Cost & quality quarterly journal : CQ最新文献

Managed care organizations (MCOs) have recently focused on the high cost per patient visit in the Emergency Department (ED). MCOs emphasize preventing low acuity patients access to the ED, believing that billions of healthcare dollars will be saved. However, a review of emergency department studies suggests a different outcome. Combined with new ED service lines, perhaps another, rather paradoxical approach to managing healthcare costs in the ED is more patient focused and more cost-effective long-term. This approach is more comprehensive and offers more services, not less. The ED is an important community resource and entry port to healthcare. It is the only place open 24-hours per day, 7 days per week with no appointment necessary, and all lab and radiology services available. The very claim that it is "overutilized" is an indication of its success. In large volume EDs, certain patient populations may be more specifically served with pediatric emergency, industrial medicine, and fast track physicians. Special facilities for chest pain patients or observation can treat patients more quickly, keep them out of hospital beds, thus lowering costs. In smaller hospitals, the well rounded ED physician can treat patients of all acuities. In the most rural communities the ED can become the local 24-hour clinic with short-term stay beds. EDs are fixed costs to hospitals. Extracting low acuity patients from the ED will raise costs for emergency patients and leave the facility underutilized. By appropriately raising prices for emergencies and decreasing low acuity patient charges to reflect marginal expense, the ED becomes a cost friendly environment for the low acuity patient.

Objective: Capitation is an increasingly common method of paying physicians, but few data exist on its impact on physician satisfaction. This study examines the perceived effects of capitation on physician satisfaction at a large, academic medical center.

Study design: Survey of physicians at a single, tertiary care hospital.

Methods: Physicians in a physician hospital organization were surveyed at an urban teaching hospital which received capitation for 5% of patients at the time of the survey but was preparing for a sharp increase in capitation. We used a 5-point Likert scale to assess physicians' satisfaction with their practice, and to compare satisfaction under fee-for-service and expected satisfaction under capitation.

Results: Of the 734 physicians surveyed, 147 were excluded because they had no direct patient care responsibilities. Of the remaining 587 physicians, 363 replied, giving a response rate of 62%. Overall, 57% of physicians were satisfied with their practice. Compared to their satisfaction under fee-for-service reimbursement, they were much less satisfied with their ability to care for capitated patients (17 of 19 questions, p < 0.05). The greatest differences were for freedom to order necessary tests and freedom to obtain referrals (0.9 and 0.8 on the 5-point scale, respectively, both p < 0.0001). Multiple logistic regression analyses revealed four independent predictors of overall satisfaction: patient load (OR = 2.7, 95% CI = 1.9-3.9), efficiency in resource utilization (OR = 1.5, 95% CI = 1.1-2.1), perceived employment stability (OR = 1.7, 95% CI = 1.3-2.2), and control over clinical time schedule (OR = 1.6, 95% CI = 1.2-2.0).

Conclusions: Physicians initially encountering capitation payment have strong negative perceptions about it, even for areas in which some policy experts expect capitation to benefit patient care. Physician education and focusing on management relations may help smooth the transition to capitated reimbursement.