John R. C. Wheeler

Private cost containment. The effects of utilization review programs on health care use and expenditures.

Utilization review has been regarded as one of the most promising approaches to the containment of health care costs. We analyzed insurance claims data on 222 groups of employees and dependents for 1984 and 1985 to evaluate the effects of utilization review programs instituted by a large private insurance carrier. The utilization review programs we studied were compulsory; patients who did not follow established utilization review procedures were subject to financial penalties. Controlling for employee characteristics, health care market area factors, and benefit-plan features, we found that utilization review reduced admissions by 12.3 percent, inpatient days by 8.0 percent, hospital expenditures by 11.9 percent, and total medical expenditures by 8.3 percent. When only groups that had relatively high admission rates before adopting utilization review were analyzed, it was found that they had a 34 percent reduction in patient days and a 30 percent reduction in hospital expenditures. The savings-to-cost ratio of utilization review for groups overall was highly favorable--approximately 8 to 1. Private utilization review programs of the type we studied appear to be effective in reducing hospital use and decreasing medical expenditures. This study did not address the possible effects of such programs on the health status of patients.

Can A Disease Self-management Program Reduce Health Care Costs?: The Case of Older Women With Heart Disease

Background. There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs. Objectives. To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program. Research Design. Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness. Subjects. Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The “Women Take PRIDE” program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman’s physician. It is tailored to the unique needs of older women. Measures. Hospital admissions, in-patient days, emergency department visits. Results. Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1. Conclusions. A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.

The Effect of Income on Use of Preventive Care: An Evaluation of Alternative Explanations

Three alternative explanations for the effect of income on use of physician services for preventive care are evaluated. Path analysis is used to estimate the direct effect of income on use (the financial constraint explanation), the indirect effect of income through health beliefs (the culture of poverty explanation), and the indirect effect through the availability of a usual source of care (the system barrier explanation). Data for the analysis are from household interviews with 781 adult residents of Washtenaw County, Michigan. A general model of utilization of preventive health services is proposed that incorporates all three explanations. Path coefficients are estimated, and the direct and indirect effects of income on use are compared. The data reveal a negligible direct effect of income on preventive use, a positive indirect effect through perceived susceptibility to illness (one operationalization of the culture of poverty explanation), and a positive indirect effect through usual source of care. These findings are consistent with other recent research on the effect of income on health services utilization and contribute to a growing body of evidence which suggests that changes in the health care delivery system may be necessary if we are to achieve equity in the utilization of preventive care services.

Factors associated with utilization of the swine flu vaccination program among senior citizens in Tompkins County.

The health belief model is tested in the context of the swine flu vaccination program for senior citizens. Analysis is based on 232 responses to a questionnaire mailed to a simple random sample of 500 senior citizens in Tompkins County, New York. Social and psychologic variables identified by the model as important in determining utilization of preventive health services are: perceived susceptibility and severity of disease, perceived efficacy and danger associated with the preventive action, and general health motivations. Differences of means between users and nonusers for these variables are computed and compared with the results of a more sophisticated analytic technique--logit analysis--for use with dichotomous dependent variables. Results reveal that the health belief model accounts for 34 per cent of the variance in use of the vaccine by senior citizens. Perceived susceptibility to the disease and amount of danger associated with receiving the swine flu immunization are found to be the most important determinants of utilization.

PRIVATE AND PUBLIC OWNERSHIP IN OUTPATIENT SUBSTANCE ABUSE TREATMENT: DO WE HAVE A TWO-TIERED SYSTEM?

As investor-owned organizations increase their presence in the mental health care sector, questions emerge regarding the effects of ownership type on service delivery. One important question is whether ownership is related to patient access to care for persons requiring treatment for substance abuse problems. Using data from a 1995 national survey of outpatient substance abuse treatment units, the authors investigate whether there are differences in measures of patient access to care among investor-owned, not-for-profit, and public provider organizations. Results indicate investor-owned units cater to and serve a clientele that differs from that of not-for-profit and public units, suggesting the presence of a two-tiered system of substance abuse treatment.

Cost-effectiveness of hospital pay-for-performance incentives.

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costs for the payer were

Self-Management of Heart Disease by Older Adults Assessment of an Intervention Based on Social Cognitive Theory

22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between

Childhood vaccine purchase costs in the public sector: Past trends, future expectations

12,967 and

The initial impact of Medicare's new prospective payment system for kidney dialysis

30,081, a level well under consensus measures of the value of a QALY.

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

A randomized, controlled trial involving 636 older individuals was conducted to evaluate an intervention to enhance self-management of heart disease. Program participants experienced less impact of illness on their psychosocial functioning (p <.05), especially their emotional behavior (p < .05) and alertness (p < .01). Compared to controls, male program participants experienced improvements in their physical functioning, specifically their ability to ambulate (p < .05) and the frequency and severity of their symptoms. Female program participants did not experience gains in physical functioning. Most group differences emerged by 12 months and decayed by the 18-month final evaluation. To accurately assess the pattern of change associated with a program of this type, evaluation over at least 18 months following program completion may be needed. Separate interventions for older men and women with heart disease appear warranted, as do follow-up activities at strategic points in time to sustain program effects.