Publication Type: Abstract
Abstract: Rationale: In analyses of physician behavior, how physicians allocate their time plays a central role. The time a physician spends during a visit is often put forward as the example of the “effort” the physician puts into a visit. Effort (time) is costly to the physician and the main input into the quality of a visit. In spite of its central importance, little is known about what determines how much time physicians spend with patients. While observable by the patient, time is regarded as not contractible. Empirical examination of how physicians spent clinic time is scarce.

Objectives: To develop a theoretical model of physician time allocation building on Becker’s theory of the allocation of time and to test the model, with videotaped behavior of physicians and patients. We study how time is allocated during a visit across the problems patients bring to the attention of their doctors.

Methodology: Direct observation of videotapes of 390 routine office visits that took place between 1998 and 2000 from three primary care practice sites in the Midwest and Southwestern regions of the U.S and surveys of participating patients and physicians inform the study. We break visits into “topics,” a natural unit of clinical decision making, and document how clinical time is spent. Using a mixed-level duration model, we analyze the effects of the nature of topics, the dynamics of time, and characteristics of patient, physician, and physician’s practice setting on how clinic time is spent.

Results. The average visit in our sample lasted 17.4 minutes and covered 6.5 topics. Patient and physician each spoke, on average, less than 1 minute per topic. Out of over 2,500 topics examined, more than 70% of the topics addressed biomedical issues. Psychosocial topics were 12%, and personal habits, 7%. Less than 4% of the topics involved mental health concerns. What happens in clinic is influenced by the contents of the discourse, physician practice setting characteristics, patient’s gender and race, and physician’s gender. When a topic was introduced during the visit and how much time has already been spent on it are also significant determinants of time allocation.

Conclusions. Physicians are likely to reduce time spent on a topic if it is raised later during the visit when the opportunity cost of physician time is higher. A large number of topics are discussed during a primary care visit, with little time spent on each topic. Efforts to improve the quality of primary care need to recognize the time pressure on both patients and physicians, and the time costs of improving information exchange.

Publication Type: Conference Paper/Unpublished Manuscript
Abstract: Abstract
Low-income and racial-ethnic minority families of children with disabilities face substantial obstacles to adequate care provision resulting in potential compromises to their children’s well-being. Low-income job conditions in a service sector economy, diminished public resources, and increased privatization of care force parents to make anguishing decisions as they negotiate the often conflicting obligations of wage work and care work. These decisions have consequences for the financial well-being of the family and the health and general well-being of the children. Minority and immigrant families face particular obstacles to services due to language and cultural barriers.
Qualitative analyses of work, care, and services in families caring for children with disabilities tend not to be cross-cultural and comparative; most of the samples include exclusively white respondents. In this project, I have sought to fill some of this gap by collecting data through in-depth interviews with single- and two-parent white and Latino families in order to explore comparatively the issues they face, the strategies they use to negotiate the competing demands in their lives, and the potential differences between social/emotional/behavioral disorders and motor or other kinds of physical disabilities, or differences across race, immigration status, employment and income, and family structure.

Publication Type: Conference Paper/Unpublished Manuscript
Abstract: Contemporary medical decision-making has been characterized as a "tug of war" between patients, who are reportedly making more demands for medical interventions such as diagnostic tests and prescription drugs, and physicians, who are encouraged to partner with patients and satisfy them while simultaneously keeping medical costs down. Understanding this struggle requires attention to the interactional strategies whereby patients indicate what they desire, how physicians respond, and how the participants apply and react to pressure for particular outcomes. This investigation is a single case analysis of a primary care visit, recorded in a General Internal Medicine outpatient clinic. Using Conversation Analysis, it reveals how the patient exerts subtle but persistent pressure for a diagnostic test and how the physician responds to her persuasive efforts.

Publication Type: Abstract
Abstract: Background: Depression screening is being considered as a future “pay for performance” measure for primary care practices. However, primary care practices do not receive reimbursement by managed behavioral health organizations for depression care. We report on one aspect of a pilot program to improve depression care in academic primary care clinics in which an insurance plan and a partner managed behavioral health organization provided reimbursement to primary care clinics for depression care of their dually insured patients by credentialed providers. This strategy meets one of the recommendations from the recent Institute of Medicine report on mental health. Credentialing involved training in depression care best practices, and payments were received by the overall clinic. Only faculty members could be credentialed.

Methods: Depression screening activity was recorded at four academic primary care clinics from 10/1/2002 to 8/30/2005. Screening activity was analyzed by provider. Additional analyses will be presented at the conference.

Results: Among the 37,872 patients seen during the study period, only 5471 were screened. Credentialed providers conducted 70% of overall screening. After excluding screening by non-eligible providers (7% of overall screening), credentialed providers conducted 86% of all screening. Few credentialed providers submitted claims for reimbursement. In the clinic providing the majority of submitted claims, only 3 of 12 credentialed providers submitted any claims even though an additional 4 providers were eligible to submit claims. Those providers submitting claims conducted 50% of screening by credentialed providers, while those eligible providers who did not submit claims conducted 37% of screening by credentialed providers.

Conclusions: Our findings suggest that financial incentives can increase depression screening activity. However, financial incentive use by credentialed providers appears low. This may be either due to lack of direct incentives, difficulty navigating through the reimbursement process, or due to low prevalence of patients meeting the criteria for claims.

Publication Type: Conference Paper/Unpublished Manuscript
Abstract: Much as been written on the effect of early maternal employment on children’s well-being. However, few have identified the pathways through which employment should exert its influence on children. This paper uses children’s time diary data from the Panel Study of Income Dynamics and its Child Development Supplement to obtain direct measures of both the quantity and intensity of time children spend with their mothers, as well as information on the quality of parenting behavior and maternal employment. The study attempts to examine three key questions: (1) Do children who receive more maternal care and/or more intense maternal care during early childhood have higher cognitive ability than those children who received less quantity/intensity of maternal care? (2) Is early maternal employment associated with negative child cognitive outcomes, controlling for the quantity and intensity of maternal time investments in childcare? (3) To what extent does the quality of early parenting influence children’s later cognitive outcomes? The preliminary results suggest that it is not the amount of time children spend with mothers nor maternal employment but the quality of early parental care that matters for children’s later development. Family home environment and positive parenting (e.g. positive mother-child relationships measured by maternal warmth, emotional encouragement, and cognitive stimulation) have the strongest and most consistent relationship with children’s cognitive test scores.