Objective: To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued.Design: Prospective cohort study in which women were followed for 18 months.Setting: Eight infertility practices.Patient(s): Three hundred ninety-eight women recruited from infertility practices.Intervention(s): Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used.Main Outcome Measure(s): Per-person and per-successful-outcome costs.Result(s): Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher-$61,377 for IVF, for example-reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not.Conclusion(s): Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment. (Fertil Steril (R) 2011; 95: 915-21. (C) 2011 by American Society for Reproductive Medicine.)

Objective: To determine the effect of income, education, and race on the use and outcomes of infertility care.Design: Prospective cohort.Setting: Eight community and academic infertility practices.Patient(s): Three hundred ninety-one women presenting for an infertility evaluation.Intervention(s): Face-to-face and telephone interviews and questionnaires.Main Outcome Measure(s): Use of infertility services and odds of pregnancy. Linear and logistic regression used to assess relationship between racial and socioeconomic characteristics, use of infertility services, and infertility outcomes.Result(s): After adjustment for age and demographic and fertility characteristics, college-educated couples (beta = $5,786) and households earning $100,000-$150,000 (beta = $6,465) and >=$150,000 (beta = $8,602) spent significantly more on infertility care than their non-college-educated, lower-income counterparts. Higher income and college-educated couples were much more likely to use more cycles of higher-intensity fertility treatment. The increased cost of infertility care was primarily explained by these differences in number and type of infertility treatment. Even after adjustment for these factors and total amount spent on fertility care, having a college degree was associated with persistently higher odds of achieving a pregnancy (OR = 1.9).Conclusion(s): Education and household income were independently associated with the amount of money spent on fertility care. This relationship was primarily explained by types and intensity of infertility treatments used. Having at least a college degree was independently associated with improved odds of pregnancy. (Fertil Steril (R) 2011;96:95-101. (C)2011 by American Society for Reproductive Medicine.)

STUDY OBJECTIVE:The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits.METHODS:Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance.RESULTS:The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74).CONCLUSION:The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.

OBJECTIVE: Describe costs of infertility medical treatment over an 18-month period by type of treatment and infertility etiology. Previous estimates have focused solely on costs of in vitro fertilization (IVF); we include all infertility-related treatment costs. DESIGN: Prospective cohort of 437 women followed for 18 months. MATERIALS AND METHODS: Women and their husbands/male partners were recruited after initial consultation at reproductive endocrinology practices in Northern California. Information on medications, diagnostic testing, and therapeutic interventions by the couple were collected from medical records. Costs were calculated based on resource use. Uniform costs based on 2005 national data were assigned to each service unit to standardize estimates across practices and over time. Infertility etiology (female only, male only, combined male and female) was determined from medical records and interviews. Bivariate analyses compared costs among treatment paths (no treatment, medication only, IUI with or without medication, IUI followed by IVF, and IVF only) and infertility etiology. Multiple regression analysis including female age, marital status, education, household income, race, and number of treatment cycles, as well as treatment path and infertility etiology, identified factors independently associated with costs. RESULTS: Cost data were available for 390 couples. Almost one third (31%, n=120) did not pursue any cycle-based medical treatment. The overall mean 18-month infertility cost was $14,480. Means for each treatment path are below.Table 1Costs by Treatment PathNo treatmentMeds onlyIUI onlyIUI with medsIUI-IVFIVF onlyOtherN (%)120 (31%)9 (2%)3 (1%)96 (25%)93 (24%)63 (16%)6 (2%)Estimated costs$935$2,247$2,181$9,784$26,297$31,813$19,957 Open table in a new tab Isolated male infertility was associated with the highest costs.Table 2Costs by Infertility EtiologyFemale onlyMale onlyFemale & malen (%)220 (56%)26 (7%)135 (35%)Estimated costs$13,709$20,485$15,090 Open table in a new tab In the multivariate model, treatment path was significantly associated with costs, but etiology was not independently associated with costs. CONCLUSIONS: Isolated male factor infertility was associated with the highest costs, but this effect was not significant after adjustment for type of treatments used and number of treatment cycles. Much of the cost of infertility treatment is driven by IVF and related treatments, but substantial costs are also associated with IUI plus medications.

STUDY OBJECTIVE:We identify frequent users of the emergency department (ED) and determine the characteristics of these patients.METHODS:Using the 2000 to 2001 population-based, nationally representative Community Tracking Study Household Survey, we determined the number of adults (aged 18 and older) making 1 to 7 or more ED visits and the number of visits for which they accounted. Based on the distribution of visits, we established a definition for frequent user of 4 or more visits. Multivariate analysis assessed the likelihood that individuals with specific characteristics used the ED more frequently.RESULTS:An estimated 45.2 million adults had 1 or more ED visits. Overall, 92% of adult users made 3 or fewer visits, accounting for 72% of all adult ED visits; the 8% of users with 4 or more visits were responsible for 28% of adult ED visits. Most frequent users had health insurance (84%) and a usual source of care (81%). Characteristics independently associated with frequent use included poor physical health (odds ratio [OR] 2.54; 95% confidence interval [CI] 2.08 to 3.10), poor mental health (OR 1.70; 95% CI 1.42 to 2.02), greater than or equal to 5 outpatient visits annually (OR 3.02; 95% CI 1.94 to 4.71), and family income below the poverty threshold (OR 2.36; 95% CI 1.70 to 3.28). Uninsured individuals were more likely to report frequent use, but this result was only marginally significant (OR 2.38; 95% CI 0.99 to 5.74). Individuals who lacked a usual source of care were actually less likely to be frequent users.CONCLUSION:The majority of adults who use the ED frequently have insurance and a usual source of care but are more likely than less frequent users to be in poor health and require medical attention. Additional support systems and better access to alternative sites of care would have the benefit of improving the health of these individuals and may help to reduce ED use.

Study objective: We identify frequent users of the emergency department (ED) and determine the characteristics of these patients. Methods: Using the 2000 to 2001 population-based, nationally representative Community Tracking Study Household Survey, we determined the number of adults (aged 18 and older) making 1 to 7 or more ED visits and the number of visits for which they accounted. Based on the distribution of visits, we established a definition for frequent user of 4 or more visits. Multivariate analysis assessed the likelihood that individuals with specific characteristics used the ED more frequently. Results: An estimated 45.2 million adults had 1 or more ED visits. Overall, 92% of adult users made 3 or fewer visits, accounting for 72% of all adult ED visits; the 8% of users with 4 or more visits were responsible for 28% of adult ED visits. Most frequent users had health insurance (84%) and a usual source of care (81%). Characteristics independently associated with frequent use included poor physical health (odds ratio [OR] 2.54; 95% confidence interval [Cl] 2.08 to 3.10), poor mental health (OR 1.70; 95% Cl 1.42 to 2.02), greater than or equal to 5 outpatient visits annually (OR 3.02; 95% Cl 1.94 to 4.71), and family income below the poverty threshold (OR 2.36; 95% CI 1.70 to 3.28). Uninsured individuals were more likely to report frequent use, but this result was only marginally significant (OR 2.38; 95% Cl 0.99 to 5.74). Individuals who lacked a usual source of care were actually less likely to be frequent users. Conclusion: The majority of adults who use the ED frequently have insurance and a usual source of care but are more likely than less frequent users to be in poor health and require medical attention. Additional support systems and better access to alternative sites of care would have the benefit of improving the health of these individuals and may help to reduce ED use.

OBJECTIVE:This study was undertaken to compare resource use outcomes for participants in the Medicine or Surgery (Ms) randomized trial. STUDY DESIGN:In a randomized controlled trial, we compared resources used during a 24-month follow-up period by women with abnormal uterine bleeding who were randomly assigned to either expanded medical treatment or hysterectomy. RESULTS:Women randomly assigned to hysterectomy used significantly more resources (medicine = $4479, hysterectomy = $6777; P = .03), with almost all the difference caused by the hysterectomy procedure. Fifty-three percent of women randomly assigned to medicine had a hysterectomy during the follow-up period; women who were able to continue on medical therapy had mean total resource use of $2595 compared with $6128 for medicine patients who eventually had surgery. CONCLUSION:For women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate, compared with expanded medical treatment, hysterectomy increases resource use significantly and results in better clinical and 6-month quality-of-life outcomes.

The economic costs and benefits to a hospital of having an emergency department (ED) have been long debated. Although EDs are sometimes thought to be magnets for indigent patients, and thus money-losers, the typical ED patient has insurance and indigent patients do not constitute a disproportionate share of ED patients.1Weber E.J. Showstack J.A. Hunt K.A. et al.Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study.Ann Emerg Med. 2005; 45: 4-12Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar An ED's economic worth to a hospital is also related to the number and types of patients admitted to the hospital through the ED, an increasingly important source of admissions at many hospitals. Because EDs need to maintain a relatively high level of staffing to meet surges in demand, there is the interesting question (at least to health economists) of whether caring for low-acuity patients in “down” times may provide, at the margin, additional revenue for the ED and hospital at a relatively low additional cost. Little information is available, however, about how much it costs to care for the approximately 30% of patients in EDs who have less than urgent or emergent conditions.2McCaig L.F. Burt C.W. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary.Adv Data. 2004; : 1-36PubMed Google Scholar In an article published in 1997, Williams3Williams R.M. The costs of visits to emergency departments.N Engl J Med. 1996; 334: 642-646Crossref PubMed Scopus (278) Google Scholar concluded that, “The true costs of nonurgent care in the ED are relatively low.” Studying the same question, but using very different methods, in this issue of Annals Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar draw a different conclusion, that the marginal cost of treating an additional case is similar to the average cost of all cases and therefore there are no “economies of scale” in EDs. Why would 2 studies by sophisticated researchers draw essentially opposite conclusions? The devil is in the details. Measuring the costs of a visit to an ED can be quite complex. In economic terms, hospitals are multiproduct or multiservice organizations. Ideally, a hospital's charge for a service would be related to the actual economic cost of producing that service. Such a calculation is relatively straightforward in a single-service organization. In a multiservice organization, however, it can be difficult to account for, and allocate among specific products and services, common costs that support several services and departments.5Helmi MA, Tanju MN. Activity-based costing may reduce cost, aid planning. Information system management helps hospitals' financial management. Healthcare Financial Management. November, 1991. Available at: http://www.findarticles.com/p/articles/mi_m3257/is_n11_v45/ai_11595903. Accessed March 7, 2005.Google Scholar In hospitals, examples of common costs include housekeeping, information systems, material services, facility maintenance, security, and registration and admissions departments. Although there are standard accounting rules that define how a hospital should allocate common costs, substantial discretion is allowed within the rules. The result is that 2 very similar hospitals may choose relatively different, but internally logical and acceptable, methods of allocating common costs between the daily bed charge and ancillary services and among different ancillary and direct service departments. An additional complexity is the need for hospitals to subsidize certain types of discretionary services, such as social work, for which payment may not be received and/or be adequate to cover the true economic costs of producing those services. There is also the related issue of the allocation of fixed and variable costs. Fixed costs are (relatively) independent of patient volume (eg, the costs of facilities and equipment); variable costs are associated with the volume of services (eg, the cost of supplies). There are also what are sometimes called “semivariable costs,” which are relatively fixed but may vary according to specific patterns of care or other circumstances. Among the most prominent of semivariable costs in a hospital are nursing services, which may vary due to a variety of factors including patient care needs, availability of nurses, and legal staffing requirements. Within hospitals, and especially in the ED with its variable census and acuity of patients, staffing patterns are a key to affecting costs, because staff constitute a significant portion of the costs of providing ED services. The ability and willingness of administrators and their nursing staff to adjust staffing patterns to day-to-day and within-day circumstances may be a key determinant of the financial health of individual EDs. Thus, determining the true economic costs of providing specific inpatient and outpatient services is less than straightforward. While comparing costs among departments within a specific hospital can be useful to administrators, differences in cost allocation methods and a paucity of good data make many health economists wary of comparing the costs of specific departments and services across multiple hospitals. Studying actual patient records, as was done by Williams,3Williams R.M. The costs of visits to emergency departments.N Engl J Med. 1996; 334: 642-646Crossref PubMed Scopus (278) Google Scholar rather than aggregate hospital cost data, allows a much more sophisticated and refined analysis of the true costs of caring for patients of varying levels of acuity. Williams examined the individual records of 24,010 ED visits at 6 community hospitals in Michigan between 1991 and 1993 and measured resource use according to standardized relative values assigned to the actual services received by individual patients. In contrast, Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar estimated the average cost of a visit to EDs in California during the period 1990 to 1998 by dividing the total yearly costs for emergency services as reported by each hospital to the state of California by the total number of “outpatient ED visits” at that hospital. Essentially, what Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar found is a lack of correlation between the estimated average cost per ED visit at a hospital and the total number of ED visits; in other words, adjusted average costs were about the same at hospitals with a low volume of ED visits compared with hospitals that had a higher number of ED visits. Although Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar included a variety of adjustments for both hospital and system level characteristics, the departmental costs reported to the state were taken as a given, that is, no attempt was made to adjust for different hospital-specific cost-accounting techniques or cost-allocation practices. Perhaps more importantly, their adjustment for severity of illness was very indirect (measuring the overall severity at the study hospital), and there was no adjustment at all for the acuity of patients admitted to specific EDs. In fact, the Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar analysis basically assumes that an ED patient who was not admitted to the hospital did not have an urgent condition (eg, that patients with conditions such as acute asthma episodes, lacerations, or dehydration who were discharged home from the ED could have received adequate care in an outpatient department), a clearly incorrect assumption. Today's EDs differ substantially from those in the 1990s studied by both Williams3Williams R.M. The costs of visits to emergency departments.N Engl J Med. 1996; 334: 642-646Crossref PubMed Scopus (278) Google Scholar and Bamezai et al4Bamezai A. Melnick G.A. Nawathe A. The cost of an ED visit and its relationship to ED volume.Ann Emerg Med. 2005; 45: 483-490Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar in ways that may have a substantial effect on costs of care. For example, the marginal cost of an ED visit depends in part on the amount of unused capacity available in an ED. Today, many EDs are crowded to the point of having to add “unofficial” beds, often in the ED's hallway, a condition much less common in the 1990s. A contributing factor is increasing hospital occupancy rates, especially in intensive and critical care units, which tend to lengthen the average time a patient spends in the ED and therefore lessen the availability of ED beds. The relationship between EDs and ambulatory care has also changed considerably in recent years. A variety of forces has coalesced to increase the use of EDs by patients who might otherwise have used clinics and other ambulatory care settings. These forces include (1) the increasing complexity of care that requires sophisticated diagnostic tests and treatment modalities not readily available in an office setting; (2) the open-door policies of EDs, reinforced by legal requirements6American College of Emergency Physicians. Fact Sheets: EMTALA. Available at: http://www.acep.org/1,393,0.html. Accessed March 7, 2005.Google Scholar to screen any patient “that comes to the ED,” irrespective of the patient's ability to pay; (3) the general dissatisfaction of patients with the use of “gatekeepers,”7Eisenberg J.M. The internist as gatekeeper. Preparing the general internist for a new role.Ann Intern Med. 1985; 102: 537-543Crossref PubMed Scopus (76) Google Scholar which has contributed to the decision by many managed care plans to loosen their restrictions on the use of EDs; (4) malpractice considerations, which lead to referrals to EDs by risk-averse physicians who otherwise might have recommended that the patient make an office appointment; (5) convenience for both patients and ambulatory physicians; and, (6) the general disarray in the primary care system.8Moore G. Showstack J. Primary care medicine in crisis: toward reconstruction and renewal.Ann Intern Med. 2003; 138: 244-247Crossref PubMed Scopus (93) Google Scholar An important lesson is that researchers need to get inside the “black box” of hospital cost accounting. Understanding what is happening inside one hospital, let alone comparing costs among hospitals, requires collection of patient-level cost and clinical data and sophisticated analyses to develop accurate estimates of the true economic costs of providing care. Ultimately, however, decisions about the role of EDs in the provision of nonurgent care may depend more on the organization and effectiveness of our ambulatory care system and on patient preferences than on empiric data about the marginal costs of an ED visit. The Cost of an Emergency Department Visit and Its Relationship to Emergency Department VolumeAnnals of Emergency MedicineVol. 45Issue 5PreviewThis article addresses 2 questions: (1) to what extent do emergency departments (EDs) exhibit economies of scale; and (2) to what extent do publicly available accounting data understate the marginal cost of an outpatient ED visit? Understanding the appropriate role for EDs in the overall health care system is crucially dependent on answers to these questions. The literature on these issues is sparse and somewhat dated and fails to differentiate between trauma and nontrauma hospitals. We believe a careful review of these questions is necessary because several changes (greater managed care penetration, increased price competition, cost of compliance with Emergency Medical Treatment and Active Labor Act regulations, and so on) may have significantly altered ED economics in recent years. Full-Text PDF

BACKGROUND:Previous reports have suggested that hospital resource utilization for revision total hip arthroplasty is substantially higher than that for primary total hip arthroplasty. However, current United States Medicare hospital-reimbursement policy does not distinguish between the two procedures. The purpose of this study was to compare primary and revision total hip arthroplasties with regard to actual hospital resource utilization and to identify clinical and demographic factors that are predictive of higher resource utilization associated with these procedures. METHODS:We evaluated the clinical, demographic, and economic data associated with 491 consecutive unilateral primary or revision total hip arthroplasties performed by two surgeons at a single institution between January 2000 and December 2002. The distributions of various demographic, clinical, and utilization characteristics were compared between the two types of arthroplasty procedures, and multivariable linear regression techniques were used to determine independent patient characteristics that were predictive of higher costs for both the primary and the revision procedures. RESULTS:The mean total hospital cost was $31,341 for the revision procedures compared with $24,170 for the primary procedures (p < 0.0001). The mean operative time was 41% longer for the revisions than for the primary procedures (4.5 hours compared with 3.2 hours, p < 0.0001), the mean estimated blood loss was 160% higher (1348 mL compared with 518 mL, p < 0.0001), the mean complication rate was 32% higher (29% compared with 22%, p = 0.072), and the mean length of the hospital stay was 16% longer (6.5 days compared with 5.6 days, p = 0.0005). A higher severity-of-illness score (a measure of preoperative medical health) was predictive of higher resource utilization for both primary and revision arthroplasty even after adjustment for other factors. Preoperative femoral and ace-tabular bone loss and a diagnosis of periprosthetic fracture were predictive of higher resource utilization associated with revision procedures. CONCLUSIONS:At one institution, hospital resource utilization for revision total hip arthroplasty was found to be significantly higher than that for primary arthroplasty. This information is not reflected by current United States Medicare hospital reimbursement, which is the same for all lower-extremity arthroplasty procedures, regardless of the diagnosis, the complexity of the procedure, or the patient's baseline medical health. If these findings are generalizable to other institutions, appropriate reimbursement formulas should be developed to accurately reflect the true costs of caring for patients with a failed total hip arthroplasty.

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Purpose Public hospitals and academic medical centers may admit more poorly insured transfer patients than do other institutions. The authors investigated the relationship of patient insurance status, hospital ownership, and hospital teaching status with interhospital transfers in California. Method In 2003, data were derived from the hospital discharge abstract database for the year 2000 from the California Office of Statewide Health Planning and Development. Hospitals were categorized by ownership and teaching status; patients were categorized as being “good” or “poor” payers depending on the level of expected insurance reimbursement. Descriptive and multivariate analyses were used to assess the number of poor payer transfers admitted by each hospital group. Results In 2000, there were 58,509 transfer and 2,320,479 direct admissions. All hospital groups admitted a higher percentage of good payer than poor payer transfer patients (85% vs. 15% respectively for all groups combined). Adjusted for total number of admissions and teaching status, the number of poor payer transfer patients admitted to county-owned and University of California hospitals was significantly higher than the statewide average (both p values < .001), while the number admitted to independent teaching hospitals was significantly lower than the statewide average (p < .001). The number of poor payer transfer patients admitted to independent teaching hospitals more closely resembled that of for-profit hospitals than that of University of California teaching hospitals. Conclusions In 2000, the likelihood of a hospital admitting a transfer patient appears to have been affected by both the patient’s insurance status and the hospital’s ownership. In general, good payer patients were more likely to be transferred than were poor payer patients, with poor payer transfer patients more likely to be admitted to publicly owned hospitals.

STUDY OBJECTIVE:We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit.METHODS:This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year.RESULTS:Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use.CONCLUSION:ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

Primary care is in crisis. Despite its proud history and theoretical advantages, the field has failed to hold its own among medical specialties. While the rest of medicine promises technology and sophistication, the basic model of primary care has changed little over the past half-century. Why has the transition from general practice to today's primary care been so difficult? Many of the causes of this struggle may lie within primary care itself, ranging from failure to articulate to the public (and insurers and policymakers) what value it, and it alone, can offer, to taking on an ever-broadening set of roles and responsibilities while all too often falling short of its promises. Perhaps most important, in the emerging health care system, the lack of a discrete definition of primary care has allowed managed care organizations and payers, among others, to define the role of primary care to suit their own interests. In response to a changing marketplace, political uncertainty, and shifting consumer expectations, primary care will need to reconstruct itself. The reconstruction will not be easy. Nevertheless, a process should begin that moves the field in the right direction. Building on its unique abilities, primary care can emerge as a redefined product that is attractive to patients, payers, and primary care practitioners alike.

Three decades ago, a renaissance helped create the foundations of primary care as we know it today. In recent years, however, new challenges have confronted primary care. We believe that the current challenges can be overcome and may, in fact, present an opportunity for a new renaissance of primary care to address the needs of our population. In this paper, we suggest seven core principles and a set of actions that will support a renaissance in, and a positive future for, primary care. The seven principles are 1) Health care must be organized to serve the needs of patients; 2) the goal of primary care systems should be the delivery of the highest-quality care as documented by measurable outcomes; 3) information and information systems are the backbone of the primary care process; 4) current health care systems must be reconstructed; 5) the health care financing system must support excellent primary care practice; 6) primary care education must be revitalized, with an emphasis on new delivery models and training in sites that deliver excellent primary care; and 7) the value of primary care practice must be continually improved, documented, and communicated. At the start of the 21st century, a vital, patient-centered primary care system has much to offer a rapidly changing population with increasingly diverse needs and expectations. If we keep the needs of persons and patients clearly in sight and design systems to meet those needs, primary care will thrive and our patients will be well served.

In response to concerns about the future of primary care, the Robert Wood Johnson Foundation sponsored a meeting in October 2001 in Glen Cove, New York, of 45 leaders in primary care and other health sectors. The purpose was to discuss the current and future challenges to primary care and to develop new and innovative ideas about how primary care might meet the needs of our current and future population. The premise of the meeting was that primary care is at a crossroads, which could lead to a new renaissance or a continued decline. Principles and ideas need to be identified to construct new primary care systems. As background for the meeting, 15 papers were written by experts in health care policy and primary care. included in this supplement are revised versions of 4 of these papers, which present an overview of the current crisis, the implications of patients' views of primary care, the Chronic illness Model as one possible solution, and a prediction of a tiering in the way primary care is delivered in the future. The final paper presents ideas and suggestions, based in part on the discussions at the meeting, about opportunities to move toward another renaissance of primary care.