Hanson K L, Butts G C, Friedman S, Fairbrother G
Robert J. Milano Graduate School of Management and Urban Policy, New School University, New York, NY 10011, USA.
J Urban Health. 2001 Mar;78(1):112-24. doi: 10.1093/jurban/78.1.112.
Private practice physicians in New York City's poorest neighborhoods are typically foreign trained, have generally substandard clinical practices, and have been accused of rushing Medicaid patients through to turn a profit. However, they also represent a sizable share of physician capacity in medically underserved neighborhoods. This article documents the level of credentials, systems, and immunization-related procedures among these physicians. Furthermore, it assesses the relationship between such characteristics and childhood immunization rates. The analysis utilizes a cross-sectional comparison of immunization rates in 60 private practices that submitted 2,500 or more Medicaid claims for children. Immunization data were gathered from medical records for 2,948 randomly selected children under 3 years of age. Half of sampled physicians were board certified (55%), and half were accepted by the Medicaid Preferred Physicians and Children (PPAC) program (51.7%). Of physicians, 43% saw patients only on a walk-in basis, while only 17% scheduled the next appointment while the patient was still in the office. There were 75% of the physicians who reported usually immunizing at acute care visits. Immunization rates were higher among PPAC physicians compared to others (41% vs. 29% up to date for diphtheria and tetanus toxoids and pertussis [DTP]/Haemophilus influenzae type b [Hib], polio, and measles-mumps-rubella [MMR], P = .01), and board-certified physicians showed a trend toward better immunization rates (39% vs. 30%, P =.07). Physicians who reported usually immunizing at acute care visits also had higher rates than those who did not (38% vs. 27%, P = .05). Scheduling a date and time for the next immunization showed a trend toward association with immunization coverage (37% vs. 28%, P= .10). Private practice physicians who provide high volumes of care reimbursed by Medicaid have improved their credentials and affiliations over time, thereby expanding reimbursement options. Credentials and affiliations were at least as effective in distinguishing relatively high- and low-performing physicians, as were immunization-related practices, suggesting that they are useful markers for higher quality care. The relative success of the PPAC program should inform efforts to improve the capacity and quality of primary care for vulnerable children. Appointment and reminder systems that effectively manage the flow of children back into the office for immunizations and the vigilant use of acute care visits for immunizations go hand in hand. Opportunity exists for payers and plans to encourage and support these actions.
纽约市最贫困社区的私人执业医生通常是在国外接受培训的，其临床执业水平普遍不达标准，还被指控催促医疗补助计划患者就诊以获取利润。然而，在医疗服务欠缺的社区，他们在医生队伍中也占了相当大的比例。本文记录了这些医生的资质水平、医疗系统及与免疫接种相关的流程。此外，还评估了这些特征与儿童免疫接种率之间的关系。该分析采用横断面比较的方法，对比了60家为儿童提交了2500份或更多医疗补助申请的私人诊所的免疫接种率。免疫接种数据从2948名随机抽取的3岁以下儿童的病历中收集。抽样医生中有一半具有专业委员会认证（55%），另一半被医疗补助优选医生及儿童（PPAC）计划接受（51.7%）。43%的医生只接受预约就诊，而只有17%的医生会在患者仍在诊所时就安排好下次就诊时间。75%的医生报告称通常在急症护理就诊时为患者进行免疫接种。与其他医生相比，PPAC计划的医生免疫接种率更高（白喉、破伤风类毒素及百日咳[DTP]/b型流感嗜血杆菌[Hib]、脊髓灰质炎及麻疹-腮腺炎-风疹[MMR]疫苗接种最新率分别为41%和29%，P = 0.01），具有专业委员会认证的医生的免疫接种率也有更高的趋势（分别为39%和30%，P = 0.07）。报告通常在急症护理就诊时进行免疫接种的医生的免疫接种率也高于未这样做的医生（分别为38%和27%，P = 0.05）。安排下次免疫接种的日期和时间显示出与免疫接种覆盖率存在关联的趋势（分别为37%和28%，P = 0.10）。随着时间的推移，大量提供由医疗补助计划报销服务的私人执业医生提升了他们的资质和所属机构，从而扩大了报销选择。资质和所属机构在区分表现相对较好和较差的医生方面至少与免疫接种相关的执业情况一样有效，这表明它们是更高质量医疗服务的有用标志。PPAC计划的相对成功应为改善弱势儿童初级医疗服务的能力和质量的努力提供参考。有效地管理儿童回诊进行免疫接种流程的预约及提醒系统，与在急症护理就诊时积极进行免疫接种相辅相成。付款方和计划制定方有机会鼓励和支持这些行动。
