Neil I. Goldfarb

The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care

Objective. Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO). Methodology. We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995. Results. Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%–73%), as well as scores for immunizations (from 62%–79%) and other preventive care (from 54%–71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects. Conclusions. Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.

Association between primary care practice characteristics and emergency department use in a medicaid managed care organization.

Background:Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes. Objectives:We sought to determine whether Medicaid patients’ ED use is associated with characteristics of their primary care practices. Research Design:This was a cohort study. Subjects:A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included. Measures:Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics. Results:On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants. Discussion:Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use. Conclusions:Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Weights for Scoring the Quality of Well-being Instrument Among Rheumatoid Arthritics: A Comparison to General Population Weights

The importance of measuring health outcomes such as functional status and quality of life has increased with the greater emphasis on efficiency and on judgements of clinical effectiveness of therapies for patients with chronic disease. One measure of health status, the quality of well-being (QWB), has received significant attention as a health policy model because it quantifies health on a scale ranging from “zero” (death) to “one” (optimal health). The scale is based on weights (values) that were derived by having several thousand individuals in the general population rate scenarios in which a patient is described in terms of mobility, physical activity, social activity, and major symptom or problem. The present study was undertaken to determine if a disease-specific population composed of patients with moderate and moderately severe rheumatoid arthritis who were participating in a national multicenter trial of a new oral therapeutic agent, would rank scenarios similarly to the general population sample. In this study, close agreement was found between the weights obtained from the general population sample and the weights obtained from the sample of rheumatoid arthritic patients (R. = 0.937). The investigators believe that the study supports the use of the original general population weights and suggest that the index may be used for populations with a specific condition as well as for general populations.

Costs to hospitals of acquiring and processing blood in the US

BackgroundLittle is known about the economics of acquiring and processing the more than 14 million units of red blood cells used annually in the US.ObjectiveTo determine the average price paid by hospitals to suppliers for a unit of red blood cells and to identify cost variations by region and facility type and size. A secondary objective was to examine costs for additional blood components as well as costs for blood-related processes performed by hospitals. Qualitative input was sought to identify potential cost drivers.MethodsA cross-sectional survey was performed of a randomized sample of hospital-based blood bank and transfusion service directors. The survey instrument assessed costs of specific blood components and services as incurred by hospitals. Analysis of variance was performed to test for significant variation in costs for red blood cells by geographic region and division, facility type and bed capacity.ResultsA total of 213 surveys were completed. The mean (SD) acquisition cost for one unit of red blood cells purchased from a supplier (n = 204) was

The advent of capsule endoscopy — a not‐so‐futuristic approach to obscure gastrointestinal bleeding

US210.74 ± 37.9 and the mean charge to the patient (n = 167) was

Impact of a Mandatory Medicaid Case Management Program on Prenatal Care and Birth Outcomes: A Retrospective Analysis

US343.63 ± 135. There was significant statistical variation in acquisition cost by US census region (p < 0.0001) and division (p < 0.0001). Teaching hospitals were more likely to receive volume discounts than other facility types. The mean prices paid per unit for fresh frozen plasma (n = 167) and apheresis platelets (n = 153) were

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures.

US60.70 ± 20 and

Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain

US533.90 ± 69, respectively. The median cost for mandated screening performed onsite (n = 56) was

High rates of inappropriate drug use in the chronic pain population.

US50.00 ± 120 and the median storage and retrieval cost (n = 46) was

Economic and health outcomes of capsule endoscopy: Opportunities for improved management of the diagnostic process for obscure gastrointestinal bleeding

US68.00 ± 81 per unit. A total of 28% of respondents reported that costs for acquisition, screening and transfusion had ‘increased dramatically’ over the past 5 years and 23% reported that blood shortages were a significant problem.ConclusionsThe cost of blood continues to increase and price varies by geography. However, the rate of increase in acquisition costs for red blood cells appears to be slowing. This information should be used by organizations and policy makers to improve financing and utilization management for blood components and services.