Over the course of three HCFO grants, Mark Doescher, M.D., Barry Saver, M.D., and colleagues from the University of Washington have examined a wide variety of health care issues including payment mechanisms for specialty physician services, individual and community factors affecting the uninsured, and the relationship between prescription drugs and resource-intensive care.

In their first HCFO study, the researchers evaluated the impact of alternative HMO payment mechanisms for specialty care – salary, fee-for-service (FFS), and capitation – on the utilization and costs of specialty care provided to HMO patients. They found that procedure rates were generally higher for patients seeing providers paid under FFS arrangements, while there were no consistent patterns for salary vs. capitation payment.

Saver remarks, “We were surprised that the findings between salary and capitation were not more clear-cut. I continue to run into anecdotes of substantially higher rates of discretionary procedures under FFS payment. It is reassuring that rates under capitation were similar to those under salary payment, helping to allay concerns that capitation incentives will lead to underperformance of needed procedures.”

In a second project, Doescher and Saver examined whether community-level characteristics, such as unequal income distribution, segregation in housing, and availability of safety net services, could explain racial/ethnic disparities in the purchase of private health insurance, as well as access to care of uninsured persons. The researchers determined that, with few exceptions, community-level factors do not explain these disparities. They concluded that voluntary approaches to insurance uptake do not appear to be solving the problem of the uninsured, and, in fact, seem to be creating greater racial and ethnic disparities.

Doescher points out, “We observed that members of racial/ethnic minority groups were much less likely to purchase nongroup health insurance than non-Hispanic whites. This gap was not explained by individual-level factors, including family income, or by an array of community-level factors. To improve this situation, we need to get a better handle on the underlying reasons why members of minority groups are relatively unlikely to purchase nongroup insurance, beyond the effects of disparities in income, education, and other known factors.”

In their third HCFO grant, the “Medicare Enrollee Drug Study” (MEDS), the researchers explored the relationship between prescription drug coverage and health care costs in a sample of elderly Medicare+Choice enrollees with common chronic health conditions. They found that seniors who lacked prescription drug coverage faced significantly greater non-pharmaceutical-related costs of care than seniors who had drug coverage. In addition, the savings in inpatient (hospital) and emergency department costs approximately offset the costs to the plan of medications for those with a benefit.

Saver notes, “While our findings come from just one health plan, it is remarkable that we found that the cost to the plan of a very generous prescription benefit, with modest copayments and no annual or lifetime caps, was virtually offset by savings in hospital-based care for persons with hypertension, coronary artery disease, congestive heart failure, and diabetes. The plan has a closed formulary emphasizing evidence-based, cost-effective drugs and obtains substantial discounts on selected proprietary drugs – prescription drug spending for persons with and without a benefit was substantially lower than found in national surveys. The disconnect between our findings, those of researchers studying prescription drug expenditures in the Veterans Health Administration, and the Medicare prescription benefit enacted by Congress is remarkable.” Doescher adds, “We hope this growing body of research will stimulate Congress to redesign the Medicare prescription benefit to be both less expensive and more effective.”

Mark Doescher is an Associate Professor of Family Medicine at the University of Washington (UW). He received his M.D. from U.C.S.F. in 1989. He then completed residency training in Preventive Medicine and Public Health at the University of Colorado Health Sciences Center and in Family Medicine at the University of Rochester/Highland Hospital. Before joining the UW faculty, he worked as a community health center physician in the Seattle area. Dr. Doescher’s main research interests are in improving health care access, reducing racial/ethnic and socioeconomic disparities in care, and improving chronic illness care.

Barry Saver, an Associate Professor of Family Medicine, came to UW in 1989 as a National Research Service Award (NRSA) fellow after working in community clinic settings in the San Francisco Bay area. His current areas of research interest include access to care by disadvantaged populations, improving quality and cost-effectiveness of health care, and the interplay between patient behavior, physician behavior, and health system factors. He obtained his M.D. from Columbia University, completed residency training in Family Medicine at UCLA, and received his MPH and completed residency training in Preventive Medicine at the University of Washington. Both Drs. Saver and Doescher currently see patients and teach residents and medical students at Harborview Medical Center, a large, inner-city, public hospital.

Manuscripts Under Review from HCFO-funded projects:

Doescher MP, Saver B, Jackson JE, Fishman P, Franks P. Risk of hospitalization among elderly Medicare+Choice enrollees: Do prescription benefits matter?

Fishman P, Doescher MP, Saver B, Jackson JE. Prescription drug coverage and health care costs among seniors with one or more chronic conditions.

Boudreau DM, Doescher MP, Saver B, Jackson JE, Fishman. Reliability of health plan automated pharmacy data by drug benefit status and type of health care delivery system.

Published Articles from HCFO-funded projects:

Jackson JE, Doescher MP, Saver BG, Fishman PA. Sticking with It: Prescription Drug Coverage and Medication Acquisition among Seniors with One or More Chronic Conditions. Medical Care, in press.

Doescher MP, Saver BG, Fiscella K, Franks P. Preventive Care: Does Continuity Count? Journal of General Internal Medicine 2004; 19(6):632-7.

Saver BG, Doescher MP, Jackson JE, Fishman P. Seniors with chronic health conditions and prescription drugs: benefits, wealth, and health. Value Health. 2004 Mar-Apr;7(2):133-43.

Boudreau DM, Doescher MP, Saver BG, Jackson JE, Fishman PA. Impact of healthcare delivery system on where HMO-enrolled seniors purchase medications (July/August). Ann Pharmacother. 2004 May 18 [Epub ahead of print]

Saver BG, Ritzwoller DP, Maciosek M, Goodman MJ, Conrad DA, Finkelstein E, Haase M, Barrett P, Cain K. Does Payment Drive Procedures? Payment for Specialty Services and Procedure Rate Variations in 3 HMOs. Am J Manag Care. 2004 Mar;10(3):229-37.

Saver BG, Doescher MP, Symons JM, Wright GE, Andrilla CH. Racial and ethnic disparities in the purchase of nongroup health insurance: the roles of community and family-level factors. Health Serv Res. 2003 Feb;38(1 Pt 1):211-31.

Fiscella K, Franks P, Doescher MP, Saver BG. Do HMOs affect educational disparities in health care? Ann Fam Med. 2003 Jul-Aug;1(2):90-6.

Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care 2002 Jan; 40(1):52-9.

Doescher MP, Saver BG, Franks, P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000 Nov-Dec;9(10):1156-63.

Doescher MP, Saver BG, Fiscella K, Franks P. Racial/Ethnic Inequities in Continuity and Site of Care: Location, Location, Location. Health Services Research 2000; 36(6), part II:78-89.

Doescher MP, Saver BG. Physicians’ Advice to Quit Smoking: The Glass Remains Half-Empty. Journal of Family Practice 2000; 49(6):543-547.