Chapter Five ('Health Maintenance Organizations')

1. Part of the increased patient load by PA's annually is because 'they see ambulatory patients exclusively, occupying an office more often and with less compensatory time off than physicians.' (p52)
   
   
2. According to Scheffler, 'PA's in institutions are more productive than PA's in private practice.' (p52) Most of these estimates are theoretical, however. Are revisits accounted for?
   
   
3. 'The theoretical estimates of PA productivity are higher in large managed care organizations and the military, with controversy centering on estimates of productivity in solo practice.' (p53) Why doesn't private practice show the same efficiencies? Is it because that HMO's are not more efficient or cost effective than small group practices, especially when administrative costs are accounted for?
   
   
4. Groups of physicians have economy of scale (~5%) compared to solo practice, according to Reinhardt (p52)
   
   
5. "In theory, productivity is a simple concept- it measures changes in total output that occur when small changes are made in one factor of production, with all other factors and circumstances held constant. Because these conditions can be met only rarely in the real world, productivity numbers are almost always rough estimates with respect to physicians." (p56)
   
   
6. 'Each provider's schedule erodes due to various factors. Inpatient services account for a large portion of this erosion: if extended hours are worked, compensatory time off decreases annual medical office visit productivity. The employee benefit package allows six weeks off for MD's, two to five weeks for PA's and NP's. Sick leave, administrative time, sabbaticals, research are all factors.' (p57)
   
   
7. "25% of all graduate PA's are in a surgical specialty or subspecialty" (p55)
   
   
8. KAISER STUDIES:
   
   
   1. 'Patients who do not keep appointments are included in productivity calulations.' (p57)
      
   2. 'Patients seen in the emergency rooms, urgency care clinics, and special clinics are usually not attributed to any single provider.' (p58)
      
   3. 'In the Kaiser Permanente Northwest Region (KPNW) Ob/Gyn 1992 studies, 67% of FTE were MD's (38.3/57.1), 22% were NP's (12.4/57.1), 11% were CNM's (6.4/57.1).' (p54)
   4. Outpatient productivity evaluations show the following for OBGYN. 'Note that FTE rate is the amount of time that providers worked, not the amount of time they saw scheduled patients and must be interpreted with caution.' (p54) Note the ~20% difference in pt/hr, and similarity between MD and CNM ratios.
      
      

      	FTE	PT.HR	PT/HR	PT/DAY	APPTS	APPT/FTE	PT.HR/FTE
      MD	38	26,800	2.67	19.4	68.4 K	1730	700
      CNM	6	4,000	2.48	16.1	9.6 K	1500	630
      NP	12	15,600	2.26	17.0	32 K	2590	1250

      
      
      
9. There is missing information about outpatient productivity:
   
   1. Role and staffing of LPN/RN nurses in these organizations
      
   2. Role of residents in these organizations
      
   3. Estimates of repeat visits/ missed diagnoses.
      
   4. Inpatient statistics
      
   5. ER/ urgent care visit statistics
      
   6. Breakdown of gyn versus ob statistics
      
      
10. 'Compensation: Medical malpractice and administrative costs have not been accounted for in the compensation studies.' (p63)
    
    1. Need to evaluate cost per patient hour of HMO compared to private practice (see p 63).
       
       
11. "The value of PA's or NP's in terms of economic rewards ought to be derived from their contributions to access, quality, efficiency, equity, and ultimately, health status of patient clients. Whether this is being accomplished at KPNW with more than 265 non-physician providers remains to be investigated." (p65)
    
    
12. Wages for NP's and PA's are rapidly rising (p65)
    
    
13. "This examination of one organization raises many questions that require a more detailed understanding of the specific activities and the allocation of time to each PA, NP, and physician. For instance, do PA's or NP's negate any of their cost-effectiveness in the way they approach similar conditions? Do they order more laboratory tests and procedures per episode of illness or prescibe more expensive medications than physicians for the same diagnosis and within the same group. Do physicians use telephone encounters differently than do PA's or NP's? Do PA and NP patients tend to return more often than physicians' patients? Which provider is more likely to refer certain conditions for consultation?" (p65)
    
    
14. In spite of the above, this chapter (by a PA) concludes:
    
    1. 'Restrictions limiting the use of NPP's should be removed.' (p66)
       
    2. 'The institution, and not the physician, should be responsible for maintaining quality.' (p66) How do you do this?
       
    3. 'Enhanced monitoring systems being developed in many institutions depend on improved and expanded documentation in the medical record.' (p66) Doesn't this imply higher administrative costs?