Prepaid Plan Research Articles

A unique approach to mental health services in an HMO: indemnity benefit and service program.

Three years' experience with a unique combination of an indemnity benefit plus an in-house service program in a prepaid group practice plan's psychiatric department demonstrates enhanced accessibility and increased utilization among formerly unserved segments of the membership plus the flexibility of freedom of choice in choosing service provider and the ability to tailor treatment to patient needs. Overall costs were similar to those reported for other prepaid plans despite the addition of benefits for long-term therapy outside the plan. Flexible use of inpatient and day hospital services enabled the program to migrate, to a large extent, major increases in hospital charges while providing greater continuity of care. This combination of benefits offers the advantages of both an indemnity benefit (Freedom of choice in treatment) and an in-house service program (greater continuity of care, more flexible use of resources, reduction of reliance on hospital care).

The reaction of the dental profession to changes in the 1970s.

This paper explores the changing realities of dentistry in the 1970s: the development of denturism; the maldistribution of dental practitioners; the growth and activities of expanded function auxiliaries; the intrusion of the Federal Trade Commission into professional issues resulting in advertising, supermarket and franchise dentistry; and the effect of prepayment plans. These realities are considered in terms of their impact on the profession and the efforts by the individual practitioner and his representative organizations to come to terms with them.

Use of hospital services under two prepaid plans.

This study compares the use of hospital services under two prepaid plans offered to Stanford University employees and their families. One is a Kaiser plan while under the other (Clinic plan), physician services are provided by the Palo Alto Medical Clinic, a multispecialty, largely fee-for-service group practice, and hospital services are covered by a Blue Cross policy. Using age- and sex-adjusted data, the hospital admission rate excluding deliveries is higher under the Clinic plan (44.2 admissions per 1,000 personyears compared with 38.2 under the Kaiser plan), but hospital days per 1,000 personyears are almost identical (249.8 days under the Kaiser plan, 250.7 under the Clinic plan). The difference in the admission rates is due to the higher surgical admission rate under the Clinic plan (32.4 admissions per 1,000 personyears compared to 25.0 under the Kaiser plan). However, when surgical procedures performed in the hospital on a nonadmission basis are added to surgical admissions, the surgical rates under the two plans become very close (35.7 admissions and procedures per 1,000 personyears under the Kaiser plan and 37.6 under the Clinic plan). This lends some support to the hypothesis that the lower hospital surgery rates found under prepaid group practice plans may be due as much to the group practice form of their organization as to their prepaid feature. The authors offer some possible reasons why surgeons in fee-for-service group practices may have relatively low surgery rates even though they do not have the incentive to hold down costs which surgeons in prepaid group practices have.

Denture service use in a selected population in a prepaid dental program

Rates of use of dental services for a large population of employees enrolled in a prepayment plan were examined. During a three-year period, the number of complete denture services that were provided declined steadily. Also, the number of simple and surgical extractions decreased, and there was an increase in the rate of use of periodontic and endodontic services.

Use of Physician Services under Two Prepaid Plans

Use of physician services under two prepaid plans offered to Stanford University staff is analyzed and compared. One is a Kaiser plan; under the other (Clinic plan), physician and outpatient ancillary services are provided by a predominantly fee-for-service group practice and hospital services are covered by a Blue Cross policy. The two plans provide much the same benefits but, in addition to the difference in their organization, they differ in their financial provisions. While the Kaiser plan has only a token copayment for office and home visits, the Clinic plan has a 25 per cent coinsurance provision applying to all physician and outpatient ancillary services. Despite these differences, the mean number of physician visits per year is the same for the two groups after account is taken of differences in age composition, socioeconomic status, health status, attitudes toward seeking care, length of plan membership, family size and satisfaction with the plan. However, when adjustment is also made for differences in physician affiliation, the Kaiser rate becomes half a visit higher than the Clinic rate. This is because under both plans, members who have a specific plan physician as regular source of care use more services than those without one, and because only 42 per cent of Kaiser members compared with 87 per cent of Clinic members stated that they had a specific plan physician.

Urgent care in the HMO: evolution of a system in Washington, D.C.

In 1961, Group Health Association, a large, non-hospital based, prepaid group practice in Washington, D.C. established an after-hours walk-in clinic on its premises for the care of medical problems requiring prompt attention. Within a year, this clinic's operation was extended to daytime hours for the use of the consumer-member at his own discretion. After 10 years, in the plan's main health center, the volume of adult visits to the acute care/walk-in center exceeded the number seen in the Department of Internal Medicine; most were of a routine rather than urgent nature. More visits to the acute care service were made during the day, when the full range of ambulatory services were available by appointment, than were made after hours. The choic of immediate first-come, first-served care over the conventional care-by-appointment by so many members was felt to have resulted in discontinuous suboptimal care, segregation of the membership along socioeconomic lines, as well as unnecessary and very costly duplications of service. The background of organizational behavior and community medical practices contribuing to this pattern of utilization are explored. Compared to traditional fee-for-service medicine, demands for outpatient services in the HMO tend to be greater. Acceptable alternatives to off-line channeling of patients with unexpected or acute conditions can be designed. In the general community today, utilization of medical services is strongly influenced by imbalances in available resources and by financial factors which are under no central control. In the HMO, all costs are prepaid and services are planned for a membership of known size. Even so, consumers' use of services in prepaid plans tends to follow the patterns seen in the community. More appropriate distribution of demands requires an active and ongoing system of patient education. A commitment by the HMO's providers and managers toward this goal is indispensable.

Industry-Sponsored Health Programs: Basis For a New Hybrid Prepaid Plan

Industry-Sponsored Health Programs: Basis For a New Hybrid Prepaid Plan

Industry-sponsored health programs: basis for a new hybrid prepaid plan.

Any successful plan to control health-care costs will necessarily focus on the physician's role in generating costs. Although physicians' incomes constitute only about 15 per cent of national healt...

Evaluation of an ambulatory medical-care delivery system.

We designed a medical-care-delivery system specifically to relieve the impaired access to care that has invariably assompanied the elimination of personal fees by prepaid plans, Medicare and other third-party payment plans. The solution involved the entry of patients through a paramedically staffed health-evaluation servece that effectively separated patients into three basic health-status groups-the well and worried well (68.4 per cent); the asymptomatic sick (3.9 per cent); and the sick (27.7 per cent)--a process that permitted matching the needs of each group with appropriate services. The system achieved increased physician accessibility to new patients by 20 times, reduced the waiting time for new appointments from six to eight weeks to a day or two, saved physician time and costs for entry work to a day or two, saved physician time and costs for entry work-up by 70 to 80 per cent reduced total resources used throughout the year by +32,550 per 1000 entrants, and proved very satisfactory to patients and generally so to staff.

A Method of Estimating Physician Requirements

This article describes and applies a method of estimating physician requirements for the United States based on physician utilization rates of members of two comprehensive prepaid plans of medical care providing first-dollar coverage for practically all physician services. The plan members' physician utilization rates by age and sex and by field of specialty of the physician were extrapolated to the entire population of the United States. On the basis of data for 1966, it was found that 34 percent more physicians than were available would have been required to give the entire population the amount and type of care received by the plan members. The "shortage" of primary care physicians (general practice, internal medicine, and pediatrics combined) was found to be considerably greater than of physicians in the surgical specialties taken together (41 percent as compared to 21 percent). The paper discusses in detail the various assumptions underlying this method and stresses the need for careful evaluation of all methods of estimating physician requirements.

Health Insurance Plans: Promise and Performance

Hetherington et al examine the differences between provider-sponsored plans, commercial carriers, and prepaid group-practice plans in southern California, basing their work on data collected from six plans in Los Angeles County, from 1965 to 1971. Information was gathered from the health insurance agencies, subscribers to each plan, and physicians who served the subscribers. Performance of the plans was measured according to amounts of medical service used, aspects of quality of those services, consumer expenditures, and consumer satisfaction. There were lower hospitalization rates in the large group-practice plans. Group plans tended to provide more preventive services and do more laboratory and radiology testing, but physicians in the large group plan "do not make note of the results as frequently as their colleagues in private practice." The hospital-sponsored plan had the highest rate of continuity of care. Families in the large group-practice plan had significantly lower out-of-pocket expenses per person while the

An adaptive social systems model of a prepaid group practice plan.

In the present study, an adaptive social systems model is developed and utilized to examine the dynamic properties of a health services delivery system. The model employs a Markov chain as a structure for analyzing the utilization of physician services both inside and outside of a prepaid plan. Four system states are defined, namely, no use, inside use, outside use, and both inside and outside use of physician services. Subscribers are considered to be in one of these states on each episode of illness. Transition probabilities are estimated from data collected from a sample of subscribers to a university health plan using a regression approach that permits a heterogeneous population to be examined within a Markovian framework. This framework is used to examine factors that account for differences in utilization patterns among individual subscribers and to examine overtime changes in the transition probabilities resulting from population shifts on specific demographic and health-related attributes. Based on the assumption that individual subscribers rather than the population as a whole follow a Markov process, the k-step transition matrix is constructed for the heterogeneous subscriber population and is used to examine the long-run effects of particular utilization patterns on the functioning of the prepaid plan.

Family mental health maintenance: a new approach to primary prevention.

The authors describe an approach to primary prevention in which indirect services are redefined to include community services aimed at promoting mental health and preventing emotional and mental disorders. At the Peninsula Hospital Community Mental Health Center such services are family-focused and include consultation, education, collaboration with other agencies, and early intervention with children and families with special needs. The authors describe some of the programs that have been developed and discuss how mental health Centers can conceivably, under contract, develop such community services for health maintenance organizations and other prepayment plans that provide comprehensive health maintenance and medical care.

Impact of Membership in an Enrolled, Prepaid Population on Utilization of Health Services in a Group Practice

Members of prepaid group-practice medical-care plans are believed to use more ambulatory, but fewer inpatient, services than populations served by fee-for-service practitioners. It is not known whether these differences are attributable to the prepayment aspects of the plan or to other circumstances. We studied the impact on use of services of only one factor-prepayment at the Marshfield Clinic, Wisconsin--with all other factors, including group practice, held constant. The findings were derived from the experience one year before, and two years after, the initiation of the prepaid program. Results showed that prepayment alone resulted in significant increases in both inpatient and ambulatory care (about 100 per cent in ambulatory-care visits, 75 per cent in hospital discharges, and 60 per cent in hospital days). These increases were far greater than comparable increases in the fee-for-service population served by the Clinic.

Factors Affecting the Choice between Prepaid Group Practice and Alternative Insurance Programs

This paper examines the basis for the selection of prepaid group practice in a dual-choice situation, and the social, attitudinal, and health characteristics of populations choosing prepaid programs in contrast to other plans. When asked in an open-ended way why they made the decisions they did, those selecting prepaid group practice most frequently referred to the more comprehensive coverage provided and to the fact that at the time of choice they lacked a continuing or adequate relationship with a physician. Enrollees in the prepaid program were better educated and, contrary to previous research, more likely to be unmarried. There was little evidence that enrollees in the prepaid plan brought with them distinctive kinds of attitudes and orientations toward illness and medical care. Enrollees in the prepaid program were also comparable to those retaining an alternative health insurance option on a number of indicators of health status. However, prepaid practice enrollees tended to report more chronic conditions than persons who declined to enroll in the prepaid program. Although the overrepresentation of persons with chronic illnesses is not large, data drawn from a related study suggests that persons with several chronic conditions tend to be heavy users of medical services.

Incentive Bonuses in Prepayment Plans

"...A physician should limit the source of his professional income to medical services actually rendered by him...to his patients."1 This precept of medical ethics is now under fire from within and without the profession. The attack comes from those who propose that prepaid group insurance plans, combined with financial rewards and punishments for physicians, are a panacea for the problems they perceive in American medicine, and especially the problem of cost.The proposal to pay incentive bonuses to physicians is taking place during a national debate on two philosophies of financing medical care.2 One philosophy proposes that people have a . . .

Home Care and Extended Care in a Comprehensive Prepayment Plan

Home Care and Extended Care in a Comprehensive Prepayment Plan

Letter: Life with dignity.

<h3>To the Editor.—</h3> We would like to add our support to Dr. Levine's concept of "The Chance to Live with Dignity" (226:672,1973). Our efforts to promote this idea have been somewhat less than successful. It is our belief that the "die with dignity" idea has become popular because it is easier to "go along" with a diagnosis already in the record than to insist on rigid criteria for its documentation or to make a new investigation. Less work is involved in allowing a patient to die in the middle of the night than in getting oneself out of bed to start an infusion or some other such "heroic measure." In the health maintenance organization (HMO) and prepaid plans of medical practice, economic saving results from letting the individual go to his reward without "expensive procedures" and an accumulation of days in the hospital. It is our plea to medical practitioners

Home Care and Extended Care in a Comprehensive Prepayment Plan

Journal Article Home Care and Extended Care in a Comprehensive Prepayment Plan Get access Home Care and Extended Care in a Comprehensive Prepayment Plan. By Hurtado AV, Greenlick MR, Saward EW. Chicago, Hospital Research and Education Trust, 1972, paper, 127 pp, illus, $3.95 James I. McKee James I. McKee Search for other works by this author on: Oxford Academic Google Scholar Physical Therapy, Volume 53, Issue 10, October 1973, Page 1150, https://doi.org/10.1093/ptj/53.10.1150 Published: 01 October 1973

Evaluation of Radiographic Techniques, Including Pantomography

A suggested list of criteria useful in the evaluation of dental radiographic techniques is presented along with a brief discussion of the need for such criteria. The basic radiographic techniques are classified and evaluated, and some of the pros and cons of individual techniques are discussed. The role of rectangular collimation in intraoral radiography is outlined. Radiographs taken with the use of nine machines and one device are evaluated. Proper identification of criteria is important because dental prepayment plans are searching for performance evaluation systems for dental radiography