Who needs a gatekeeper? Patients' views of the role of the primary care physician

BACKGROUND: The primary care physician serving as a 'gatekeeper' can make judicious decisions about the appropriate use of medical services, and thereby contribute to containing costs while improving the quality of care. However, in Israel, sick funds competing for members have not adopted this model for fear of endangering their competitive stance. The purpose of this study was to examine, for the first time, the stated preferences and actual behaviour of a national sample of members of the four Israeli sick funds regarding self-referral to specialists, and to identify the characteristics of patients who prefer the gatekeeper model. METHODS: Data were derived from a national telephone survey carried out in 1997. A random representative sample of 1084 of all adult sick fund members were interviewed, with a response rate of 81%. Bivariate analysis was conducted using over all chi-square tests, and multivariate analysis was performed using logistic regression models. RESULTS: A third of all respondents prefer self-referral to a specialist, 40% prefer their family physician to act as gatekeeper and 19% prefer the physician to co-ordinate care but to refer themselves to a specialist. Independent variables predicting preference for the gatekeeper model are: living in the periphery, sick fund membership, low level of education, being male, fair or poor health status, having a permanent family physician and being satisfied with the professional level of the family physician. A significant correlation was found between practising self-referral and preference for self-referral. CONCLUSIONS.: The findings indicate the importance of surveying patients' attitudes as an input in policy formulation. The study identified specific population groups which prefer the gatekeeper model, and explored the advantages of a flexible model of gatekeeping.     

Universal health care? The views of Negev Bedouin Arabs on health services

BACKGROUND: This study examines health and health care attitudes, practices and utilization patterns among the Bedouin Arab minority in the south of Israel. Particular attention is given to the effects of the new National Insurance Law that provides universal coverage for the first time, and to the identification of critical issues for further research. METHODS: Focus groups, adapted to Bedouin culture, were the primary method of data collection. Twelve groups (158 participants) from throughout the Negev met for 3-7 sessions each, using specially trained local moderators and observers. Issues discussed and analyzed included experience and satisfaction with the current health system (both modern and traditional), health service availability/barriers, health care needs, influences of social change, and the National Insurance Law. RESULTS: Participants voice dissatisfaction with modern health services in the Bedouin sector and the state of health of Negev Bedouin. They place great emphasis on the connection between health and the rapid social and economic changes, which this traditionally nomadic group is undergoing. Traditional health care is felt to still exist, but its importance is waning. The National Insurance law is having a major impact on the Bedouin, particularly because it provides universal health insurance coverage where only partial coverage had been in effect. CONCLUSIONS: This study, one of the first of its kind in the Bedouin sector, showed that the focus group method, if properly modified to cultural norms, can be a valuable research tool in traditional communities and in health service research. The findings from this research can be used to direct efforts to improve health policy and health services for this group, as well as preparing the way for further qualitative or quantitative studies.     

The District: the place of management of community health services or the place of governance of primary health care? The epidemiologic context

This is a review of epidemiologic requirements for the governance of District health services. The governance concern both the health system (organization, management and assessment of health services) and the population's health (health needs, health services needs, determinants of health).     

Docs with their eyes on the clock? The effect of time pressures on primary care productivity

This paper examines how time pressure, an important constraint faced by medical care providers, affects productivity in primary care. We generate empirical predictions by incorporating time pressure into a model of physician behavior by Tai-Seale and McGuire (2012). We use data from the electronic health records of a large integrated delivery system and leverage unexpected schedule changes as variation in time pressure. We find that greater time pressure reduces the number of diagnoses recorded during a visit and increases both scheduled and unscheduled follow-up care. We also find some evidence of increased low-value care, decreased preventive care, and decreased opioid prescribing.     

The impact of team-based primary care on health care services utilization and costs: Quebec’s family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec’s Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients’ health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.     

The selling of health care services: are all sales jobs the same?

The selling activities of 272 salespeople were identified by polling 122 health care services organizations nationwide. A taxonomy of sales jobs was developed to classify the range of selling tasks within health care. The taxonomy is presented, discussed, and compared with a similar industrial one. Managerial implications and suggestions for future research are discussed.     

Is the physician office the wild, wild west of health care?

Elective, office-based surgery has captured the interest of consumers and, more recently, the attention of state health care regulatory agencies. In most states today, patients can undergo cosmetic surgery, liposuction, endoscopy, colonoscopy, microlaparoscopy, and various other procedures requiring sedation or anesthesia in physician offices even though no regulatory safeguards that would ordinarily benefit patients in accredited or licensed facilities exist. Media accounts of deaths and serious injuries associated with liposuction and anesthesia performed in physician offices resulted in legislative and regulatory initiates, such as those in California and New Jersey. Increased regulatory oversight, changes in patterns of reimbursement, and greater consumer awareness of safety and quality-of-care issues should aid in reducing the risks of office-based surgery.     

Does managing behavioral health care services increase the cost of providing medical care?

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting—by denying care or impeding access to care—and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.     

Has the influence of managed care waned? Evidence from the market for physician services

Managed care has been the dominant organization of health care coverage in the United States, and seeks to achieve cost control by constraining services. The restrictive practices of managed care organizations have been widely criticized and the role of managed care in constraining health care services may be declining. Physician behavior is also believed to be influenced by the practices of managed care organization. This study examines the evolving nature of managed care and its restrictive effects on the provision of physician services. Physicians can choose whether and to what extent they are involved in managed care, so it is an endogenous decision. We employ instrumental variables method to correct for this endogeneity. Using data from the Community Tracking Study physician surveys from 2000–2001 and 2004–2005, we find that managed care organizations have became relatively less restrictive over time in terms of limiting the provision of physician services, compared to non-managed care organizations. These results suggest that managed care and non-managed care are converging in their effects on the provision of physician services.     

Consent: what is the role of health care workers?

This article considers legal and ethical aspects of consent, as well as the need for consent to be a communication process that informs patients about procedures. Recent examinations of the use of agents (such as nurses and allied health professionals) in securing consent are discussed. While there is a clear role for nonphysician health care workers in advocating for the patient and assuring that consent has been secured; their actual role in securing consent in the absence of a physician is less clear.     

How do small rural primary health care services sustain themselves in a constantly changing health system environment?

Background

Services for Rheumatoid Arthritis (RA) have evolved with the development of independently led outreach Rheumatology Practitioner (RP) clinics in Primary Care (PC). Their clinical and cost effectiveness, compared with Secondary Care (SC) services, has not been assessed. The RECIPROCATE study aims to evaluate their clinical and cost effectiveness. This part of the study aimed to explore health professionals?? opinions of rheumatology outreach service.

Methods

Using a qualitative design, semi-structured interviews were conducted with GPs, practice nurses, hospital doctors and RPs, from one hospital and seven PC practices in Norfolk, to elicit their opinions of the service. The interviews were analysed using thematic analysis.

Results

All participants agreed the service was supportive and valuable providing high quality personalised care, disease management, social, and educational support. Advantages identified included convenience, continuity of care and proximity of services to home. RPs helped bridge the communication gap between PC and SC. Some participants suggested having a doctor alongside RPs. The service was considered to be cost effective for patients but there was uncertainty about cost effectiveness for service providers. Few disadvantages were identified the most recurring being the lack of other onsite services when needed. It was noted that more services could be provided by RPs such as prescribing and joint injections as well as playing a more active role in knowledge transfer to PC.

Conclusions

Professionals involved in the care of RA patients recognised the valuable role of the RP outreach clinics. This service can be further developed in rheumatology and the example can be replicated for other chronic conditions.     

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.