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PubMed1995

Primary care: the driver in health care reform.

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.

Health Care Reform↗
PubMed1995

Strategic issues requiring public accountability: food for thought.

Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place.

Community-Institutional Relations↗
PubMed1998

The health care reform in Italy: transition or turmoil.

Health care reform in Italy is transforming its centrally planned, vertically integrated National Health Service into a market-oriented system in which public funders contract directly with individual providers. A model is envisaged in which a plurality of public and private care providers compete for contracts with capitated health agencies responsible for assuring uniform levels of services for geographically defined populations. The ultimate goal of the reform is to guarantee universal coverage and secure global spending limits while, at the same time, promoting efficiency in the delivery of care and enhancing responsiveness to consumers. The emphasis upon incentives for the individual provider which will be introduced should, however, be considered against the quest for equity in health care which was the central tenet of the 1978 reform and is yet to be attained. The fragmentation of the National Health Service into many separate, competing delivery units might well damage the ability to plan strategically for addressing the substantial inequities in health status, health care utilization, and health service availability which still exist across the country. Competition between a plurality of providers and fee-for-service payment schemes add additional concerns about unnecessary care and supplier-induced demand. It creates the need for developing rules to make competition manageable and providing sound clinical and financial information that make enforcement possible. The poor record scored in managing the contractual relationships between the LHUs and the strong private health sector suggests that massive investment in promoting managerial skills and developing appropriate clinical and financial information systems are required. Careful experimentation in implementing the reform and continuous monitoring of its impact on the health care system are, therefore, the imperatives of the next two years.

Capitation Fee↗
PubMed1994

The National Health Care Reform Debate.

Because of increasing costs and decreasing access, most policymakers agree with the public perception that the health care system in the United States is in need of change. This chapter summarizes the various proposals under consideration, which ranges from a single-payer model similar to the system in Canada to the less radical concept of managed competition.

Journal Article↗
PubMed1999

Hospitalists: do they represent a best practice for patients? Part I.

Hospitalists: Do they improve care? Hospitalists are physicians dedicated to the care of hospitalized patients. The use of hospitalists is growing rapidly nationwide, primarily in markets marked by competitive managed care environments. When hospitalists are used, length of stay and costs are cut about 20%. The "handoff" of the patient from primary physician to hospitalist upon admission is seen by many as a weak, and possibly fatal, characteristic of the hospitalist model. The key to making the hospitalist model work in today's health care system is to make the "handoff at the hospital" voluntary, thereby garnering vital primary physician support.

Benchmarking↗
PubMed1999

PHOs and risk: aligning incentives with internal subcapitation.

Many PHOs have not realized the efficiencies they anticipated when they accepted capitation payments on behalf of their member organizations. Internal subcapitation of professional and facility expenses can promote the organizational alignment of incentives necessary for PHOs to succeed in competitive managed care markets. PHOs may establish subcapitation budgets and corresponding leakage pools to augment efficiency and promote patient access within the PHO. Care should be taken, however, that sufficient resources needed to collect and analyze utilization data, as well as the infrastructure needed to administer subcapitation, are in place.

Budgets↗
PubMed1999

Rationing: how and who?

Rationing health services, in the sense of denying care deemed of positive benefit by at least some health system actors, is a problem that politicians would like to avoid. Health policy analysis has offered a number of approaches, such as global budgeting, technology assessment, managed competition, legal recourse and public participation as palliatives for this difficult problem. Each of these approaches on its own falls short, but no country has yet designed a process for explicit rationing. Israel, in the context of its recent health reform, has gone as far as any country in this direction. However, significant political leadership will be required to frame the public discussion of these difficult issues.

Cost Control↗
PubMed2000

Preparing for a decision support system.

The increasing pressure to reduce costs and improve outcomes is driving the health care industry to view information as a competitive advantage. Timely information is required to help reduce inefficiencies and improve patient care. Numerous disparate operational or transactional information systems with inconsistent and often conflicting data are no longer adequate to meet the information needs of integrated care delivery systems and networks in competitive managed care environments. This article reviews decision support system characteristics and describes a process to assess the preparedness of an organization to implement and use decision support systems to achieve a more effective, information-based decision process. Decision support tools included in this article range from reports to data mining.

Decision Support Systems, Management↗
PubMed2006

NHS core principles must be protected.

Jason Rayfield explores the implications of the increasing use of private sector funding, risk management, competition principles and expertise for NHS healthcare delivery.

Health Care Reform↗
PubMed1994

Year 2000 scenario for physician-hospital organizations.

The coming of managed competition and health care reform requires the development of medical organizations on which to build the community care networks of the future. This chapter postulates a scenario for such development by the year 2000.

Group Practice↗
PubMed1994

Reimbursement: current status and future outlook.

Third-party payer reimbursement policies have undergone significant changes in recent years and will probably continue to do so as the nation's health care system is reformed. These changes will have important implications for oncologists, similar to those that have arisen as a result of Medicare's payment system changing from one of "reasonable charges" to a fixed-fee schedule. The likely growth of managed competition as part of health care reform may prove to be disadvantageous to the oncologist without laws or rules guaranteeing cancer patients the right to treatment by a specialist and to tertiary care. Other areas of importance that will probably be affected include reimbursement of patient care costs associated with clinical trials and of drug costs when the drug is used for off-label indications.

Antineoplastic Agents↗
PubMed1994

The use of intensive care unit severity scoring systems in reimbursement strategies.

In summary, there are several important aspects of the GCHQCP. First, it was not mandated by any government or agency. It is the result of a business initiative designed to reduce costs by rewarding quality outcomes and efficiency. Second, it is a collaborative effort involving hospitals, physicians, and business. This cooperation initially may have been induced by a potential threat of a loss of patients, but, nonetheless, it exists. Third, the first report includes no information about costs or charges. The GCHQCP wants the focus to be on quality of care, but, in addition, the businesses involved already know a great deal about what they are paying for health care. Future financial arrangements are much more important to those involved than the documentation of current practice. The GCHQCP has required tremendous energy and cooperation on the part of many individuals and institutions. Initiating and maintaining the project has required an unprecedented level of cooperation among groups that often have divergent interests, including business leaders, physicians, and hospital administrators. Nevertheless, the GCHQCP suggests that the monitoring of clinical outcomes using validated regression models to predict expected outcomes can assist community-sponsored programs in evaluating hospital performance in large health care systems. It is hoped that with such data, consensus can develop regarding the value of health care services to patients, payers, and providers in an arena of changing societal values and priorities regarding these services. Whatever the results of the initial release of information comparing hospitals, there are bound to be legitimate concerns regarding the methods of analysis selected. These concerns may focus on methodology, issues regarding the stratification of patient risk, or the ethical questions of what outcomes are desirable in certain subgroups of critically ill patients. If this project is successful, business, the health care community, and patient concerns will be taken into account and the evaluative process will evolve and improve. In a market-based strategy to reduce costs such as managed competition, there will be winners and losers. It is our job to develop ways to ensure that patients and those who practice quality medicine efficiently are winners.

Diagnosis-Related Groups↗
PubMedDate not supplied

Analysis of prevention benefits in comprehensive health care reform legislation in the 102nd Congress.

One of the most important factors affecting the use of preventive services is health insurance coverage; however, until recently, most public and private health plans have explicitly excluded coverage of most preventive care. As a result, preventive services are used less frequently than recommended guidelines suggest, which contributes to the high incidence of preventable morbidity and mortality in the United States. Recent congressional efforts to enact national health care reform legislation present an important opportunity to analyze coverage for preventive services. This article presents the results of an analysis of the prevention benefits in 23 comprehensive health care reform bills introduced in 1991 during the first session of the 102nd Congress. I classified each bill by type (employer-based, single payer, managed competition, tax credit, and insurance market reform) and through a content analysis identified benefits for immunization, screening, and counseling services (including cost-sharing provisions), as well as funding for community-based health promotion. I interviewed congressional staff members of the sponsors of each bill to discuss their rationale for including or excluding specific prevention benefits and their reliance on existing policy, guidelines, and health services research or on the involvement of interest groups in developing prevention benefits. I conclude that health care reform is likely to address prevention, particularly in covering specific clinical preventive services, such as well-child visits, prenatal care, immunizations, family planning, and cancer screening. The prevention benefits least likely to be included in health care reform are coverage for counseling services and funding for community-based health promotion.

Health Care Reform↗
PubMed1993

Anatomy of health care reform proposals.

The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements.

Delivery of Health Care↗
PubMed1993

Physiatrics at the forefront: physical medicine and rehabilitation in the 1990s.

Physiatry, a specialty title derived from the word "physical," is the second-fastest-growing medical specialty in the United States. The interdisciplinary team-management system is the key to the success of physiatric services. The goal is to maximize functional outcome for physically challenged patients who have any of a broad scope of disorders causing disabilities or pain. Rehabilitation of these patients is cost-effective and provides improved quality of life for those treated. The job of the four excellent Physical Medicine and Rehabilitation (PM&R) training programs in Texas is to educate young physicians with knowledge regarding medicine, general science, electrodiagnostics, and allied health-care science. Young physiatrists may gravitate towards various subspecialties in the field or choose to provide a variety of services to assist other physicians in the management of patients over a prolonged period. In the age of managed competition, costs versus access, and quality-of-care issues, physiatrists must educate physicians, the public, legislators, and insurance carriers (federal, state, workers' compensation, and third-party) as to why rehabilitation should be included in any and every health-care plan.

Education↗
PubMed1993

Restructuring American health care financing: first of all, do no harm!

Health care costs are climbing throughout the western world. Aging populations and the costs of advanced technology are the principal forces behind much of this global increase. No country has yet succeeded in containing these growing costs other than by some form of rationing. A variety of experimental strategies, including managed competition, are being considered or tested, but none is clearly effective. American health care expenditures differ, not in that they are rising, but in their enormously high starting point. Among other things, our higher costs reflect administrative costs of more than 20%, double those of Canada and nearly triple the European average; a malpractice system that, whatever its possible advantages, costs more than 10 times as much as it pays out to the injured; the enormous medical costs of poverty; maldistribution of physician specialties and incomes; and reimbursement systems that eliminate consumer input and oversight. Restructuring the system of health care financing to bring administrative costs in line with those of other nations could save at least $70 billion annually; another $25 billion or more could be saved by replacing the malpractice system with more cost-effective alternatives. These savings could defray the costs of insuring all those not now covered, without increasing either costs to the middle class, through taxation of benefits, or total health care expenditures. With all Americans covered, the necessary restructuring of the system of health care delivery could be conducted without the current pressure for immediate drastic reform, which carries with it the risk of serious error. In dealing with the sick, physicians are taught to apply two maxims: "primum non nocere" or "first of all, do no harm!"; and the rule of therapeutic restraint. The latter states that a severe chronic illness may respond better, and with fewer complications, to gradual corrective measures than to highly aggressive therapy. Both rules could well be applied to curing the American health care system.

Delivery of Health Care↗