Edmund R. Becker

Patient Satisfaction With Primary Care: Does Type of Practitioner Matter?

Objective:The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). Study Design:We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. Results:Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. Conclusions:Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.

Cross-Subsidies and Payment for Hospital Care

This study uses hospital data from the 1979 American Hospital Association Reimbursement Survey in a multivariate framework to assess the impact of discounts and third-party reimbursement on hospital costs and profitability. Three central issues are addressed: (1) Is a differential payment justified for Medicare, Medicaid, and/or Blue Cross on the basis of differential costs? (2) Have the cost-containment efforts of the dominant payers reduced total payments to hospitals? and (3) What part of the overall savings in payments to hospitals is in the form of reduced costs rather than reduced profits? On the basis of the evidence in this study, we find (1) that the differential payment is not justified; (2) that the cost-containment efforts of the dominant payers have reduced total payments to hospitals somewhat, but a substantial amount of cost-shifting remains; and (3) that the savings is in profits, rather than in costs.

An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries.

In service industries other than health care, unit employees who report a favorable service climate—characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative—have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO’s 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.

Structural Determinants of Union Activity in Hospitals

This study uses national data from the American Hospital Association and the National Labor Relations Board in a multivariate framework to assess the impact of various structural factors on union activity in hospitals. The theoretical framework includes both management and union perspectives in evaluating (1) whether the hospital had a signed collective-bargaining contract in 1980; (2) whether a union election had been held; and (3) whether the union won the election. The results indicate that certain structural characteristics (hospital size, ownership, teaching status, and location) have had a significant impact on union activity in hospitals, while other characteristics (third-party reimbursement and area factors) have not. The results also show that prospective reimbursement has a positive impact on union activity.

South/Non-South Differentials in National Labor Relations Board Certification Election Outcomes: Comment*

A recent study of National Labor Relations Board (NLRB) certification elections concluded that there are no regional differences in the probability of unionization. This paper suggests that it is inappropriate to draw such broad inferences from NLRB data, since elections occur only where an initial preference for unionism has been expressed. Using a national data set on private sector hospitals, we demonstrate that Southern location significantly reduces the probability of having an election and the probability of negotiating a collective bargaining agreement, but it does not affect the probability of a union election victory.

Evidence that electronic health records can promote physician counseling for healthy behaviors.

BACKGROUND Health behavior counseling services may help patients manage chronic conditions effectively and slow disease progression. Studies show, however, that many providers fail to provide these services because of time constraints and inability to tailor counseling to individual patient needs. Electronic health records (EHRs) have the potential to increase appropriate counseling by providing pertinent patient information at the point of care and clinical decision support. PURPOSE This study estimates the impact of select EHR functionalities on the rate of health behavior counseling provided during primary care visits. METHODOLOGY Multivariable regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to examine whether eight EHR components representing four core functionalities of EHR systems were correlated with the rate of health behavior counseling services. Propensity score matching was used to control for confounding factors given the use of observational data. To address concerns that EHR may only lead to improved documentation of counseling services and not necessarily improved care, the association of EHR functionalities with prescriptions for smoking cessation medications was also estimated. FINDINGS The use of an EHR system with health information and data, order entry and management, result management, decision support, and a notification system for abnormal test results was associated with an approximately 25% increase in the probability of health behavior counseling delivered. Clinical reminders were associated with more health behavior counseling services when available in combination with patient problem lists. The laboratory results viewer was also associated with more counseling services when implemented with a notification system for abnormal results. PRACTICE IMPLICATION An EHR system with key supportive functionalities can enhance delivery of preventive health behavior counseling services in primary care settings. Meaningful use criteria should be evaluated to ensure that they encourage the adoption of EHR systems with those functionalities shown to improve clinical care.

United States physician payment reform: background and comparison with the Canadian model.

This study reviews the new prospective Medicare Fee Schedule that will be used to pay United States physicians and compares it with the Canadian method of physician payment. The research basis and independent reviews of the resource-based relative value scale, and its conclusions and implications are also examined.

PS2-33: Understanding Racial Disparities in Physician Advice and Patient Actions to Control Blood Pressure in an MCO

Background/Objective: The Chronic Care Model (CCM) links proactive practice teams and activated patients with better chronic care outcomes. We studied the associations of blood pressure (BP) control with 1) physician advice and patient actions on lifestyle behaviors (exercise, diet, salt and alcohol intake) to control BP and 2) medication adherence in a cohort of adults with hypertension (HTN) in a managed care organization (MCO). Our primary analysis focused on the apparent paradox that, in this MCO, African Americans were more likely to report receipt of advice and be taking actions to control BP yet had worse BP control. Methods: Adults 18–74 years of age with HTN were identified from computerized data. Two independent samples of 3,000 adults each (750 per JNC-VII level) were randomly selected for telephone survey in October 2007 and March 2008. The survey included BRFSS items on advice and actions to control BP and self-reported race and education. Medication adherence was measured as proportion of days covered (PDC) with any HTN-related medication in the 12-month period preceding the survey. Mean SBP and DBP were measured from computerized data in the same period. Associations among receipt of advice, taking actions, PDC, and BP control were estimated using multivariate path analysis (controlling for age, gender, and education) for the 1,330 respondents who were African American (751) or white (579). Results: Compared to whites, African Americans had significantly (p<0.05) higher SBP (standardized beta of 0.137). Better medication adherence was associated with lower SBP (0.229); however, African Americans had lower medication adherence (0.074). Patients taking action to control BP were more likely to have received physician advice to take action (0.232); and, African Americans were more likely to receive advice (0.187) and to take action (0.056). Poor SBP was associated with greater likelihood of taking action (0.075). A similar pattern of associations was observed for DBP. Conclusions: Compared to Whites, African Americans in this MCO were less adherent with antihypertensive medications; and, this contributed to worse BP control. Worse BP control, however, increased the likelihood that physicians advised African Americans to take actions to control BP. Consistent with the CCM, physicians appear to be directing their advice on lifestyle actions to the subset of patients most likely to benefit with improved BP control.

An analysis of hospital union election activity: 1985-1987--by hospital ownership, size, and system, and employee organization and bargaining-unit size.

During the three-year period 1985-1987, there were 238 elections in nongovernmental, short-term hospitals to determine whether or not unions would represent the employees. Unions had a success rate of 47.1 percent, similar to that of earlier years. This study reports these election results by hospital and election characteristics. For hospitals, the analysis includes elections by census region, ownership, bed size, and multi-institutional characteristics. For elections, the analysis includes the nature and type of election, employee organization, and employee bargaining-unit-size characteristics. This study concludes that the number of union elections decline as hospital bed size increases, and the union success rate is curvilinear and higher in both small and very large hospitals; union success declines as bargaining-unit size increases. Investor-owned and nonprofit, religious hospitals that are members of multi-institutional systems have lower union success rates than nonsystem hospitals do in their ownership category. However, unions are much more successful in multi-union and decertification elections compared with single-unit elections and initial recognition elections.