Contracted Physicians Research Articles

Socio-medical assessment: an inventory of the Medical Service of the Federal Employment Agency

The Medical Service of the Federal Employment Agency is responsible for socio-medical assessments of clients whose ability to work in the labor market is in question. Data about the Medical Service, its structure, and its performance were previously only available within the Federal Employment Agency. In October 2023, data from the Medical Service containing information on the employee structure, clients, and orders were extracted from three data systems, processed, and analyzed. The number of full-time equivalents (FTEs) in the Medical Service decreased significantly from 2016 (n = 859.1 FTEs) to 2021 (n = 799.0 FTEs). This holds true for the professional groups of physicians, specialist assistants, medical assistants, and externally contracted physicians. The number of female employee FTEs rose significantly during this period from 85.6% (2016) to 87.0% (2021). The part-time ratio also increased significantly from 41.4% (2016) to 50.6% (2021). The number of assignments to the Medical Service was stable in 2017-2019 at around 630,000 but showed areduction in 2020 (n = 518,538) and 2021 (n = 545,289); in particular, the number of assessments with client contact decreased significantly from 2019 (n = 166,980) to 2020 (n = 52,484). Most of the assignments came from the field of job placement (n = 349,346). The size of the Medical Service was in line with the total number of orders, which can certainly be seen as COVID-19-related in 2020 and 2021 and is likely due to the overall shortage of skilled personnel. The proportion of women and part-time employees increased significantly, with anationwide part-time trend emerging not only among women. In order to enable all clients who may be unable to perform in the labor market to receive aquick assessment, it is necessary that the number of employees in the Medical Service does not decrease in the future.

Role of social medicine within the German Federal Employment Agency

Social medicine deals with the interrelationships between health and society-as across-sectional subject within medicine and abridging subject at the interfaces to other specialist disciplines. In the public and within the health system, social medicine still does not receive the attention it should be given, despite to its medical and socioeconomic importance. Asignificant proportion of social medicine specialists in Germany work as experts for social security providers. Using the example of the Medical Specialist Service ("Ärztlichen Dienstes", ÄD) of the German Federal Employment Agency ("Bundesagentur für Arbeit", BA), the medical tasks in social medicine are outlined. About 350 full-time medical employees nationwide as well as other contracted physicians support the specialists of the employment agencies and job centers to integrate those seeking training, jobs and employees with health restrictions into the labor market or maintaining an existing integration. In each individual case, they assess the extent of the health restrictions, the performance/earning ability, the suitability for training and professions as well as the requirement and type of vocational rehabilitation services. The ÄD's approximately 500,000 expert opinions each year are not only of far-reaching importance for the BA's affected customers, but also contribute to the responsible, effective, and accurate use of social system resources.

Patient Experiences With Prescription Cannabinoids in Germany: Protocol for a Mixed Methods, Exploratory, and Anonymous Web-Based Survey.

Medical cannabinoids are controversial. Their use is comparatively rare, but it is rising. Since 2017, cannabinoids can be prescribed in Germany for a broader range of indications. Patient surveys on these drugs are hampered by the stigmatization of cannabinoids and their (still) low prevalence in medical contexts. Against this background, patients' willingness to provide information is limited. Moreover, it is logistically challenging to reach them with a survey. A thorough knowledge of currently ongoing therapies and their effects and side effects, however, is important for a more appropriate and effective use of cannabinoids in the future. This study is an exploratory data collection using a representative sample. The main goal is to provide a detailed picture of the current use of medical cannabinoids in Germany. It is intended to identify subgroups that may benefit particularly well or poorly. We are conducting a representative, anonymous, cross-sectional, one-time, web-based survey based on mixed methods in 3 German federal states. Health conditions under cannabinoid therapy and before are documented with validated, symptom-specific questionnaires. This allows an estimation of the effect sizes of these therapies. The selection of parameters and questionnaires was based on the results of independent qualitative interviews in advance. Representative samples of the hard-to-reach study population are obtained by cluster sampling via contracted physicians of the statutory health insurance companies. Recruitment was ongoing until the end of June 2022, with 256 enrolled participants. Validated questionnaires on pain, spasticity, anorexia or wasting, multiple sclerosis, nausea or vomiting, depression, and attention deficit hyperactivity disorder (ADHD) were selected. Symptom scores are being assessed for both current conditions under cannabinoid therapy and conditions prior to this therapy (in retrospect). Validated questionnaires are also used for treatment satisfaction and general quality of life. These are supplemented by existing diagnoses, a detailed medication history, any previous experiences with cannabis or illegal substances, experiences with the prescription process, and sociodemographic data. Based on the results of the previous qualitative interviews, questions were added regarding prior experience with relaxation methods and psychotherapy, personal opinions about cannabinoids, pre-existing or symptom-related psychological trauma, and different experiences with different cannabis-based therapies. The exploratory mixed methods approach of this project is expected to provide valid and relevant data as a basis for future clinical research. The study design may be representative for a large proportion of outpatients treated with cannabinoids in the German federal states studied. It may have less bias toward social desirability and may provide valuable information in addition to existing studies. Due to the observational and cross-sectional nature of this study, various limitations apply. Causal relations cannot be drawn. German Clinical Trials Register DRKS00023344; https://drks.de/search/en/trial/DRKS00023344. DERR1-10.2196/38814.

General practitioner-centered care: a model with potential for improvement?

General practitioner (GP)-centered care was introduced into outpatient care on the basis of the GKV Modernisation Acts (GKV, gesetzliche Krankenversicherung: German statutory health insurance) of 2004 and 2007. These are predominantly selective contracts according to §73b of the German Social Code (Sozialgesetzbuch, SGB) V, which are signed between management companies such as the German GP Contract Association (Hausärztliche Vertragsgemeinschaft, HÄVG ) and the health insurance funds. The latter are obliged to enter into contracts, while participation by contracted physicians and patients is voluntary. The contract landscape of the AOK and the MEDI association in Baden-Württemberg, Germany, is considered a lighthouse project nationwide: here, approximately 5,300 general practitioners and 3,000 specialists participate in general practitioner (GP)-centered care, and about 1.7 million patients are enrolled. In addition to the higher remuneration for medical services, advantages include better control and continuity of care, the avoidance of misallocations, and the strengthening of the GP as a health guide. The increased administrative burden for participating practices and, on closer analysis, the predominantly economic focus of the contract contents, as well as the fact that they are exclusive to general practices, have proven to be disadvantages. Doing business on the basis of selective contracts leads to a division of the entire medical profession, and medical freelancing is at stake. In order to strengthen primary care in the long term, the collective-contract situation must be expanded and improved through special add-on contracts. At the same time, the risk of morbidity must not be unilaterally passed on to the medical profession through budgeting. A forward-thinking and transparently designed primary care can only be ensured with the full participation of internists in close cooperation with specialists.

Reasons for the relocation of contracted family physicians and job satisfaction

The aim of this study was to determine the reasons for the relocation of contracted family physicians and the relationship of this situation with burnout and job satisfaction status. This study was conducted with contracted family physicians in Bursa province between May 2019 and December 2019. The physicians were visited in the family health centres where they worked. The participants were asked to fill out a socio-demographic data form, Maslach Burnout Inventory Scale and Minnesota Job Satisfaction Questionnaire. In addition, physicians who had relocated were asked to fill out a questionnaire examining the reasons for this change. The most common reasons for the relocation of physicians were distance from home (65.30%), novelty seeking (25.60%) and burnout (24.80%). Being female (P = 0.004), duration of medical experience (P < 0.001), shorter time passed in family practice (P = 0.043) and job dissatisfaction (P = 0.006) were risk factors for relocation in a regression analysis model. Receiver operating characteristic analysis revealed a cut-off point value for the Minnesota overall score as ≤3. In family practice, it is favourable to provide continuity of care to the patient with the same physician. However, migration of physicians within the province for social and cultural reasons to more prosperous regions, often to where they live, was observed. Young female family doctors will probably continue to migrate to better locations within the city regardless of payment advantages in poor settlements. The roles of female physicians in society (as mother, wife and daughter) may have an effect on this preference.

Distribution of Visits for Chronic Conditions Between Primary Care and Specialist Providers in Medicare Shared Savings Accountable Care Organizations.

Medicare Shared Savings Program Accountable Care Organizations (ACOs) may focus more on primary care given ACO financial incentives. We examine variation in primary care treatment of 8 prevalent chronic conditions across ACOs and the factors affecting the variation, and compare the role of primary care in ACOs and non-ACOs. We conduct regression models at the ACO-level to identify factors predicting higher proportions of chronic condition visits delivered by primary care providers (PCPs) using 2013 Medicare claims and enrollment data. We compare the distribution of visits to PCPs, specialists and advanced practice providers between ACO-attributed and non-ACO-attributed beneficiaries. At the ACO-level, the proportion of patients who are white and of the local population who are college educated, the complexity of the patient population, and the supply of specialists were negatively associated with the proportion of chronic condition visits delivered by PCPs, whereas the percentage of contracted physicians within the ACO who were PCPs was positively associated. These results varied when subanalyses were conducted for each specific chronic condition. ACO care for chronic conditions was managed similar to that of care for non-ACO Medicare beneficiaries in 2013, but that some ACOs utilize PCPs to manage chronic conditions more than others. Many ACOs may underutilize PCPs, and thus could actively shift care to less expensive primary care for potential savings to payers. Barriers to that shift could include low numbers of PCPs contracted in the ACO, and existing referral patterns and patient relationships with specialists.

New System for Korean Nursing Home Contracted Physicians Began in 2017

New System for Korean Nursing Home Contracted Physicians Began in 2017

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, whereas contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (n = 16,653) and contracted care settings (n = 5,552). From 2006 to June 2014, the percentage of COT patients receiving ≥120 mg morphine equivalent dose declined from 16.8% to 6.3% in the group practice versus 20.6 to 13.6% among COT patients of contracted physicians. The proportion receiving excess opioid days supplied declined from 24.0 to 10.4% among group practice COT patients and from 20.1 to 14.7% among COT patients of contracted physicians. Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients. PerspectiveWashington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. Group practice physicians were exposed to both initiatives, whereas the health plan's contracted physicians were exposed to only the statewide changes. Reductions in prescribing of high opioid dose, average daily dose, and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

Community LTC, HCR ManorCare, and Mark Gloth

Community LTC, HCR ManorCare, and Mark Gloth

The accuracy of dermatology network physician directories posted by Medicare Advantage health plans in an era of narrow networks.

IMPORTANCE Insurers are increasingly deploying “narrow networks” with fewer contracted physicians both in health plans offered in new state exchanges under the Affordable Care Act and in Medicare Advantage (MA) plans, which are commercial alternatives offered to Medicare beneficiaries. Patients choosing health plans rely on the accuracy of network directories posted by insurers. The MA plans must meet network adequacy requirements,and inaccurate directories of participating physicians might prejudice those determinations.OBJECTIVE To determine the accuracy of MA plan directories of participating dermatologists,and the appointment availability of listed physicians.DESIGN, SETTING, AND PARTICIPANTS Scripted telephone calls were placed to every dermatologist listed in directories for the largest MA plans in 12 US metropolitan areas. The caller sought an appointment on behalf of his fictitious father who had severe itch for several months, asked whether the dermatologist accepted the relevant plan, and asked for the next available appointment date.MAIN OUTCOMES AND MEASURES Appointment availability and wait time.RESULTS Among 4754 total physician listings, 45.5%represented duplicates in the same plan directory. Among the remaining unique listings, 48.9% of physicians were reachable,accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized. The mean (range) wait time for appointments among the remaining listings was 45.5 (1-414) days. Both the accuracy of network directories and the appointment wait times varied substantially by health plan and metropolitan area. For 1 plan, our caller was unable to obtain an appointment with any listed dermatologist. CONCLUSIONS AND RELEVANCE Medicare Advantage physician directories for dermatology in many areas substantially overestimate the number of in-network physicians available to treat patients with medical skin conditions. These inaccuracies occurred in areas with long appointment wait times and where plans are terminating selected physician contracts. This suggests a lack of capacity that would be exacerbated by further network narrowing.Accurate physician directories are essential for proper oversight of network adequacy, and for patients who rely on these listings to evaluate health plan options during open enrollment.

Transforming Public Servants’ Health Care Organization in Greece through the Implementation of an Electronic Referral Project

ObjectiveThe Greek Public Servants’ Health Care Organization aiming to organize, monitor, and enhance the health care services provided to 1,500,000 public servants decided to respond to the national alert of the economic crisis through the reduction of costs caused by diagnostic tests (€300,000,000 claims for 2008), to improve working conditions of contracted physicians and laboratories, and to enhance services provided to insured members. In September 2010, the Greek Public Servants’ Health Care Organization initiated a pilot project that electronically records the prescription process of the diagnostic tests, which is Web-based, is open source, and was provided for free to the contracted physicians and diagnostic centers. MethodsIn this article, we present some interesting findings resulting from the implementation of the pilot electronic referral project by examining a 9-month period. ResultsFifty-eight percent of the physicians had the necessary equipment for the operation of the system, more than 3600 physicians used it, 17,495 public servants had been served through the system, and 178,456 paraclinical examinations had been prescribed with a cost of €1,394,980. In addition, the analysis revealed that the implementation of an electronic referral system could provide significant benefits, such as a faster referral process, valid and coherent information, minimization of the risk of misinterpreting the electronic referral due to illegibility of handwriting, and improvement in quality of services. ConclusionsThe Greek electronic referral system was one of the first attempts toward creating the basis of a society of transparency and cost control. The lessons learnt from this article should not be ignored in the process of redesigning and improving the electronic referral system for Greece.

The Role of Medicaid Managed Care Interventions in Chlamydia Screening by Physicians

Chlamydia trachomatis (CT) guidelines call for annual screening of all sexually active young females. In previous studies, Medicaid health maintenance organizations (HMOs) did not consistently recommend CT and other sexually transmitted disease guidelines, but physicians with HMO practices were more likely to comply with guidelines than those without HMO practices. This study examines the relationship between HMO interventions and physician adherence to annual (CT) screening guidelines for sexually active young (ages 15-25) females. Medicaid HMOs (N = 17) of California were surveyed regarding their interventions to increase physician adherence with national CT screening guidelines in 2002. Primary care physicians (N = 941) who contracted with these HMOs were also surveyed on their frequency (always/usually) of CT screening. Data were analyzed using logistic regression models. HMO-reported recommendations for CT screening and other interventions were associated with significantly higher odds of frequent CT screening by contracted physicians in unadjusted models. HMO recommendations to screen young females increased the odds of frequent CT screening, but other interventions were no longer significantly associated after controlling for physician characteristics. Physicians also had higher odds of reporting frequent CT screening if they had received training in the past, had received feedback from their contracted HMOs, or reported having access to national CT screening guidelines. Physician gender, specialty, years of clinical experience, and other factors were also significantly associated with the odds of frequency of CT screening. Improving physician adherence with CT screening guidelines requires a refinement of current approaches with targeted interventions that are tailored to the characteristics of physicians. In addition, interventions are more likely to be effective if provided in formats that are perceived and acknowledged by physicians.

How is Greece conforming to Alma-Ata's principles in the middle of its biggest financial crisis?

The international Alma-Ata conference held on September 1978 by the World Health Organisation (WHO) set equity, comprehensiveness, continuity of care, and patient centeredness, as targets for all health systems in the world.1 In order to achieve these targets, it mobilised a ‘primary healthcare movement’ that shifted global thinking about health from specialist, tertiary care towards ambulatory care.2 WHO's report of 2008, Primary Health Care: Now More Than Ever ,3 reconfirmed WHO's adherence to primary health care as the only way for health systems to respond to the challenges of a changing world. How has Greece dealt with Alma-Ata's principals for the last 30 years? And how relevant are these principles today, in the middle of the country's biggest financial crisis? Inspired by Alma-Ata's ideals, Greece instituted a national health system in 1983, so that it could ‘ guarantee that all citizens enjoy the benefits of a complete range of services of high quality, free at the point of service ’.4 Since then, the Greek NHS has been providing free access and full coverage to the entire population, including immigrants. Within NHS or social insurance context, primary healthcare services are delivered through health centres and provincial surgeries in rural areas and through outpatient departments of regional and district hospitals, polyclinics of the social insurance institutions and contracted physicians and diagnostic centres in urban areas. There are also many private physicians and diagnostic centres that provide services directly to the population. A major shortcoming of the Greek healthcare system is that …

Alfons Zarzoso, L'Exercici de la medicina a la Catalunya de al Il·lustració (segle XVIII), Manresa, Publicacions de l'Arxiu Històric de les Ciències de la Salut (PAHCS), 2006, pp. 184, illus., no price given (paperback 84-611-2808-7).

Alfons Zarzoso, L'Exercici de la medicina a la Catalunya de al Il·lustració (segle XVIII), Manresa, Publicacions de l'Arxiu Històric de les Ciències de la Salut (PAHCS), 2006, pp. 184, illus., no price given (paperback 84-611-2808-7). - Volume 52 Issue 4

Screening in Austria: the cases of mammography, PSA testing, and routine use of ultrasound in pregnancy.

To study cases of screening in Austria to learn about national strategies to handle the health policy challenge of early detection of widespread diseases and about the outcome of those strategies. The article describes three healthcare interventions (mammography, PSA testing, and routine use of ultrasound in pregnancy) and the instruments of Austrian health policy that are used-with or without explicit intention-to enforce or to control the widespread use of (early) diagnoses. Data and information collection on healthcare services, their accessibility, rate of use, expert consensus, and official regulations. For all three case studies, expert interviews were carried out with main actors. Risk-group screening is not a priority in Austrian federal health policy. Although health promotion and prevention is a national task, examinations for early detection of specific diseases (i.e., carcinoma) are left to the health insurance funds, which delegate the decision to offer early diagnoses to their contracted physicians. In this opportunistic screening, general practitioners or specialists are encouraged by their health insurance funds or motivated by professional guidelines to offer certain examinations. Screening is a coordinated effort to acquire a grasp of a common disease at an early stage in a specified population. To achieve this objective, a culture of coordination and centralization has to be implemented. The collection of data is an essential element in coordination of decentralized medical interventions as much as quality control is an essential task in looking at and comparing the outcome of interventions. In the three case studies, neither of these two essential criteria were met. Evaluations and scientific evidence on the effectiveness of interventions were not used.