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BACKGROUND: As Medicaid clients have come to be enrolled in managed care, concerns have arisen about the ability of private sector systems to meet the needs of enrollees with substance abuse problems. OBJECTIVES: This project describes treatment initiation and duration for Medicaid and commercial substance abuse treatment clients in a large health maintenance organization (HMO). RESEARCH DESIGN: This study was a prospective secondary analysis of information from HMO databases. Subjects were 641 adult Medicaid clients who contacted the HMO's addiction medicine department in 1996 or 1997 and commercial HMO addiction medicine patients (n=447). First contact with addiction medicine during the study period was the index event. MEASURES: Chief dependent variables were initiation and duration of substance abuse treatment after the index event. RESULTS: Logistic regression showed that longer HMO enrollment predicted treatment initiation after substance abuse assessment, but Medicaid status was not a significant predictor. A competing risks analysis using Cox proportional hazards models indicated that once subjects had initiated, Medicaid was not significantly related to exit from substance abuse treatment. Analysis of health plan disenrollment by Medicaid clients indicated that the most common reason was loss of Medicaid eligibility. CONCLUSIONS: These results raise the possibility that state Medicaid policies may make it difficult for clients to obtain suitable chemical dependency treatment services. [ABSTRACT FROM AUTHOR]

Men and women differ in their use of alcohol, in their rates of chronic illnesses and psychological symptoms, and in the social support they receive. In this paper, we assess how the latter three factors are associated with alcohol use, and how these associations differ by gender. Respondents were 3,074 male and 3,947 female randomly selected Health Maintenance Organization members who responded to a mail survey in 1990. Hierarchical multiple regression analyses indicate that social support is associated with alcohol consumption in similar ways for both genders, yet the associations between some demographic, physical health/functioning, and psychological well-being measures are different for men and women. Men with fewer role limits due to physical health drank more, while women with better psychological well-being drank less. Poor psychological well-being may be a modifiable risk factor for increased alcohol use among women; practitioners should be alert for greater consumption among men with few functional limitations and good health.

Objective: To identify the factors that predict professional satisfaction, organizational commitment, and burnout among physicians working for health maintenance organizations (HMOs)., Methods and Participants: Data came from mail surveys of Kaiser Permanente physicians in the Northwest and Ohio regions. The average response rate was 80% (n = 608)., Results: The single most important predictor for all 3 outcomes was a sense of control over the practice environment. Other significant predictors included perceived work demands, social support from colleagues, and satisfaction with resources. The relative importance of these predictors varied, depending on the outcome under consideration. All 3 outcomes were also related to physician age and specialty. Older physicians had higher levels of satisfaction and commitment and lower levels of burnout. Pediatricians were more satisfied and committed to the HMO and were less likely to burn out., Conclusions: Physicians who perceive greater control over the practice environment, who perceive that their work demands are reasonable, and who have more support from colleagues have higher levels of satisfaction, commitment to the HMO, and psychological well-being. Interventions and administrative changes that give physicians more control over how they do their professional work and that enhance social supports are likely to improve both physician morale and performance.

Objective: To reduce variability in primary care physicians' use of procedures for imaging the lumbar spine., Design: Controlled intervention using clinical practice guideline and practice pattern feedback., Study Sample: Sixty-seven internists and 28 family practitioners in a large, group-model HMO., Measurements and Main Results: Intervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians' changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study., Conclusions: Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed.

Health maintenance organizations have employed physician assistants, nurse practitioners, and other nonphysician providers for decades, yet there is little information on how satisfied these providers are with this form of practice. This paper examines how physician assistants evaluate their experience practicing in a large group model health maintenance organization and compares their attitudes and satisfaction levels with those of other nonphysician providers-nurse practitioners, optometrists, mental health therapists, and chemical dependency counselors. The data source is a 1992 survey of 5,000 nonphysician employees of a health maintenance organization. The survey instrument was a self-administrated questionnaire that included both structured and open-ended questions. The response rate averaged 88 percent for physician assistants and the other non-physician providers. Physician assistants expressed the most satisfaction with the amount of responsibility, support from coworkers, job security, working hours, supervision, and task variety. They were less satisfied with workload, control over the pace of work, and opportunities for advancement. Most physician assistants were also satisfied with pay and fringe benefits. Compared with other nonphysician providers, chemical dependency counselors expressed the highest levels of satisfaction across the various dimensions of work and optometrists the lowest. Nurse practitioners, chemical dependency counselors, and mental health professionals also tended to be satisfied with most aspects of practice in this setting. In a number of instances, they were more satisfied than the physician assistants. The findings are consistent with other studies that found health maintenance organizations to be favorable practice settings for physician assistants. The limits of physician assistant involvement and their role satisfaction and efficient use in HMOs are more likely to relate to physician attitudes and acceptance than to lack of support by coworkers and other attributes of the work environment.

Kaiser Permanente Northwest Region is a prepaid group practice health maintenance organization. Among the employed are 65 physician assistants (PAs) who work in primary care and in certain subspecialties. Kaiser Permanente was one of the first managed health care systems to use PAs and has contributed to the historical documentation of their effectiveness. An interest in experimenting with new forms of health care delivery as well as enabling State legislation has contributed to an expanded role for nonphysician providers. Together with nurse practitioners, PAs comprise 20 percent of the primary care staff and write 25 percent of the prescriptions for the membership. The use of PAs in managed health care settings will likely increase to meet growing primary care demands. Analysts have found the cost of a PA ranges from 25 percent to 53 percent of the cost of a physician. PAs are capable of providing care for 86 percent of the diagnoses seen in outpatient primary care setting, and patient acceptance is high.

This study identified consistently high and low users of medical care services in a group of older HMO members continuously enrolled for six years. Consistently high users made up 26% of the sample, but accounted for more than 50% of total outpatient contacts and hospital admissions. Average ambulatory care costs were more than four times greater for the high users compared with the low users. Consistently high users were older than consistently low users, but did not differ significantly in other sociodemographic characteristics. Compared with the low users, the high users reported more total medical conditions and were more likely to indicate they had arthritis, high blood pressure, heart conditions, and other chronic problems. They perceived themselves to be in poorer health and reported higher levels of psychologic distress. The low users tended to be less satisfied, but the two user groups were not significantly different regarding use of services outside the HMO.

Smoking behavior of consistently high and low users of medical care services were compared in two groups of older health maintenance organization (HMO) members continuously enrolled for five years and a subgroup who were continuously enrolled for 10 years. Smokers and former smokers, combined, were more likely than never-smokers to be consistently high users of ambulatory services (52 percent vs 34 percent in the five-year group, and 45 percent vs 30 percent in the 10-year group).

When evaluating the effectiveness of medical care programs, one concern is whether receipt of care is based upon health care needs or upon socioeconomic status. This study describes the relation between health status and socioeconomic status and attempts to determine which has the greater effect on ambulatory care utilization. The study setting was an operating HMO serving a cross-sectional membership of nearly 200,000 persons. Outpatient utilization data were derived from the medical records of a five per cent sample of health plan members for 1969 and 1970. Social, economic, situational, and attitudinal data were provided by 2,603 respondents in a household interview survey. Since a population's perceived health status may reflect health need, information from the survey provided measures of health status that ranged from specific symptoms and complaints to a general measure of perceived health status. Although the findings varied somewhat according to which variables were considered, they generally showed health status to correlate more highly than socioeconomic factors with the utilization of services in this medical care system. An exception was the use of preventive services, which was not significantly related to health status measures but rather, for women, to education and, to a lesser extent, income.

A special program of outreach services was implemented to assist a poverty population to appropriately use health services in the Kaiser-Permanente Medical Care Program. A study was conducted to determine the effect of outreach workers' intervention on the use of preventive services by this population. Intially, families were divided into two groups, one with and one without outreach workers. Outreach workers (neighborhood health coordinators) were trained in prevention and health education. They were then assigned to specific subgroups of the poverty population to teach the importance of preventive services and to motivate persons to use these services. This paper focuses on the effect of outreach workers' services on the use of selected preventive care services (immunizations and tine test) by preschool children from poverty families. Preschool children in families with coordinator services had higher use rates for preventive care. The sub-group for which outreach workers were specially trained to focus on preventive procedures for the pre-school group had markedly higher use rates for preventive care. The findings suggest that special intervention programs, using indigenous and nonprofessional outreach workers, can increase preventive service utilization by poverty groups.

The relationships between duration of membership and the use of outpatient medical care services for disadvantaged and general membership groups in a prepaid group practice were analyzed. The effects of duration of membership upon utilization rates during a six-year study period were estimated by retrospective cohort analyses. Rates were computed for successive three-month intervals. There were no significant start-up effects on use for new enrollees in either study population. This finding is in contrast to what has been reported in other studies. New HMOs or existing HMOs with many new members may not require the additional resources previously thought necessary. Average cohort utilization rates were higher for the disadvantaged cohorts, with the exception of young males 0 to 14 years old. We also examined the persistence of utilization patterns over time. Consistently high users and nonusers were found in both populations. In general, these findings suggest that length of time does not affect ambulatory care use. Age, sex, socioeconomic background and health status are more important than duration of membership in accounting for differences in utilization.

Data from a 6-year follow-up period were used to analyze the mortality of adults who had been continuously enrolled in a prepaid group practice health maintenance organization (HMO) for the previous 7 years. Thirteen percent of the HMO members were classified as consistently high users of outpatient care. Even after adjustment for age, sex, and cigarette smoking, this high user group's mortality rates during the follow-up period were significantly greater than those of the other HMO enrollees. The HMO members as a whole had mortality rates marginally lower than the mortality of the general Oregon population. It can be concluded that HMO enrollees who consistently use high quantities of health care resources generally have significant medical problems in addition to psychosocial difficulties. Assuming that mortality reflects health, long-term HMO members as a group are not much healthier than ordinary Oregonians.

This article explores the potential for collaboration between investigators in institutions outside of the VA and those engaged in research within the VA. The focus is on the potential for collaborative work in health services research; our perspective is that of researchers in a freestanding HMO research center affiliated with the Veterans Administration's Northwest Health Services Research and Development Field Program. The paper begins with a review of the reasons that make collaboration between VA researchers and other health services researchers so appropriate at this time. An example of collaboration is presented, drawing on the experience of the Northwest Field Program and the Kaiser Permanente Center for Health Research. Finally, some difficulties inherent in collaboration between VA and other health services researchers are discussed.

Use by physicians of medical care resources to treat similar patients and morbidities has implications for the efficiency and effectiveness of medical care. This study examined the variation in primary care physicians' use of outpatient laboratory, radiology, drugs, and hospital admissions; the relationships among the uses of these resources by physicians; and uses of these resources by physicians over time. The setting was a large HMO and the physicians were internists (n = 30), pediatricians (n = 20), and obstetrician/gynecologists (n = 17). Resource use was a dollar rate for laboratory, radiology, and drug, and an admission rate per contact for the hospital. The physicians' use rates were derived from the computerized utilization record of a sample of HMO members for 1976-1978. Substantial variation occurred in the rates of use of each resource by physicians in each specialty. The relationships among the resource rates were similar for internists and pediatricians, and were somewhat stronger than expected clinically. There were also substantial consistencies over time in the levels of use of laboratory and drugs by internists and pediatricians. Findings suggest a potential for more judicious use of ambulatory care resources by primary care physicians in this setting.

Criteria used in this study established that 13% of long-term adult members of a prepaid group practice health maintenance organization (HMO) were consistently high users of outpatient medical care services. This population accounted for 31% of the total doctor office visits (DOVs), 35% of the hospital admissions, and 30% of the outpatient surgical services for long-term members. The most frequent reason for DOVs in this high user group was treatment and/or follow-up of chronic conditions. Patterns of utilization were unrelated to marital status, income, occupation, and perceived social class. Smoking and alcohol use also were not associated with utilization patterns. However, the consistently high users were more likely to perceive their health status as fair or poor and to report a higher number of physical symptoms. They were also more likely to be characterized by a higher degree of psychological distress, especially depression. Contacts with the HMO's mental health department constituted less than 1% of their total medical care contacts, and only 13% made at least one mental health contact over the study period. The findings are discussed in terms of their health and medical care implications.