Use Of Physician Services Research Articles

The Use and Costs of Physician Services for Ophthalmic Surgical Procedures in 1988 and 1991

To examine the change in volume and costs of physician services for ophthalmic surgical procedures associated with physician fee cuts. The authors analyzed the physician claims (Part B) data for a 5% random sample of the Medicare population. Number, rate, average allowed charge, and total cost of physician services for ophthalmic surgical procedures were compared for 1988 and 1991. An estimated 3.1 million (98 per 1000) ophthalmic surgical procedures were performed on Medicare beneficiaries in 1991, compared with 2.3 million (76 per 1000) in 1988. There was a 35% increase in number and a 28% increase in rate. The average allowed charge for these services decreased by 26% ($1155 vs $852 per procedure), with an overall cost of $2.6 billion in both years. A reduction in fee for physician services for ophthalmic surgical procedures from 1988 to 1991 was associated with an increase in the volume of the services. The overall costs of physician services for ophthalmic surgical procedures remained consistent between the two years.

Employer-based health insurance and seniors: the case of Bermuda.

This article examines the importance of economic factors in physician and other health service utilization among older adults living in Bermuda. Using data drawn from a national survey of 500 Bermudian elders, the findings reveal economic factors to be unrelated to the use of physician services directly, but to be significant determinants of the use of other health services. Need plus non-need factors are related to the use of both physician and other health services. The employer-based system does seem to provide universal access, but factors in addition to need influence the receipt of care.

Stress, Gender, Cognitive Impairment, and Outpatient Physician use in Later Life

The purpose of this study was to look at the interface between stressful life events, gender, cognitive impairment, and the use of outpatient physician services among older adults. A theoretical rationale is presented, suggesting that older men who are suffering from either mild or moderate levels of cognitive impairment are especially likely to use outpatient physician services when they are confronted by undesirable stressful events. Analyses with data provided by a nationwide sample of elderly people provide support for this complex three-way interaction.

Health Care Use by Preschool Children: Effects of Maternal Occupation and Household Structure

This study examines the effects of a mother's occupation and the presence or absence of a father figure at home on the use of pediatric services by 5,611 preschool children. The children with the lowest number of physician visits are those whose mothers are employed in traditionally female‐specific occupations and who live in a household where afatherfigure is present. Health insurance, Medicaid, age and gender of child, number of siblings, mother's education, and health condition of child also were found to be important factors associated with the use of physician services by preschool children.

The use of hospital emergency departments for nonurgent health problems: a national perspective.

The use of the hospital emergency department (ED) for nonurgent health problems has been a subject of considerable controversy, in part because there is no widely accepted definition of "nonurgent." Elimination or substantial reduction in nonurgent ED use is frequently offered as a strategy for reducing health expenditures. Previous studies, often limited to individual hospitals or communities, have limited generalizability and do not permit examination of multiple factors likely to influence nonurgent ED utilization or examination of ED use for nonurgent problems in the context of overall outpatient utilization. This analysis of the 1987 National Medical Expenditure Survey (NMES) provides a nationally representative examination of nonurgent ED utilization that describes the frequency of ED use for nonurgent problems, characteristics of individuals that are associated with an increased likelihood of nonurgent ED use, the use of other outpatient physician services, and expenditures associated with nonurgent ED visits.

The role of health insurance in the use of health services among the non-elderly.

Ronald Andersen's behavioral model was used to develop and test predictive expectations about the role of health insurance in the use of hospital and physician services. Health insurance should be more predictive of the use of physician than hospital services and it should not be predictive of the use of health care for those in poorer health who are in greater need of care. As expected, health insurance status was a predictor of physician use and not of hospital use. However, contrary to expectation, health insurance was also a predictor of hospital and physician use for those in poorer health. The results underscore the national debate concerning the uninsured and their access to health care, particularly for those in poorer health.

Children's Health: Racial and Ethnic Differences in the Use of Prescription Medications

Although racial and ethnic differences in the use of hospital and physician services have been well established, research has not examined the relationship between minority status and the use of prescription medications for children with some access to the health care system. This study examines differences in probability and number of prescribed medications by race and ethnicity, and whether the differences remain if socioeconomic factors, indicators of need, and number of physician visits are taken into account. Using data from the 1987 National Medical Expenditure Survey, multivariate regression analysis was used to examine the probability of receiving a prescription medication and number of medications for two samples of children, ages 1 to 5 (N = 1347) and ages 6 to 17 (N = 2155). Descriptive statistics indicate that compared with white children, black and Hispanic children are less likely to receive a prescribed medication and have on average, fewer medications. The multivariate results of this analysis show that those differences persist, depending on age group of the child, after adjusting for socioeconomic factors, health conditions, and number of physician visits. The relationship between racial and ethnic status and the use of prescription medication mirrors other types of services, such as physician visits, and affirms that minorities receive fewer services than whites.

Rising Use of Physician Services by the Elderly: The Contribution of Morbidity

ABSTRACTUse of medical services by the elderly population is increasing. While rising numbers of elderly persons account for much of the overall increase, per capita increases in use of medical services within this group have been substantial. This phenomenon is commonly attributed to greater need due to the “aging” of the elderly population (i.e. an increased proportion of those 85 years of age and over) and to changing patterns of morbidity or to changing patterns of servicing the old and sick. Research to date suggests that the impact of the aging of the elderly population has been small. However, because the relationship between morbidity and rising utilization has not yet been studied, there is considerable debate about the extent to which increased “need” for care contributes to patterns of rising utilization. This research studied the impact of changes in numbers, demographics, and morbidity patterns of the elderly on per capita and aggregate consumption of ambulatory physician services at two points in time. Linked survey and physician claims data for representative samples of the elderly in 1971 and 1983 were used to study patterns of utilization of total ambulatory, consultative and non-consultative care by age and health status. The research found that per capita utilization of both consult and non-consult visits rose across all categories, with older individuals and those in poor health experiencing greater increases in utilization than younger and healthier individuals. At the aggregate level, a large percentage of the increase in utilization of medical services was related to increased numbers of elderly. Changes in ‘need’ attributable to aging of the elderly population and increased morbidity had only minor effects. At least 35 per cent of the increase in non-consult visits and 50 per cent of the increase in consult visits were not specifically related to changes in need of the elderly population and remain as unexplained changes in patterns of servicing individuals. While some of this increase was directed to individuals in poor health, the majority of increased servicing (32% of the increase in non-consultative visits and 58% of the increase in consultation visits) was directed to individuals in good health. Policy implications are discussed.

Changes in physician utilization over time among older adults.

Although much is known from cross-sectional studies about the use of physician services among older adults, little is known about the consistency of or changes in that utilization over time. Hierarchical multivariable regression analysis of data on the 2,430 older adults who were enrolled in the LSOA and successfully reinterviewed in 1986, 1988, and 1990 is used to model changes in the number of physician visits between 1984 and 1990 based on the predisposing, enabling, and need (including functional status) characteristics measured in 1984, and subsequent changes in functional status. Overall, 19 percent of the variance in physician utilization is explained, with 8 percent coming from the introduction of the need characteristics, 4.7 percent from the subsequent introduction of the number of physician visits at baseline, and 4.9 percent from the subsequent introduction of changes in functional status. Declines in each of the functional status measures are significantly associated with increases in physician utilization, although improvements are fundamentally unrelated.

Medicaid physician fee levels and children's access to care.

This study examines the effects of physician fees on children's use of preventive and illness-related ambulatory physician services under the Medicaid program. Using data from the 1987 National Medical Expenditure Survey (NMES), we examine the effects of Medicaid fee generosity on physician service use and overall ambulatory physician spending. The results indicate that more generous fees are associated with a greater likelihood of having a doctor's office as a usual source of care and a higher number of preventive visits at office-based sites of care. Having a doctor's office as a usual source of care is associated with lower overall ambulatory physician expenditures.

Effect of antihypertensive formulation on health service expenditures

A major barrier to the management of hypertension is the extent to which patients comply with the treatment regimen. Herein we report the findings of a retrospective analysis designed to discern the relationship between antihypertensive formulation, regimen compliance and the utilization of health care services. Data for this analysis were derived from the state of South Carolina's Medicaid computer archive. The study population consisted of 1,000 randomly selected beneficiaries initially prescribed one of the following antihypertensive regimens as monotherapy: atenolol (daily); captopril (twice daily); oral clonidine (twice daily); transdermal clonidine (once a week); diltiazem (twice daily); enalapril (twice daily); metoprolol (twice daily); prazosin (twice daily); terazosin (daily); and verapamil-SR (daily). Multivariate regression analysis was used to determine the incremental influence of selected demographic characteristics, utilization of medical services prior to diagnosis for hypertension, initial antihypertensive medication, medication possession ratio for antihypertensive therapy, and the number of maintenance medications for disease state processes other than hypertension on post-period health care expenditure. Results indicate that patients initially prescribed antihypertensive medication requiring daily or weekly administration experience infrequent changes in their therapeutic regimen, far less use of concomitant therapy for blood pressure control, an increased utilization of antihypertensive medication, and a decrease in the use and cost of physician, hospital and laboratory services.

OBRA Fee Reduction and Physician Behavior

To the Editor. —In a recent article 1 inThe JOURNAL, I reported that the Medicare fee reductions for overpriced procedures under the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) did not affect the use of physician services by Medicare patients. Drs Ginsburg and Hogan, 2 in an accompanying Commentary, disagree with my conclusions, alleging methodological problems with my study. They contrast my findings with those of the Physician Payment Review Commission (PPRC), 3 which found that the OBRA 87 fee reductions resulted in higher use of surgeons services (ie, a behavioral offset). Ginsburg and Hogan contend that the changes in Medicare fees that occurred during the period of my study (1987 to 1989) were driven largely by physicians' own pricing behavior rather than Medicare payment policy, rendering the interpretation of fee/utilization correlations problematic. Their assertion, however, reflects an incorrect reading of the available data. In 1989, Medicare fees

Effects of Lower Surgical Fees on the Use of Physician Services Under Medicare

The changes in physician fees that will occur under the resource-based Medicare Fee Schedule (MFS) are similar to those that took place under the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), when Medicare fees for selected "overpriced" procedures and diagnostic tests were reduced. To gain insight regarding the changes in utilization that may occur under the MFS, this study examines the effects of the OBRA 87 fee reductions on the use of physician services by Medicare patients. The five specialties that were most affected by the OBRA 87 fee reductions were studied: ophthalmology, thoracic surgery, urology, orthopedic surgery, and gastroenterology. Medicare physician claims files for 1987 and 1989 were used to obtain data on utilization and fees. Multivariate regression analysis was used to assess the effect of changes in fees on changes in utilization. The best estimate of the effect of the OBRA 87 fee reductions on overall physician-services utilization, obtained by pooling the five study specialties, was that every 1% decrease in fees led to a 0.09% decrease in the volume and complexity of services (95% confidence interval, 0.49% decrease to 0.31% increase). This result was not sensitive to minor changes in the covariates included in the regression model. To calculate payment levels during the transition to the MFS, the Health Care Financing Administration assumed that physicians whose Medicare revenue declines under the MFS will increase service volume and complexity enough to make up one half of the lost revenue. The findings of this study suggest that the Health Care Financing Administration's assumption was, at best, extreme.

Effects of lower surgical fees on the use of physician services under Medicare

Effects of lower surgical fees on the use of physician services under Medicare

Do working mothers have healthy children?

This paper examines the effects of maternal employment on children's physical and mental health. The data used are from the Health Interview Survey 1981, Child Health Supplement. A health production model is developed on the basis of Becker's household production theory. The results reveal that a mother's employment is a significant factor affecting her child's physical health. Use of physician services, prices (i.e., CPI used as a proxy variable), sex of the child, receipt of Medicaid, the number of relocations, the mother's education, the mother's health status, breast-feeding practices, and the birth weight of the child are other important variables explaining the health status of children. The role of each of these factors varies according to the marital status of the mother.

Access to ambulatory care among noninstitutionalized, activity-limited persons 65 and over.

This study examined the impact of income and insurance type on ambulatory care contact use by persons 65 and over who expressed a limitation in their activity. This large group (39% of noninstitutionalized older persons in 1984) had significantly more health problems and ambulatory care contacts than persons not activity-limited. The only previous study on equity in use of physician services among elderly in poorer than average health found relatively little inequality of use due to income and insurance. This study came to the opposite conclusion. Activity-limited persons without Medicare private supplementary insurance, as well as those with supplementary insurance in the bottom and middle of the income distribution, had 15-32% fewer ambulatory care contacts than activity-limited persons with higher income and private supplementary insurance. Particularly striking were the declines in consumption among middle income persons relative to the reference group, indicating that the issue of equity in consumption of health services among older disabled persons affects a much broader group than only the poor and near-poor.

Loneliness-distress and physician utilization in well-elderly females

Two samples (N = 112 and 115) of females aged 65–85, recruited from senior centers and groups, were surveyed with respect to the determinants of their use of physician services. The results of the two samples are fairly consistent: (a) Sociodemographic variables are not useful in predicting physician utilization; (b) health status accounts for about 30% of the variance in frequency of visits; (c) psychosocial factors, in particular loneliness-distress, account for an additional 13%–14% of the variance in frequency of visits; (d) when subject to discriminant analysis, health status and psychosocial variables together correctly classify about 60% of the high utilizers (those in the top quarter of the sample in physician visit rate), with a less than 10% false-positive rate.

Prevalence, Determinants, and Consequences of Chronic Neck Pain in Finland

Chronic neck pain is a relatively mild musculoskeletal condition, but common enough to be a possible public health problem. The distribution, determinants, and consequences of chronic neck pain have hitherto been described inadequately. In the Mini-Finland Health Survey, a representative population sample of 8,000 Finns aged greater than or equal to 30 years was invited to participate in a comprehensive health examination comprising an interview and a clinical examination; 90.2% complied. Predetermined criteria were used to diagnose major cardiovascular, musculoskeletal, respiratory, mental, and other disorders, regardless of other simultaneous disorders. Chronic neck syndrome was diagnosed in 9.5% of the men and 13.5% of the women. When adjusted for age and sex, the prevalence of the neck syndrome was associated with a history of injury to the back, neck, or shoulder and with mental and physical stress at work. Among those aged 30 to 64 years, overweight and parity were also significant determinants. Other musculoskeletal and mental disorders were associated with neck syndrome, and the association persisted after working conditions, injuries, overweight, and parity were adjusted for. There was some independent association between neck syndrome and disabilities, use of physician services, and use of pain killers.

Hospital Outpatient Services and Medicaid Patients?? Access to Care

This article examines the relationship between the use of hospital outpatient services by Medicaid patients, Medicaid physician fees, and the use of office-based physician services. Past research has indicated that the use of outpatient facilities by Medicaid patients substitutes for care by private physicians and might be reduced by raising physician fees, but these studies may be estimated at too high a level of geographic aggregation and include many outpatient services that are not substitutes for office-based physician care. The results in this study, which are estimated using LISREL on county level Medicaid claims data from the state of Illinois, provide little evidence that outpatient care substitutes for care by physicians or that raising physician fees would reduce inappropriate outpatient usage by medicaid patients.

Utility of a transdermal delivery system for antihypertensive therapy. Part 1

A retrospective evaluation of patient-level Medicaid claims data from two states was undertaken to discern the fiscal utility of transdermally delivered clonidine versus both the oral formulation of clonidine and oral formulations of eight other antihypertensive agents. In the first phase of our two-part study, we compared paid claims data (n = 1,135) from Florida for transdermal and oral clonidine. Multivariate regression analysis was used to evaluate the incremental impact of six variables on health-care expenditures in the first year after patients were given a diagnosis of hypertension. These variables were: age, gender, prior utilization of medical services, regimen complexity, and dosage formulation. Patients prescribed transdermal clonidine experienced a significant (p ≤ 0.001) increase in prescription expenditures and significant reductions in the use of physician (p ≤ 0.05), laboratory (p ≤ 0.10), and hospital (p ≤ 0.05) services. Moreover, savings were maximized (p ≤ 0.001) where multi-drug regimens incorporated the transdermal delivery system. In the second phase of our study we compared paid claims data (n = 8,894) from South Carolina for transdermal clonidine and for nine oral antihypertensive agents: atenolol, captopril, clonidine, diltiazem, enalapril, metoprolol, prazosin, terazosin, and verapamil-SR. Once again, regression analysis was used, this time to evaluate the incremental impact of five variables on health-care expenditures in the first year post diagnosis: age, gender, prior utilization of medical services, regimen complexity, and Medication Possession Ratio (MPR), an index of compliance. The data from part 2 of our study revealed that patients assigned a b.i.d. oral antihypertensive agent experienced a significant reduction (p ≤ 0.05) in MPR and a significant (p ≤ 0.05) increase in health-care expenditures when compared to patients prescribed the transdermal delivery system and to patients prescribed once-daily oral medications. These data confirm previous findings concerning the impact of complicated dosing regimens on compliance in hypertensive patients. In this two-part paper we report the data from both phases of our study.