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Better, but not good enough. At the end of 1997's fourth quarter, the average operating profit margin for the 17 publicly traded HMOs tracked by Douglas Sherlock, an analyst in Gwynedd, Pa., was 0.1%. Most margins were well under 2%. The fourth-quarter 1996 average operating margin was -1.6%.
Material management is a chain that links every element of the supply function: requisitioning, purchasing, receiving storage and the user departments. This article presents three (3) major areas where an effective computerized materials management system can produce substantial savings. Central inventories, supply distribution, and purchases can all be positively improved.
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The article reviews the prospective, controlled experience of the introduction of a physician network service (health maintenance organisation 5000 insured persons). There was a reduction of cost (26%-33%) compared with the control group, without loss of quality. This reduction still holds good after four years. Risk selection explains only a small part of the reduction in cost. The only interventions consisted of gatekeeping plus continuing medical education (CME). Diagnosis and financial data were not available and profiling was not used to control the experience. CME was provided by a quality circle once a week. In these meetings, the subjective and objective features particular to outpatient medicine were addressed.
The rapid growth in outpatient expenditures and the congressional mandate for development of a prospective payment system (PPS) for these expenditures are discussed. Extension of diagnosis-related groups to outpatient care is shown to be infeasible. Alternative patient classification schemes and options for defining the unit of payment and establishing weights and rates are discussed. A PPS primarily controls price and can only address volume by defining a broad unit of payment, such as an episode of care. Therefore, adoption of a volume performance standard approach could be effective. Outpatient payment policies must be integrated with those of other ambulatory care providers.
The purpose of the present work is to work out an approach for the development of software and the choice of hardware structures when designing subsystems for automatic control of technological processes realized in living objects containing limited space (microenvironment). The subsystems for automatic control of the microenvironment (SACME) under development use the Devices for Air Prophylactic Treatment, Aeroionization, and Purification (DAPTAP) as execution units for increasing the level of safety and quality of agricultural raw material and foodstuffs, for reducing the losses of agricultural produce during storage and cultivation, as well as for intensifying the processes of activation of agricultural produce and industrial microorganisms. A set of interconnected SACMEs works within the framework of a general microenvironmental system (MES). In this research, the population of baker's yeast is chosen as a basic object of control under the industrial fed-batch cultivation in a bubbling bioreactor. This project is an example of a minimum cost automation approach. The microenvironment optimal control problem for baker's yeast cultivation is reduced from a profit maximum to the maximization of overall yield by the reason that the material flow-oriented specific cost correlates closely with the reciprocal value of the overall yield. Implementation of the project partially solves a local sustainability problem and supports a balance of microeconomical, microecological and microsocial systems within a technological subsystem realized in a microenvironment maintaining an optimal value of economical criterion (e.g. minimum material, flow-oriented specific cost) and ensuring: (a) economical growth (profit increase, raw material saving); (b) high security, safety and quality of agricultural raw material during storage process and of food produce during a technological process; elimination of the contact of gaseous harmful substances with a subproduct during various technological stages; (c) improvement of labour conditions for industrial personnel from an ecological point of view (positive effect of air aeroionization and purification on human organism promoting strengthened health and an increase in life duration, pulverent and gaseous chemical and biological impurity removal). An alternative aspect of a controlled living microenvironment forming is considered.
OBJECTIVE: To assess the views of primary care physicians (PCPs) in Spain regarding the purpose of inspection validation of prescriptions (IVP) and its impact on prescription and patients, as well as doctors' acceptance of this measure. DESIGN: Cross-sectional study through a telephone survey. SETTING: Primary care centres. PARTICIPANTS: PCPs prescribing oral diabetes drugs requiring IVP, or who were familiar with IVP. METHODS: Telephone survey conducted in October-November, 2003, of 1471 PCPs. Sample size was calculated to ensure accuracy to 10% in each autonomous region. RESULTS: 91.9% of the 1600 PCPs contacted who agreed to participate in the study met the inclusion criteria. On average, they prescribed 30.6 drugs requiring IVP per month (95% CI, 28.0-33.2), requiring an additional 4.6 minutes per prescription (95% CI, 4.4-4.8). 64.7% of PCPs increased their clinical work-time for this reason. 71.3% of PCPs (95% CI, 69.0-73.6) considered IVP an obstacle when prescribing a drug that requires it and 44.5% (95% CI, 42.0-47.0) believed that the IVP puts patients' right to receive the appropriate treatment at risk. PCPs considered that inspectors refuse authorization of their prescriptions requiring IVP for administrative (43.3%), economic (36.5%), or clinical (13.2%) reasons. 87.1% of PCPs stated that medical prescription is a sufficient control system and that IVP is not necessary for medicines for diseases managed in primary care such as Type-2 DM. 76.2% believed that the health authorities imposed the IVP requirement for some oral diabetes drugs in order to control expenditure on drugs, and 75.4% supported its withdrawal. CONCLUSION: According to PCPs, the objective of the IVP is mainly economic and may affect negatively their clinical practice and patients. Therefore, in general, they do not support it, at least for drugs for diseases mainly managed in primary care.
Although physician services account for approximately 22 percent of personal healthcare expenditures, 70 to 80 percent of all healthcare resources are allocated according to physician decisions. Therefore, physician motives and behavior must be understood by the financial manager. Profit, duty, and self-defense all interact to influence how the physician will respond to a particular situation. Financial managers should play an active role in helping physicians concentrate on the duty to serve the patient's best interests through judicious resource use.
BACKGROUND: As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources. METHODS: The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation. RESULTS: CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant. CONCLUSIONS: The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.
Now that universal access to health care is back on the governmental agenda, elected officials are faced with the dilemma of expanding our present pluralistic system of numerous private and public payers, with its built-in administrative inefficiencies and inflationary pressures, or scrapping the present system of financing and moving to a tax-based scheme like the Canadian Medicare program, an option fraught with political difficulties. There is, however, a third option. The New York State Department of Health has developed a proposal for universal access--Universal New York Health Care, or UNY-Care--that would retain the existing payers, including employer-based insurance coverage, but combine them in a one-payer framework. Providers would no longer have to interact with the many public and private payers, each with its own rules, criteria, and levels of payment. The single payer would serve as the only payer for most health care services and would also negotiate reimbursement rates. The single-payer framework should bring savings in administrative and billing costs and should move government closer to the goal of buying health care services--getting good value for payment rendered--rather than simply paying bills as they are submitted. Although the single-payer strategy could be implemented at either the state or the federal level, it seems ideal as the principal responsibility of the states in a national plan for universal coverage.
OBJECTIVE: To report the experiences of 66 surgical specialists from 15 different hospitals who performed 43 CPT-based procedures more than 16,000 times. SUMMARY BACKGROUND DATA: Surgeons are under increasing pressure to demonstrate patient safety data as quantitated by objective and subjective outcomes that meet or exceed the standards of benchmark institutions or databases. METHODS: Data from 66 surgical specialists on 43 CPT-based procedures were accessioned over a 4-year period. The hospitals vary from a small 30-bed hospital to large teaching hospitals. All reported deaths and complications were verified from hospital and office records and compared with benchmarks. RESULTS: Over a 4-year inclusive period (1999-2002), 16,028 elective operations were accessioned. There was a total 1.4% complication rate and 0.05% death rate. A system has been developed for tracking outcomes. A wide range of improvements have been identified. These include the following: 1) improved classification of indications for systemic prophylactic antibiotic use and reduction in the variety of drugs used, 2) shortened length of stay for standard procedures in different surgical specialties, 3) adherence to strict indicators for selected operative procedures, 4) less use of costly diagnostic procedures, 5) decreased use of expensive home health services, 6) decreased use of very expensive drugs, 7) identification of the unnecessary expense of disposable laparoscopic devices, 8) development of a method to compare a one-surgeon hospital with his peers, and 9) development of unique protocols for interaction of anesthesia and surgery. The system also provides a very good basis for confirmation of patient safety and improvement therein. CONCLUSIONS: Since 1998, Quality Surgical Solutions, PLLC, has developed simple physician-authored protocols for delivering high-quality and cost-effective surgery that measure up to benchmark institutions. We have discovered wide areas for improvements in surgery by adherence to simple protocols, minimizing death and complications and clarifying cost issues.
Low-dose trimethoprim (TMP), trimethoprim-sulfamethoxazole (TMP-SMZ), and nitrofurantoin macrocrystals were found to be safe and effective as prophylaxis against recurrent urinary tract infections. Women given placebo had 2.8 infections per patient-year during the six-month study period, while women given TMP, TMP-SMZ, or nitrofurantoin had significantly lower infection rates (0.015 per patient-year). The effect of prophylaxis appeared to be limited to the period when the agents were taken. Only one patient had a TMP-resistant coliform isolated from cultures obtained during prophylaxis and six months afterwards. The sole factor associated with the recurrence of infection after prophylaxis was a history of three or more infections in the year preceding prophylaxis. Thirty-one of the 60 women in the trial were monitored for a mean of 6.1 years before and 3.2 years after they entered the study. Analysis of infection rates indicated that about half these women were experiencing an infection cluster when they entered the study and that the prestudy baseline infection rate correlated with the poststudy rate. Thus, prophylaxis did not appear to exert a long-term effect on the baseline infection rate. Urinary prophylaxis generally appears to become cost-effective when the baseline infection rate exceeds two per patient-year.