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Objectives: This study examined the decisions of small group employees to enroll in prepaid plans offered through Healthcare Group of Arizona (HCGA), a state-sponsored and state-administered voluntary insurance program., Methods: The study population included 653 potential employee enrollees who were offered the option of two health plans between January 1993 and June 1993, with 447 enrolling in one of the two plans. Data sources included two telephone surveys, HCGA administrative files, and enrollment application forms., Results: The estimates of adjusted price elasticity were in the range of -0.12 to -0.24 for employees with prior insurance and were in the range of -0.42 to -0.51 for employees without prior insurance. The likelihood of enrolling in HCGA increased with log(income) and decreased with log(income) squared. The average income elasticity across income groups was 0.12., Conclusions: The results indicate that small group employees without prior insurance were more sensitive to the price of health insurance than those with prior insurance. Healthcare Group of Arizona health plans may have been viewed as inferior goods by high income employees possible because of their association with the Medicaid program.

The role of specialist versus generalist providers regularly surfaces in health-care reform debates about costs and quality of care. By changing incentives to seek and deliver care, different payments systems can affect both the probability of initial specialty care and the duration of this patient-provider relationship. The authors compare provider selection (psychiatrist, nonphysician mental-health specialist, general medical provider) and duration of this relationship among depressed patients in prepaid and fee-for-service plans. Regarding initial care, depressed patients in prepaid plans are significantly less likely to see a psychiatrist and more likely to see a nonphysician mental-health specialist than patients in fee-for-service plans. Although the mix of providers differs, patient demographic and clinical characteristics have similar effects on specialty in both payment systems, ie, there are no differences in who gets specialty care by type of payment, but in how many get specialty care. The average duration of a patient-provider relationship is significantly shorter in prepaid plans. Durations are significantly shorter for patients of both psychiatrists and general medical providers in prepaid plans, but do not differ by payments type for nonphysician therapists. In both payments systems, patients of nonphysician providers end the relationship sooner than patients of psychiatrists or general medical providers. Although the authors find provider switching to be associated significantly with discontinuing antidepressant medication, there is no significant direct effect on patient health outcomes.

This study compares severity of depression for patients of general medical clinicians, psychiatrists, and nonphysician therapists receiving prepaid or fee-for-service care. Cross-sectional severity comparisons were conducted among 715 outpatients with current major depression or dysthymia, by independent assessment. Severity was assessed by counts of current and lifetime depressive symptoms, prognostic and treatment response indicators, and global measures of psychological and physical sickness. Patients of psychiatrists were the most psychologically ill, patients of nonphysician therapists were intermediate, and general medical patients were least ill; but even in the general medical sector, depression severity was at least ill; but even in the general medical sector, depression severity was at least moderate. No differences in global physical sickness by specialty remained after demographic adjustment. General medical patients whose depression had been detected were only slightly sicker than undetected cases. Type of payment was not consistently related to either psychological or physical aspects of sickness, and payment did not interact with specialty. Mental health specialists, especially psychiatrists, encountered more severely depressed patients, but patients in all sectors were sick enough to warrant treatment. Even undetected patients in the general medical sector were relatively sick, raising questions about gatekeeper policies. There was no evidence of a greater severity gradient by specialty in prepaid care. Because payment was unrelated to severity, treatment implications are similar under prepaid and fee-for-service care. Implications for clinical practice, public policy, and outcomes research design are discussed.

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

The incidence of reoperation and mortality after prostatectomy was studied in 8,219 men who underwent surgical treatment for benign prostatic hypertrophy between 1976 and 1987 while they were members of the Kaiser Permanente Medical Care Program, Northern California Region. The vast majority (94.5%) received transurethral prostatectomy (TURP). The cumulative 8-year probability of a second prostatectomy was 7.6% after TURP and 2.1% after open prostatectomy. The risk of mortality associated with transurethral prostatectomy relative to open prostatectomy was 1.6 (95% confidence interval 1.2, 2.1) 8 years postsurgery. The increased risk of mortality associated with transurethral prostatectomy was most prominent during the first 5 years postsurgery (relative risk 1.8, 95% confidence interval 1.3, 2.5) and declined to 1.1 (95% confidence interval 0.8, 1.6) for deaths occurring after the first 5 years. The finding of an increased risk of mortality associated with transurethral prostatectomy is consistent with other studies and is unexplained.