Faculty Bibliography

BACKGROUND:Telephone consultation is widely used in primary care and can provide an effective and efficient alternative for the in-person visit. Gouverneur Health, a safety-net primary care practice in New York City serving a predominately immigrant population, evaluated the feasibility and physician and patient acceptability of a telephone visit initiative in 2015. MEASURES/METHODS:Patient and physician surveys, and physician focus groups. RESULTS:Though only 85 of 270 scheduled telephone visits (31%) were completed, 84% of patients reported being highly satisfied with their telephone visit. Half of physicians opted to participate in the pilot. Among participating physicians, all reported they were able to communicate adequately and safely care for patients over the telephone. CONCLUSIONS:Participating patients and physicians in a linguistically and culturally diverse urban safety-net primary care clinic were highly satisfied with the use of telephone visits, though completion of the visits was low. Lessons learned from this implementation can be used to expand access and provision of high-quality primary care to other vulnerable populations.

Background: Historically, psychiatrists have been less likely to accept new patients with private insurance than other physicians. Requirements in The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act may have affected psychiatrists' decisions whether to participate in private plan networks. Our objectives are to examine changes in psychiatrists' acceptance of new patients with private insurance in recent years(2011-2014), and to compare patients characteristics and treatments provided by psychiatrists who do and psychiatrists who do not accept new patients with private insurance. Methods: Data for this study come from the National Ambulatory Medical Care Survey(2005-2014), a nationally representative annual cross-sectional survey of physicians providing ambulatory care. We examine responses of psychiatrists who report accepting new patients(N=802). Results: Significantly more psychiatrists were accepting new privately insured patients in the years since MHPAEA(2011-2014) compared to 2010(64.9% versus 50.3%; p=.039), although psychiatrists were still much less likely to accept these patients compared to other physicians (64.9% versus 89.5%; p<.001). Compared to psychiatrists accepting privately insured patients, psychiatrists not accepting privately insured patients had fewer visits with patients with Serious Mental Illness(42.5% versus 53.4%; p=.016). There were no differences in the proportion of visits in which treatment included psychotherapy(48.5% vs 43.7%; p=.518). Conclusions: Fewer psychiatrists accept new privately-insured patients compared to other specialties, although there have been meaningful increases in recent years associated with MHPAEA. Policymakers and other stakeholders should consider additional insurance regulation or other incentives to encourage greater psychiatrist participation in private insurance networks

OBJECTIVES: Out-of-network (OON) care is one area where patients might be more likely to challenge their healthcare bills due to the high out-of-pocket costs and unexpected charges related to emergency care or hospital-affiliated providers. We aimed to determine whether, and under what circumstances, patients negotiate with either insurers or providers when services are billed OON and how often patients that do engage in negotiation are successful. STUDY DESIGN: Internet-based survey. METHODS: We conducted a 2011 Internet survey on OON care on a nationally representative sample of privately insured adults (n = 721). We considered whether patients would be more likely to negotiate OON charges by demographic characteristics and under several scenarios: emergency visits, bills from hospital-affiliated OON providers at in-network hospitals, and balance bills. RESULTS: We found patients negotiated 19% of OON bills, were successful in lowering their costs 56% of the time, and were more likely to be successful negotiating with providers compared with insurers (63% vs 37%; P <.01). Men were more likely than women to be successful in lowering their costs (76% vs 50%; P <.05). OON bills for emergencies, providers at in-network hospitals, and with a balance bill were more likely to be negotiated, although bills from providers at in-network hospitals and with balance bills were less likely to be successfully negotiated. CONCLUSIONS: Patients had low rates of success in negotiating OON bills for emergency care and for OON providers at in-network hospitals. Policy makers aiming to protect patients under these scenarios should consider policies that allow for an easily accessible, formal, and unbiased mediation process.

BACKGROUND: Approximately 40 percent of individuals using out-of-network physicians experience involuntary out-of-network care, leading to unexpected and sometimes burdensome financial charges. Despite its prevalence, research on patient experiences with involuntary out-of-network care is limited. Greater understanding of patient experiences may inform policy solutions to address this issue. OBJECTIVE: To characterize the experiences of patients who encountered involuntary out-of-network physician charges. METHODS: Qualitative study using 26 in-depth telephone interviews with a semi-structured interview guide. Participants were a purposeful sample of privately insured adults from across the United States who experienced involuntary out-of-network care. They were diverse with regard to income level, education, and health status. Recurrent themes were generated using the constant comparison method of data analysis by a multidisciplinary team. RESULTS: Four themes characterize the perspective of individuals who experienced involuntary out-of-network physician charges: (1) responsibilities and mechanisms for determining network participation are not transparent; (2) physician procedures for billing and disclosure of physician out-of-network status are inconsistent; (3) serious illness requiring emergency care or hospitalization precludes ability to choose a physician or confirm network participation; and (4) resources for mediation of involuntary charges once they occur are not available. CONCLUSIONS: Our data reveal that patient education may not be sufficient to reduce the prevalence and financial burden of involuntary out-of-network care. Participants described experiencing involuntary out-of-network health care charges due to system-level failures. As policy makers seek solutions, our findings suggest several potential areas of further consideration such as standardization of processes to disclose that a physician is out-of-network, holding patients harmless not only for out-of-network emergency room care but also for non-elective hospitalization, and designation of a mediator for involuntary charges.

OBJECTIVE: Previous research has shown relatively high use of out-of-network mental health providers, although direct comparisons with rates among general health providers are not available. We aimed to (1) estimate the proportion of privately insured adults using an out-of-network mental health provider in the past 12 months; (2) compare rates of out-of-network mental health provider use with out-of-network general medical use; (3) determine reasons for out-of-network mental health care use. METHODS: A nationally representative sample of privately insured US adults was surveyed using the internet in February 2011. Screener questions identified if the participant had used either a general medical physician or a mental health professional within the past 12 months. Respondents using either type of out-of-network provider completed a 10-minute survey on details of their out-of-network care experiences. RESULTS: Eighteen percent of individuals who used a mental health provider reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider (P<0.01). The most common reasons for choosing an out-of-network mental health provider were the physician was recommended (26.1%), continuity with a previously known provider (23.7%), and the perceived skill of the provider (19.3%). CONCLUSIONS: Out-of-network provider use is more likely in mental health care than general health care. Most respondents chose an out-of-network mental health provider based on perceived provider quality or continuing care with a previously known provider rather than issues related to the availability of an in-network provider, convenient location, or appointment wait time.

OBJECTIVE: To determine the proportion of privately insured adults using an out-of-network physician, the prevalence of involuntary out-of-network use, and whether patients experienced problems with cost transparency using out-of-network physicians. DATA SOURCES: Nationally representative internet panel survey conducted in February 2011. STUDY DESIGN: Screener questions identified a sample of 7,812 individuals in private health insurance plans with provider networks who utilized health services within the prior 12 months. Participants reported details of their inpatient and outpatient contacts with out-of-network physicians. An inpatient out-of-network contact was defined as involuntary if: (1) it was due to a medical emergency; (2) the physician's out-of-network status was unknown at the time of the contact; or (3) an attempt was made to find an in-network physician in the hospital but none was available. Outpatient contacts were only defined as involuntary if the physician's out-of-network status was unknown at the time of the contact. PRINCIPAL FINDINGS: Eight percent of respondents used an out-of-network physician. Approximately 40 percent of individuals using out-of-network physicians experienced involuntary out-of-network care. Among out-of-network physician contacts, 58 percent of inpatient contacts and 15 percent of outpatient contacts were involuntary. The majority of inpatient involuntary contacts were due to medical emergencies (68 percent). In an additional 31 percent, the physician's out-of-network status was unknown at the time of the contact. Half (52 percent) of individuals using out-of-network services experienced at least one contact with an out-of-network physician where cost was not transparent at the time of care. CONCLUSIONS: The frequency of involuntary out-of-network care is not inconsequential. Policy interventions can increase receipt of cost information prior to using out-of-network physician services, but they may be less helpful when patients have constrained physician choice due to emergent problems or limited in-hospital physician networks.