Michael Finch

The Relationship of Patient Satisfaction with Care and Clinical Outcomes

OBJECTIVES The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status). METHODS A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis. RESULTS Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores. CONCLUSIONS Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.

Outcomes for older men and women with congestive heart failure.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).

Effect of tiered prescription copayments on the use of preferred brand medications

Background and Objective. Health plans are increasingly using more open drug formularies that offer differential prescription copayments as an incentive to enrollees to use brands that plans prefer. How much this financial incentive affects use of preferred brands has not been widely reported. The aim of this study was to estimate the effect of tiered copayments on the choice between preferred and nonpreferred brand medications. Materials and methods. Longitudinal logistic regression analyses of pharmacy claims from 1998 and 1999 comparing concurrent groups that were or were not exposed to tiered copayments. Subjects. Enrollees in four independent physician practice association model health plans who had pharmacy claims for angiotensin converting enzyme inhibitors (ACEI), proton pump inhibitors (PPI), or hydroxymethylglutaryl coenzyme A reductase inhibitors (STATINS). Outcome Measure. Change in the percentage of prescription claims that were for preferred brands. Main Results. Regression adjusted estimates of the average net increase in the percentage use of preferred brands of ACEI, PPI and STATIN from first quarter 1998 to third quarter 1999 attributed to tiered prescription copayments were 13.3 (P = 0.001), 8.9 (P = 0.03), and 6.0 (P <0.001) percentage points, respectively. Conclusions. Tiered prescription copayments were associated with a significant shift from nonpreferred to preferred brand medications. This type of financial incentive can help purchasers providing open access drug benefits by steering use of medications toward lower cost brands. The clinical effects of changes in medication use brought about differential copayments warrant further investigation.

Use of post-hospital care by Medicare patients.

BACKGROUND: Medicares introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post‐hospital care. Medicare coverage provides for various types of post‐hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post‐hospital care.

Developing a New Metric for ADLs

BACKGROUND: Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency.

Alcohol dependence and the price of alcoholic beverages

This study estimates the impact of the price of alcoholic beverages on latent dimensions of current alcohol dependence and abuse. A three-part econometric model is used to estimate the impact of price on three latent dimensions (factors). For heavier drinking, the estimated price elasticity is -1.325 (P = 0.027); for physical and other consequences of drinking, -1.895 (P = 0.003); for increased salience of drinking, -0.411 (P = 0.339). For a single latent factor characterized simply as dependence/abuse, estimated price elasticity is -1.487 (P = 0.012). These results suggest that higher prices for alcohol reduce important dimensions of current alcohol dependence and abuse.

Adolescent Work Experience and Depressive Affect

Using longitudinal data from a panel of youth followed from the 9th to the 10th grade, we examine how facets of adolescents work influence depressive affects. The results support the hypothesis that work experiences contribute to depressed mood among adolescents. The findings also indicate that workers are more emotionally independent of their parents than non-working adolescents.

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

ocial Health Maintenance Organizations (SMMOs) are S milestones in the quest for improved and better integrated systems of acute care and long-term care (LTC). As part of a long-lived demonstration program implemented at four sites in the mid 1980s, S/HMO leaders were involved heavily in fashioning technology for LTC in managed care. In 1991, while the evaluation of SMMOs was still in progress, Congress reaffirmed its enthusiasm to continue S/HMOs and stipulated that new S/HMOs be created. In January 1995, the Health Care Financing Administration (HCFA) awarded planning grants to six prospective second generation S/HMOS.~ These projects are now engaged in developing their plans, including their benefit structures and rates. Like their predecessors, the second generation S/HMOs are intended to demonstrate the integration of acute care and LTC within a capitated managed-care framework. The second generation differs from the first, however, in several key respects: ( 1 ) Rather than controlling for adverse selection by proportional enrollment at various impairment levels, they will establish reimbursement rates based on the individual members impairment and illness profile at time of enrollment and annually thereafter. An enrollees reimbursement rate will not change during each year if an enrollees status changes (as occurred with S/HMO I); rather, the rate will apply for the full enrollment year. (2 ) They have committed to clinical as well as financial integration. Building upon the experience of the first SMMOs, they are planning state-ofthe-art geriatric health care programs, which will apply, as appropriate, to all enrollees, not just those who use LTC. (3) The projects are committed to coordinating the acute care with a set of flexible, user-friendly, efficient LTC services. (4) Sites plan a special emphasis on serving underrepresented groups, including rural, Medicaid, and minority populations.

Use of community-based mental health programs by HMOs: evidence from a Medicaid demonstration.

BACKGROUND Proposals to enroll Medicaid beneficiaries in health maintenance organizations (HMOs) have raised concerns that community-based mental health treatment programs would be adversely affected. METHODS In Hennepin County (Minnesota) 35% of Medicaid beneficiaries were randomly assigned to prepaid plans. Random samples of individuals with severe mental illness with selected from the prepaid enrollees and from beneficiaries remaining with traditional Medicaid. The two groups were compared with respect to their use of community treatment programs and the write-off (the proportion of patient charges for which payment was not received) experienced by those programs for members of the study sample. RESULTS There was no strong evidence that Medicaid beneficiaries with severe mental illness who were randomly assigned to prepaid plans used community-based mental health treatment programs differently than did other Medicaid beneficiaries. However, write-offs were consistently higher for enrollees in prepaid plans. CONCLUSIONS In the short run, the use of community-based mental health treatment programs need not be affected by enrollment of Medicaid beneficiaries in prepaid plans, providing that Medicaid program administrators take steps to minimize the disruption of ongoing treatment, offer beneficiaries a choice among prepaid plans, and encourage community treatment programs to contract with plans to serve beneficiaries.

Adult foster care for the elderly in Oregon: a mainstream alternative to nursing homes?

BACKGROUND In Oregon, adult foster care (AFC) homes, which are private residences where a live-in manager cares for one to five disabled residents, have been covered by Medicaid since 1981 and seem to offer a mainstream alternative to nursing homes. They house almost 6000 older people, two thirds of which pay privately. METHODS In a cross-sectional study, we interviewed 400 AFC and 400 nursing home residents. Data analyses included descriptive cross-tabulations; hierarchial loglinear models for judging the effects of care setting and payment status on resident characteristics; and logit analyses for predicting care setting and payment status within care settings. RESULTS On average, nursing home residents were more physically and cognitively impaired than AFC residents, but there was considerable overlap in patterns of frailty in the two settings. Medicaid AFC residents were less disabled than privately paying AFC residents. AFC residents reported more social activity, even when we controlled for disability status. AFC residents and their families were more likely to value privacy and homelike settings when choosing a care setting, whereas nursing home residents were more likely to value rehabilitation and organized activity programs. CONCLUSIONS Both AFC and nursing homes are viable components of a long-term care repertoire. The greater disability levels of private-pay AFC residents refutes the criticisms that disabled Medicaid residents were being inappropriately channeled to AFC.