A System for Interactive Assessment and Management in Palliative Care

The availability of psychometrically sound and clinically relevant screening, diagnosis, and outcome evaluation tools is essential to high-quality palliative care assessment and management. Such data will enable us to improve patient evaluations, prognoses, and treatment selections, and to increase patient satisfaction and quality of life. To accomplish these goals, medical care needs more precise, efficient, and comprehensive tools for data acquisition, analysis, interpretation, and management. We describe a system for interactive assessment and management in palliative care (SIAM-PC), which is patient centered, model driven, database derived, evidence based, and technology assisted. The SIAM-PC is designed to reliably measure the multiple dimensions of patients’ needs for palliative care, and then to provide information to clinicians, patients, and the patients’ families to achieve optimal patient care, while improving our capacity for doing palliative care research. This system is innovative in its application of the state-of-the-science approaches, such as item response theory and computerized adaptive testing, to many of the significant clinical problems related to palliative care

Selective Enrollment in and Disenrollment from Hmos By Medicaid Recipients.

Medicaid recipients could choose to obtain health care from either of two Health Maintenance Organizations (HMOs) or from fee-for-service providers. Lower hospital use among Medicaid HMO families led to speculation that a large proportion of lower-risk families had chosen HMOs. Some HMO physicians saw both HMO and non-HMO Medicaid families and had financial incentives to selectively influence enrollment and disenrollment decisions. The purpose of this study was to assess evidence of selective enrollment and disenrollment, and evidence of physician influence. Enrollment and utilization data were analyzed for cases with continuous Medicaid eligibility by using Contingency tables, Discriminant Analysis and Logit Analysis. HMO families had lower than average per capita expenses during the three months preceding enrollment. Over 69 percent of these HMO families had no physician contacts during this pre-enrollment period. Among those families who saw HMO physicians exclusively prior to joining the HMO, there was no clear evidence that the lower-risk families were influenced to join the HMOs or the higher-risk families were retained as private patients. Post-disenrollment hospital utilization and total expenses were higher than average during the three months after families left the HMOs. However, most disenrolled families either began to see non-HMO physicians or received no medical care during this time period. Thus, there was no evidence that HMO physicians had influenced higher-risk families to disenroll so that they then could continue to see them as private patients. It would seem that selective enrollment occurred not because of physician influence, but because the HMOs were more successful in enrolling families that did not have ongoing relationships with physicians. Because those without physicians were probably healthier than average, this resulted in favorable recruitment by the HMOs. Reasons for relatively high use following disenrollment are more difficult to interpret, and need to be explored using more direct methods such as interviews.Ph.D.Public healthUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/159368/1/8314267.pd

A four-system comparison of patients with chronic illness: the Military Health System, Veterans Health Administration, Medicaid, and commercial plans

We compared chronic care utilization in four major health systems in the U.S.: the military health system (TRICARE), the Department of Veterans Affairs (VA), Medicaid, and employer-sponsored commercial plans. Prevalence rates and key performance indicators were constructed from administrative data in federal fiscal year 2003 for eight chronic conditions: hypertension, major depression, diabetes, tobacco dependence, ischemic heart disease, severe mental illness, persistent asthma, and stroke. Continuously enrolled beneficiaries under 65 years old were studied: TRICARE (N = 2,963,987), VA (N = 2,114,739), Medicaid enrollees in five states (N = 5,554,974), and commercial insurance (N = 5,212,833). Condition-specific adjusted prevalence rates and measures were compared using the standardized rate ratio. For the majority of the conditions, the estimated prevalence rates were highest in the VA and Medicaid populations. Prevalence rates were generally lower in TRICARE and commercial plans. Medicaid beneficiaries had the highest hospitalization rates in four of the six conditions where hospitalization rates were measured. These results provide empirical evidence of differences in chronically ill patient populations in several of the major U.S. health insurance systems