tively unusual, making up 17 percent of the estimated 717.6 million ambulatory care visits made by adults in 1998.

  • Prevention services are more likely to be provided when patients see their primary care physician, but less than half (44 percent) of ambulatory care visits made by adults in 1998 were to a patient’s primary care provider.

  • Counseling about risk behaviors such as smoking cessation or describing the pros and cons of screening procedures can be time-consuming, yet most adult patients (63 percent) spend less than 15 minutes with the physician during their ambulatory care visits.

  • During ambulatory care visits, adult patients generally spend time with physicians, but they also see other providers, although they see them less often. Patients see, for example, nurses, nurse practitioners, or physician’s assistants, but these encounters occur during roughly only 20 percent of ambulatory care visits. These nonphysician providers can be important sources of counseling services, even though they are not frequently encountered.

One of the reasons most frequently cited by clinicians for not implementing prevention services is a real or perceived lack of time given the other demands of a primary care practice (Ashford et al., 2000; Battista and Mickalide, 1990; Burns et al., 2000; Cooper et al., 1998; Dunn et al., 2001; Jaen et al., 1994; Kottke et al., 1993; Kushner, 1995; Rafferty, 1998; Walsh et al., 1999). Responses to the patient’s presenting complaints and concerns often take precedence (Burns et al., 2000; McBride et al., 1997; Stange et al., 1994). The total amount of time needed by the physician to deliver effective preventive services may not be prohibitive. Physicians can, for example, initiate a smoking cessation intervention, and this can be followed by provision of most of the intervention and follow-up by another clinician (e.g., a nurse, a nurse practitioner, or a physician’s assistant). Physicians can deliver prevention services at high rates and still have a productive practice, as defined by relative value units, when formal systems for the delivery of prevention services are implemented (Kottke et al., 1993).

Systems of care may reduce institutional or organizational barriers to the use of prevention services with strategies that facilitate a usual source of care or a “regular doctor,” the centralization of services, or the provision of an integrated structure (e.g., a centralized screening program [Thompson et al., 1995]), a requirement for minimal patient copayments for members, or reduction of clinicians’ financial disincentives (Gordon et al., 1998; Weinick and Beauregard, 1997). Financial incentives, management strategies, the physical plant, and normative influences of colleagues can all interact to facilitate or hinder the provision of preventive services (Malin et al., 2000).

Organizational characteristics of HMOs might contribute to the relatively high rates of use of prevention services, for example, dedicated behav-



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