type="main" xml:id="irel12127-abs-0001">

Employer-provided health insurance may restrict job mobility, resulting in “job lock.” Previous research on job lock finds mixed results using several methodologies. We take a new approach to examine job lock by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure for identifying age in months from matched monthly Current Population Survey data and a relatively unexplored administration measure of job mobility, we compare job mobility among male workers in the months just prior to turning age 65 to job mobility in the months just after turning age 65. We find no evidence that job mobility increases at the age 65 threshold when Medicare eligibility starts. We also do not find evidence that other factors such as retirement, reduction in hours worked, Social Security eligibility, pension eligibility, and sample changes confound the results on job mobility in the month individuals turn 65.

Objectives

To describe patterns of care for primary open-angle glaucoma (POAG) and assess conformance with the American Academy of Ophthalmology's Preferred Practice Pattern (PPP).

Methods

We obtained administrative, survey, and eye care records data on 395 working-age patients with POAG enrolled in 6 managed care plans between 1997 and 1999. We assessed processes of care at the initial and follow-up visits, control of intraocular pressure (IOP), intervals between visits and visual field tests, and adjustments in therapy.

Results

We found high rates of performance on most recommended processes during initial evaluations, although only 53% of patients received an optic nerve head photograph or drawing and only 1% had a target IOP level documented. Recommended processes were performed at 80% to 97% of follow-up visits. Using loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma. Intervals between visits and visual field tests were generally consistent with PPP recommendations. Adjustments in therapy were more likely with worse control of IOP, although adjustments occurred in only half of visits where the IOP was 30 mm Hg or higher.

Conclusions

Our study suggests that, in many respects, patients with POAG are receiving care that is consistent with the PPP. However, care is falling short on several key aspects, and POAG may be undertreated relative to standards for IOP control established in recent clinical trials.

OBJECTIVES: To describe the variation in practice structure, financial arrangements, and utilization and quality management systems for eye care practices with managed care contracts. STUDY DESIGN: Cross-sectional survey of 88 group and 56 solo eye care practices that contract with 6 health plans affiliated with a national managed care organization. The survey contained modules on practice structure, financial arrangements, utilization management, and quality management. The survey response rate was 85%. RESULTS: Group practices with both ophthalmologists and optometrists were triple the size of ophthalmology-only groups, and 5 times the size of optometry-only groups. Fee-for-service payments were the primary source of group practice revenues, although 60% of groups derived some revenues from capitation payments. Group practices paid their physicians almost exclusively with fee-for-service payments or salary arrangements, with minimal capitation at the individual level. Almost no practices used both capitation and bonuses to compensate providers. Most practices received practice profiles and three fourths were subject to utilization review, which mainly consisted of preauthorization for procedures, tests, or referrals. Nearly all practices used clinical guidelines, protocols, or pathways in managing patients with diabetic retinopathy or glaucoma. Further, nearly all group practices used computerized information systems to assist in delivering care, and most had provider education programs. CONCLUSIONS: Managed care has affected the way eye care providers organize, finance, and deliver healthcare. In general, our findings paint an optimistic picture of eye care practices that contract with managed care organizations. Few practices bear substantial financial risk, and nearly all practices use quality management tools that could help to improve the quality of care.

BACKGROUND:The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential. OBJECTIVE:To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). SUBJECTS/STUDY SETTING: A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices. STUDY DESIGN:We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction. PRINCIPAL FINDINGS:Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction. CONCLUSIONS:Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction.