Jeffrey P. Koplan

Patients' Trust in Their Physicians: Effects of Choice, Continuity, and Payment Method

OBJECTIVE: To evaluate the extent to which physician choice, length of patient-physician relationship, and perceived physician payment method predict patients’ trust in their physician.DESIGN: Survey of patients of physicians in Atlanta, Georgia.PATIENTS: Subjects were 292 patients aged 18 years and older.MEASUREMENTS AND MAIN RESULTS: Scale of patients’ trust in their physician was the main outcome measure. Most patients completely trusted their physicians “to put their needs above all other considerations” (69%). Patients who reported having enough choice of physician (p<.05), a longer relationship with the physician (p<.001), and who trusted their managed care organization (p<.001) were more likely to trust their physician. Approximately two thirds of all respondents did not know the method by which their physician was paid. The majority of patients believed paying a physician each time a test is done rather than a fixed monthly amount would not affect their care (72.4%). However, 40.5% of all respondents believed paying a physician more for ordering fewer than the average number of tests would make their care worse. Of these patients, 53.3% would accept higher copayments to obtain necessary medical tests.CONCLUSIONS: Patients’ trust in their physician is related to having a choice of physicians, having a longer relationship with their physician, and trusting their managed care organization. Most patients are unaware of their physician’s payment method, but many are concerned about payment methods that might discourage medical use.

A cost-effectiveness analysis of exercise as a health promotion activity.

We used cost-effectiveness analysis to estimate the health and economic implications of exercise in preventing coronary heart disease (CHD). We assumed that nonexercisers have a relative risk of 2.0 for a CHD event. Two hypothetical cohorts (one with exercise and the other without exercise) of 1,000 35-year-old men were followed for 30 years to observe differences in the number of CHD events, life expectancy, and quality-adjusted life expectancy. We used jogging as an example to calculate cost, injury rates, adherence, and the value of time spent. Both direct and indirect costs associated with exercise, injury, and treating CHD were considered. We estimate that exercising regularly results in 78.1 fewer CHD events and 1,138.3 Quality Adjusted Life Years (QALYs) gained over the 30-year study period. Under our base case assumptions, which include indirect costs such as time spent in exercise, exercise does not produce economic savings. However, the cost per QALY gained of

Pertussis Vaccine: An Analysis of Benefits, Risks, and Costs

11,313 is favorable when compared with other preventive or therapeutic interventions for CHD. The value of time spent is a crucial factor, influencing whether exercise is a cost-saving activity. In an alternative model, where all members of the cohort exercise for one year, and then only those who like it or are neutral continue, exercise produces net economic savings as well as reducing morbidity.

Live or inactivated poliomyelitis vaccine: an analysis of benefits and risks.

Using decision analysis, we estimated the benefits, risks and costs of routine childhood immunization against pertussis. Without an immunization program, we predict that there would be a 71-fold increase in cases and an almost fourfold increase in deaths (2.0 to 7.6) per cohort of one million children. With a vaccination program, we predict 0.1 case of encephalitis associated with pertussis and five cases of post-vaccination encephalitis; without a program, there would be only 2.3 cases of encephalitis associated with pertussis. Community vaccination would reduce by 61 per cent the costs related to pertussis. Our analysis supports continuation of vaccination in routine childhood immunization programs, but suggests the need for more reliable data on complications from the vaccine, further study of the epidemiology of pertussis and development of a less toxic vaccine.

CDC's strategic plan for bioterrorism preparedness and response.

Using decision analysis we evaluated the benefits and risks of continued primary reliance on oral poliomyelitis vaccine (OPV) compared to use of inactivated poliovirus vaccine (IPV). We followed a hypothetical cohort of 3.5 million children from birth to age 30 assuming 95 per cent coverage with 98 per cent effective vaccine. Primary reliance on IPV would result in more cases of paralytic poliomyelitis as well as more susceptibles remaining in the population than would be expected with continuing OPV use (74.1 vs 10.0 cases and 5.9 per cent vs 1.1 per cent susceptibles, respectively). However, with OPV use, most cases of paralysis seen would be associated with the vaccine. Our analysis supports a continuation of current US policy placing primary reliance on OPV but the conclusion is heavily dependent on assumptions of risk of exposure to wild virus in the United States. Major declines in risk of exposure to wild virus could alter the balance significantly.

Physician Incentives and Disclosure of Payment Methods to Patients

The Department of Health and Human Services (DHHS) has played a critical lead role over the past two years in fostering activities associated with the medical and public health response to bioterrorism. Based on a charge from Secretary Donna Shalala in 1998, the Centers for Disease Control and Prevention (CDC) is leading public health efforts to strengthen the nations capacity to detect and respond to a bioterrorist event. As a result of our efforts, federal, state, and local communities are improving their public health capacities to respond to these types of emergencies. For many of us in public health, developing plans and capacities to respond to acts of bioterrorism is an extension of our long-standing roles and responsibilities. These are stated in the CDC Mission Statement: to promote health and quality of life by preventing and controlling disease, injury, and disability, and the Bioterrorism Mission: to lead the public health effort in enhancing readiness to detect and respond to bioterrorism. CDCs infectious diseases control efforts are summarized below: --Initially formed to address malaria control in 1946; --Established the epidemic Intelligence Service in 1951; --Participated in global smallpox eradication and other immunization programs; --Estimated 800-1,000 + field investigations/year since late 1990s; --New diseases: Legionnaires Disease, toxic shock syndrome, Lyme disease, HIV, hantavirus pulmonary syndrome, West Nile, etc. -- Today: focus on emerging infections and bioterrorism. Over the past 50 years, CDC has seen a decline in the incidence of some infectious diseases and an increase in some, whereas others continue to present on a more unpredictable basis (i.e., hantavirus). Outbreak identification, investigation, and control have been an integral part of what we do for more than 50 years. We estimate that 800 to 1,000 field investigations have occurred every year since the late 1990s. Today, however, we have a new focus on emerging infectious diseases and bioterrorism.

Decision analysis and polio immunization policy.

OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients’ awareness of and interest in physician payment information or its potential impact on patients’ evaluation of their care.DESIGN: Cross-sectional survey.SETTING: Managed care and indemnity plans of a large, national health insurer.PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga.; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%).MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians’ payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Nonmanaged fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians’ payment method. Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary.CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted.

Managed care and public health.

Dr. Salks comments on our paper fall into four major categories: our use of the techniques of decision analysis, the assumptions we used, the fact that we did not include individual and social values in the model, and the way in which vaccine policies are developed in the United States. We believe that the methods were used correctly, that the assumptions we used are defensible, and that our conclusions were both appropriate and appropriately worded. We explicitly did not include individual and social values since we were addressing the scientific and epidemiologic issues rather than ethical and moral issues. Vaccine policy development in the United States is carried out in public forums with opportunity for presentation of all sides of an issue.

Public health policy toward atypical measles syndrome in the United States.

Both public health and managed care organizations share an interest in ensuring the health status of a defined population. We explore the existing and potential relationships between managed care organizations and public health in several major public health areas, specifically clinical preventive services, prevention-oriented social and political policies, and core public health functions. The latter include health information, health education, personal health services provision, work force and research, community partnerships, and evaluation of health care. We believe there is much potential to improve the populations health through the collaboration of these two sectors of the health care system.

The Benefits and Costs of Immunizations Revisited

Shortly after the introduction of killed measles vaccine (KMV) in 1963, an illness was reported which occurred in persons who had been exposed to live measles virus one to several years after vaccination with KMV [1]. This illness, termed atypical measles syndrome (AMS), is characterized by a centrifugal rash, commonly involving the palms and soles, and pulmonary infiltrates on roentgoenography with or without clinical evidence of pneumonia. The syndrome may represent an exaggerated immune response to exposure with a wild virus [2]. It is generally considered to be noncommunicable, but one report of possible transmission has appeared [3]. Persons with atypical measles syndrome may have severe clinical illness and be hospitalized, but only one death possibly attributable to AMS has been