Goodman Robert
Blue Care Network of Michigan, Southfield, MI 48076, USA.
Health Serv Manage Res. 2011 Aug;24(3):130-41. doi: 10.1258/hsmr.2011.011005.
To explore whether a common industry measure of overall patient illness burden, used to assess the total costs of members in a health plan, would be suitable to describe variation in a summary metric of utilization that assesses specialist physician direct patient care services not grouped into clinical episodes, but with exclusion criteria applied to reduce any bias in the data. Data sources/study setting Calendar year 2006 administrative data on 153,557 commercial members enrolled in a non-profit single-state statewide Health Maintenance Organization (HMO) and treated by 4356 specialists in 11 specialties. The health plan's global referral process and specialist fee-for-service reimbursement likely makes these results applicable to the non-managed care setting, as once a global referral was authorized there was no required intervention by the HMO or referring primary care provider for the majority of any subsequent specialist direct clinical care. Study design Specialty-specific correlations and ordinary least-squares regression models to assess variations in specialist direct patient care work effort with patient overall illness burden, after the application of exclusion criteria to reduce potential bias in the data. Principle findings Statistically significant positive correlations exist between specialist direct patient care work effort and patient overall illness burden for all studied specialties. Regression models revealed a generally monotonic increasing relationship between illness burden categories and aggregate specialist direct patient care work effort. Almost all regression model differences from the reference category across specialties are statistically significant (P ≤ 0.012). Assessment of additional results demonstrates the relationship has more substantive significance in some specialties and less in others. The most substantive relationships in this study were found in the specialties of orthopaedic surgery, general surgery and interventional cardiology.
For many specialties, specialists do vary physician direct patient care utilization with patient overall illness burden. Accounting for patient overall health status is important to fairly compare specialists of certain specialties on utilization for health plan specialist network management. Additional study is required to evaluate health plan application of this methodology.
探讨一种用于评估健康计划成员总成本的通用行业整体患者疾病负担衡量指标，是否适用于描述一种利用情况汇总指标的变化。该指标用于评估专科医生直接为患者提供的护理服务，这些服务未归类到临床诊疗过程中，但应用了排除标准以减少数据中的任何偏差。数据来源/研究背景 2006 年日历年的行政数据，涉及 153,557 名参加非营利性单州全州健康维护组织（HMO）的商业成员，他们由 11 个专科的 4356 名专科医生进行治疗。该健康计划的整体转诊流程和专科医生按服务收费的报销方式，可能使这些结果适用于非管理式医疗环境，因为一旦整体转诊获得批准，在大多数后续专科医生直接临床护理过程中，HMO 或转诊的初级保健提供者无需进行干预。研究设计 特定专科的相关性和普通最小二乘法回归模型，用于在应用排除标准以减少数据中潜在偏差后，评估专科医生直接为患者提供护理的工作强度与患者整体疾病负担之间的差异。主要发现 对于所有研究的专科，专科医生直接为患者提供护理的工作强度与患者整体疾病负担之间存在统计学上显著的正相关。回归模型显示，疾病负担类别与专科医生直接护理的总工作强度之间通常呈单调递增关系。几乎所有专科与参考类别之间的回归模型差异均具有统计学意义（P≤0.012）。对其他结果的评估表明，这种关系在某些专科中具有更大的实质意义，而在其他专科中则较小。本研究中最具实质意义的关系出现在骨科手术、普通外科和介入心脏病学专科。
对于许多专科而言，专科医生确实会根据患者的整体疾病负担来调整其直接为患者提供护理的利用情况。在健康计划专科网络管理中，考虑患者的整体健康状况对于公平比较某些专科的专科医生的利用情况非常重要。需要进一步研究以评估该方法在健康计划中的应用。
