Diagnostic testing and return visits for acute problems in prepaid, case-managed medical plans compared with fee-for-service

Article Abstract:

Because of the high cost of medical care, state and federal governments tried to reduce the costs of Medicaid by lowering reimbursement rates, and by instituting utilization controls, case management, and capitation. It was feared that these changes would lead to less medical care for the poor. In 1981 the Health Care Financing Administration developed a system of waivers to the usual Medicaid regulations, and Medicaid Competition Demonstrations were used in six states. These demonstrations, using enrollees in the Aid to Families with Dependent Children (AFDC), used various methods of capitation and case management. These programs realized little overall cost savings. This study was undertaken because it was thought that physicians under capitated payment would order fewer diagnostic tests and return visits, especially for those patients whose illnesses were less serious and had the fewest long-term consequences. Records from patients who had vaginitis, pelvic inflammatory disease (PID), or urinary tract infection (UTI) were examined for 2,382 patients. There was no evidence that the case-managed, prepaid demonstration resulted in fewer diagnostic tests or return visits for any of these diseases. The tests for these diseases have a low profitability, and utilization of high-profit tests such as chest X-rays and electrocardiograms has been shown in other research to differ. Return visits for vaginitis, the least serious condition, were the most frequent in a clinic setting. However, there are almost no data regarding the medical necessity of follow-up visits for many medical diagnoses, and there is no consensus on the advisability of return visits for many illnesses. Because payment to these physicians in Medicaid programs was low compared with fees charged by other physicians in their community, physicians did not perceive a financial advantage to treating the Medicaid patients differently. These Medicaid interventions appear to have little effect, either on saving money or on clinical care. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Laws, regulations and rules, Medicaid, United States. Office of Family Assistance. Aid to Families with Dependent Children Program

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From forms to focus: a new teaching model in ambulatory medicine

Article Abstract:

The increased use of ambulatory or outpatient care that has followed changes in patient reimbursement has often made it difficult for interesting cases to be discussed amongst the staff. This is particularly important in teaching hospitals and medical school affiliated services. A method of addressing this issue is presented which includes the use of a clinical encounter form (CEF), a device for capturing critical patient history, laboratory, and clinical findings in summary form. The CEFs from a day's service are collected, reviewed overnight by an attending physician and serve as the basis for a presentation the following day. The system is reminiscent of hospital teaching rounds, where senior staff with interns and residents in tow visit a large number of hospitalized patients whose cases are reviewed and discussed. The simple device allows individual cases to be discussed and encourages important self-analysis of clinical issues and decision-making.

Innovations, Study and teaching, Ambulatory medical care, Ambulatory care, Graduate medical education, Physician services utilization

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Comprehensive primary health care: a letter to a medical student

Article Abstract:

A method of developing an office practice in internal medicine that is directed toward providing comprehensive primary care is presented. The author has developed a system whereby his patients pay an annual retainer fee, instead of being billed on a fee-for- service basis. As a result he can insist that all patients have annual physicals and other diagnostic tests. When warranted by age or special conditions, this means that patients receive sigmoidoscopic or colonic endoscopic examinations, breast examinations, and conventional blood tests without concern for the cost. All patients taken into the practice are told that scheduled examinations are mandatory. This method has converted the usual symptomatic care practice to a system of preventive medicine and comprehensive primary care.

Management, Preventive medicine, Medicine, Preventive, Medical fees

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