A National Survey of the arrangements managed-care plans make with physicians

Abstract Background. Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians. Methods. In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independentpractice–association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs). Results. Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians’ previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fiftysix percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs. Conclusions. Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed. (N Engl J Med 1995;333:1678-83.

Sums of hermitian squares and the BMV conjecture

Recently Lieb and Seiringer showed that the Bessis-Moussa-Villani conjecture from quantum physics can be restated in the following purely algebraic way: The sum of all words in two positive semidefinite matrices where the number of each of the two letters is fixed is always a matrix with nonnegative trace. We show that this statement holds if the words are of length at most 13. This has previously been known only up to length 7. In our proof, we establish a connection to sums of hermitian squares of polynomials in noncommuting variables and to semidefinite programming. As a by-product we obtain an example of a real polynomial in two noncommuting variables having nonnegative trace on all symmetric matrices of the same size, yet not being a sum of hermitian squares and commutators.Comment: 21 pages; minor changes; a companion Mathematica notebook is now available in the source fil

Lower orbital frontal white matter integrity in adolescents with bipolar I disorder.

ABSTRACT Objective: To examine white matter microstructure, as assessed via diffusion tensor imaging (DTI), in adolescents with bipolar I disorder compared with control volunteers. Method: Twenty-six (12 male and 14 female subjects) adolescents (mean age, 16.0 years) with bipolar I disorder and 26 (14 male and 12 female subjects) control volunteers (mean age, 15.3 years) completed structural and DTI examinations. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps were compared between groups in the brain white matter using a voxelwise analysis after intersubject registration to Talairach space. Exploratory analyses were performed to assess structureYfunction correlations in a subgroup of 11 patients with available neuropsychological measures. Results: Compared with the control volunteers, the patients demonstrated abnormalities in white matter regions predicted to differ a priori between groups, including lower FA in the right orbital frontal lobe and higher ADC in the right and left subgenual region (p < .005, uncorrected; cluster size Q 100). There were no areas of higher FA or lower ADC in patients compared with control volunteers. Lower FA across regions that differed significantly between groups correlated significantly with slower visuomotor speed among patients with bipolar disorder. Conclusions: Abnormalities involving the orbital frontal and subgenual white matter in adolescents with bipolar disorder are consistent with neurobiological models that implicate dysregulation of affective systems and impulsivity in the pathophysiology of the disorder. Preliminary findings suggest that white matter abnormalities in pediatric bipolar disorder have functional correlates and may be useful in constructing neurobiological models of the disorder

Principles of Quantitative Fluid and Cation Replacement in Extreme Hyperglycemia

Hyperglycemia may cause profound deficits of water, sodium and potassium through osmotic diuresis, which continues during treatment as long as there is glucosuria. Replacement fluids should cover both the deficits at presentation and the ongoing losses during treatment. At presentation with hyperglycemia, quantitative estimates of the deficits in water, sodium and potassium are based on rapid body weight changes, which indicate changes in body water, and on the serum sodium concentration corrected to a normal serum glucose level. The corrected serum sodium concentration provides a measure of the water deficit relative to the cation deficit (sodium, plus potassium) that is useful in guiding the choice of monovalent cation concentration in the initial replacement fluids. Monitoring clinical status, serum chemistries (glucose, sodium, potassium, total carbon dioxide), urine flow rate, and urine chemistries (sodium and potassium) during the course of fluid and cation replacement therapy is critical. This monitoring guides the volume and composition of replacement solutions for deficits developing during treatment and the management of potassium balance and acid-base abnormalities, including metabolic acidosis, respiratory acidosis, rarely, and others

Length of the weaning period affects postweaning growth, health, and carcass merit of ranch-direct beef calves weaned during the fall

Bovine respiratory disease (BRD) is the most economically devastating feedlot disease. Risk factors associated with incidence of BRD include (1) stress associated with maternal separation, (2) stress associated with introduction to an unfamiliar environment, (3) poor intake associated with introduction of novel feedstuffs into the animal\u27s diet, (4) exposure to novel pathogens upon transport to a feeding facility and commingling with unfamiliar cattle, (5) inappropriately administered respiratory disease vaccination programs, and (6) poor response to respiratory disease vaccination programs. Management practices that are collectively referred to as preconditioning are thought to minimize damage to the beef carcass from the BRD complex. Preconditioning management reduces the aforementioned risk factors for respiratory disease by (1) using a relatively long ranch-of-origin weaning period following maternal separation, (2) exposing calves to concentrate-type feedstuffs, and (3) producing heightened resistance to respiratory disease-causing organisms through a preweaning vaccination program. The effectiveness of such programs for preserving animal performance is highly touted by certain segments of the beef industry. Ranch-of-origin weaning periods of up to 60 days are suggested for preconditioning beef calves prior to sale; however, optimal length of the ranch-of-origin weaning period has not been determined experimentally. The objective of this study was to test the validity of beef industry assumptions about appropriate length of ranch-of-origin weaning periods for calves aged 160 to 220 days and weaned during the fall

Transmissibility of non-linear output frequency response functions with application in detection and location of damage in MDOF structural systems

Transmissibility is a well-known linear system concept that has been widely applied in the diagnosis of damage in various engineering structural systems. However, in engineering practice, structural systems can behave non-linearly due to certain kinds of damage such as, e.g., breathing cracks. In the present study, the concept of transmissibility is extended to the non-linear case by introducing the Transmissibility of Non-linear Output Frequency Response Functions (NOFRFs). The NOFRFs are a concept recently proposed by the authors for the analysis of non-linear systems in the frequency domain. A NOFRF transmissibility-based technique is then developed for the detection and location of both linear and non-linear damage in MDOF structural systems. Numerical simulation results verify the effectiveness of the new technique. Experimental studies on a three-storey building structure demonstrate the potential to apply the developed technique to the detection and location of damage in practical MDOF engineering structures

Neurologic improvement after thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries

Study Design. Retrospective. Objective. With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord. Summary of Background Data. Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients. Methods. Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. Results. A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P \u3c 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury. Conclusion. Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others

Extinction of cue-evoked drug-seeking relies on degrading hierarchical instrumental expectancies

There has long been need for a behavioural intervention that attenuates cue-evoked drug-seeking, but the optimal method remains obscure. To address this, we report three approaches to extinguish cue-evoked drug-seeking measured in a Pavlovian to instrumental transfer design, in non-treatment seeking adult smokers and alcohol drinkers. The results showed that the ability of a drug stimulus to transfer control over a separately trained drug-seeking response was not affected by the stimulus undergoing Pavlovian extinction training in experiment 1, but was abolished by the stimulus undergoing discriminative extinction training in experiment 2, and was abolished by explicit verbal instructions stating that the stimulus did not signal a more effective response-drug contingency in experiment 3. These data suggest that cue-evoked drug-seeking is mediated by a propositional hierarchical instrumental expectancy that the drug-seeking response is more likely to be rewarded in that stimulus. Methods which degraded this hierarchical expectancy were effective in the laboratory, and so may have therapeutic potential

A Nearly Linear-Time PTAS for Explicit Fractional Packing and Covering Linear Programs

We give an approximation algorithm for packing and covering linear programs (linear programs with non-negative coefficients). Given a constraint matrix with n non-zeros, r rows, and c columns, the algorithm computes feasible primal and dual solutions whose costs are within a factor of 1+eps of the optimal cost in time O((r+c)log(n)/eps^2 + n).Comment: corrected version of FOCS 2007 paper: 10.1109/FOCS.2007.62. Accepted to Algorithmica, 201