proximity of providers to patients (geographic accessibility). Interviewers posing as Medicaid beneficiaries telephoned providers in Floridas Medicaid primary care case management program, to determine whether the provider was accepting new patients, had weekend or evening hours, and how long it would take to get an appointment. Approximately 87% were accepting new patients, but only 68% were accepting new Medicaid patients. The survey also showed that beneficiaries may encounter difficulty in reaching physicians and making appointments: 22% of all calls were not answered on the first attempt and over two-thirds of providers had no weekend or evening hours.

Managed care and outpatient substance abuse treatment intensity.

This study examines the extent to which managed care behavioral controls are associated with treatment intensity in outpatient substance abuse treatment facilities. Data are from the 1995 National Drug Abuse Treatment System Survey, a nationally representative survey that includes over 600 provider organizations with a response rate of 86%. Treatment intensity is measured in three ways: (1) the number of months clients spend in outpatient drug treatment, (2) the number of individual treatment sessions clients receive over the course of treatment, and (3) the number of group treatment sessions clients receive over the course of treatment. After accounting for selection bias and controlling for market, organization, and client characteristics, there is no significant relationship between the scope of managed care oversight and treatment intensity. However, the stringency of managed care oversight activities is negatively associated with the number of individual and group treatment sessions received over the course of treatment.

THE EFFECTS OF MANAGED CARE ON ADMINISTRATIVE BURDEN IN OUTPATIENT SUBSTANCE ABUSE TREATMENT FACILITIES

tention in empirical studies and policy debates. This study examines one such consequence-administrative burden on organizations that deliver outpatient substance abuse treatment (OSAT). Administrative burden may be defined as the costs to an organization of managing the requirements of managed care. These costs are expressed in terms of time that administrative and treatment staff spend in nontreatment-related activity in response to the requirements of managed care organizations. To the extent that managed care administrative time exceeds that normally re-

Managed care and technical efficiency in outpatient substance abuse treatment units.

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.

Michigan’s Fee-For-Value Physician Incentive Program Reduces Spending And Improves Quality In Primary Care

As policy makers and others seek to reduce health care cost growth while improving health care quality, one approach gaining momentum is fee-for-value reimbursement. This payment strategy maintains the traditional fee-for-service arrangement but includes quality and spending incentives. We examined Blue Cross Blue Shield of Michigans Physician Group Incentive Program, which uses a fee-for-value approach focused on primary care physicians. We analyzed the programs impact on quality and spending from 2008 to 2011 for over three million beneficiaries in over 11,000 physician practices. Participation in the incentive program was associated with approximately 1.1 percent lower total spending for adults (5.1 percent lower for children) and the same or improved performance on eleven of fourteen quality measures over time. Our findings contribute to the growing body of evidence about the potential effectiveness of models that align payment with cost and quality performance, and they demonstrate that it is possible to transform reimbursement within a fee-for-service framework to encourage and incentivize physicians to provide high-quality care, while also reducing costs.

Managed Care Penetration in Outpatient Substance Abuse Treatment Units

The authors present the first nationally representative data on managed care penetration in the outpatient substance abuse treatment (OSAT) sector. Thirty-eight percent of all OSAT units were involved in some form of managed care in 1995, with 22 percent of their client base covered by managed care. There is also variation in managed care penetration and activity across different types of treatment units. Private for-profit units are involved in managed care to a greater extent than are public and private, not-for-profit organizations. Units affiliated with a hospital have greater participation and penetration than other units. Smaller OSAT facilities have a disproportionately large percentage of their client base in managed care arrangements. Finally, private managed care arrangements are more prevalent, more evenly distributed across organizational types, and represented in larger numbers than are public sources of managed care.

Tailoring of outpatient substance abuse treatment to women, 1995-2005

Background:Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options. Objectives:This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices. Research Design:Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women. Measures:Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients’ needs. Results:Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women. Conclusions:Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer 1 mechanism for counteracting these trends.

The quality of surgical care in safety net hospitals: A systematic review

OBJECTIVE The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs. STUDY DESIGN We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article. PRINCIPAL FINDINGS Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent. CONCLUSION Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States.

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored womens programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and womens treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence womens treatment duration. Methadone programs may be more vulnerable to external influences.

Selective Contracting in Managed Care: The Case of Substance Abuse Treatment

The authors address two critical questions concerning managed care and outpatient substance abuse treatment organizations. Specifically, they consider (1) to what extent selective contracting occurs between managed care firms and treatment providers and (2) what attributes of treatment providers and their operating environments are associated with selective contracting. Using data from a nationally representative sample of outpatient treatment organizations, the authors find evidence of systematic selection. Several indicators of providers’ quality and costs, including accreditation status, private ownership, size, and prior experience with managed care, are positively associated with managed care contracting. By contrast, units providing methadone treatment are less likely to be involved in managed care. To a lesser extent, characteristics of treatment providers’ operating environment, including extent of competition based on costs and attributes of the Medicaid managed care program, are also positively associated with managed care contracting.