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PubMed1995

Case study update. Arizona's UMC model of patient-center care thrives after four years. Three new features of redesign at University Medical Center, Tucson.

In January 1992, this publication introduced a promising one-year-old program of patient-centered care at 312-bed University Medical Center (UMC), Arizona Health Sciences Center, in Tucson. Since then, the groundbreaking program (dubbed the "Arizona Model" by admiring colleagues in other states) has continued to grow, even as the small teaching institution saw its environment evolve into "a war zone" of managed care competition. In the last year, three important enhancements have been implemented.

Academic Medical Centers↗
PubMed1998

Beyond coverage and supply: measuring access to healthcare in today's market.

OBJECTIVE/PURPOSE: To stimulate discussion within the research and policy community about the value of and issues surrounding different ways to describe access to care in a health system reconfigured by the growth of managed care, competition, and other marketplace changes. PRINCIPLE FINDINGS: The concept of access has evolved over time to address shifting health policy concerns like the growing interest in looking beyond utilization as a measure of access to a better consideration, too, of the effectiveness of services used as judged by costs and outcomes. Yet current frameworks used to look at access are person-based and do not capture the complexity of the healthcare system and the complex structures involved in managed care organizations that combine delivery and financing and vary substantially within and across markets. In addition, many at times competing or conflicting policy goals on access exist. There also is an increasingly diverse and widening set of uses that include benchmarking against national goals, measuring performance of accountable entities, and providing consumer information. CONCLUSIONS AND RECOMMENDATIONS: Traditional access frameworks are invaluable in encouraging focus on historical measures of access, like insurance coverage and other barriers to system entry. But much greater attention needs to be paid to adapting current access frameworks so that they also better support the ability to understand how processes inherent in diverse health delivery and financing arrangements influence access to services within a system and what this means for how well individuals negotiate healthcare systems and the effects on care outcomes. The increasing demands on access measures and the growing diversity of users also point to a need for collaboration to better pool insights, share experiences, and honestly confront trade-offs or disagreements to progress in addressing these issues.

Delivery of Health Care↗
PubMed2006

[Recommendations for sports participation in patients with arrhythmia].

Nowadays, sports are a wonderful mean for social success, and the high-level athlete is the symbol of a perfect hygiene of life. Despite this, the occurrence of unexplained sudden death (SD) is not exceptional, especially during training and competition. In this context, it is important to intensify medical controls for these athletes, especially in a very early phase, in order to detect subjects at risk. In case of detection of a cardiac disease prone to cardiovascular or arrhythmic event, the practice of any high-level sportive activity or even any sustained sportive activity must be forbidden without hesitation, with the aim of protecting these subjects. Even though a total interdiction of sports practice can be a tough decision to be accepted, it should prevail on the dramatic consequences of sudden death. Physicians' responsibility issues in the screening and management of competition or leisure-time sportsmen are of high importance since in case of sudden death, the physician and the medical community liabilities can be considered. As a consequence, the medical community set up recommendations on the screening, treatment and even interdiction of sportive activity for athletes, which should also be applied to leisure-time sportsmen. In the first part of this article, the different causes (especially the arrhythmia-related) of sudden death occurring in sportsmen are reviewed. In the second part, the recommendations on practice of high-level sports in case of arrhythmia or genetic arrhythmic cardiac disease are summarized.

Arrhythmias, Cardiac↗
PubMed2001

Are urban safety-net hospitals losing low-risk Medicaid maternity patients?

OBJECTIVE: To examine data on Medicaid and self-pay/charity maternity cases to address four questions: (1) Did safety-net hospitals' share of Medicaid patients decline while their shares of self-pay/charity-care patients increased from 1991 to 1994? (2) Did Medicaid patients' propensity to use safety-net hospitals decline during 1991-94? (3) Did self-pay/charity patients' propensity to use safety-net hospitals increase during 1991-94? (4) Did the change in Medicaid patients' use of safety-net hospitals differ for low- and high-risk patients? STUDY DESIGN: We use hospital discharge data to estimate logistic regression models of hospital choice for low-risk and high-risk Medicaid and self-pay/charity maternity patients for 25 metropolitan statistical areas (MSAs) in five states for the years 1991 and 1994. We define low-risk patients as discharges without comorbidities and high-risk patients as discharges with comorbidities that may substantially increase hospital costs, length of stay, or morbidity. The five states are California, Florida, Massachusetts, New Jersey, and New York. The MSAs in the analysis are those with at least one safety-net hospital and a population of 500,000 or more. This study also uses data from the 1990 Census and AHA Annual Survey of Hospitals. The regression analysis estimates the change between 1991 and 1994 in the relative odds of a Medicaid or self-pay/charity patient using a safety-net hospital. We explore whether this change in the relative odds is related to the risk status of the patient. PRINCIPAL FINDINGS: The findings suggest that competition for Medicaid patients increased from 1991 to 1994. Over time, safety-net hospitals lost low-risk maternity Medicaid patients while services to high-risk maternity Medicaid patients and self-pay/charity maternity patients remained concentrated in safety-net hospitals. IMPLICATIONS FOR POLICY: Safety-net hospitals use Medicaid patient revenues and public subsidies that are based on Medicaid patient volumes to subsidize care for uninsured and underinsured patients. If safety-net hospitals continue to lose their low-risk Medicaid patients, their ability to finance care for the medically indigent will be impaired. Increased hospital competition may improve access to hospital care for low-risk Medicaid patients, but policymakers should be cognizant of the potential reduction in access to hospital care for uninsured and underinsured patients. Public policymakers should ensure that safety-net hospitals have sufficient financial resources to care for these patients by subsidizing their care directly.

Comorbidity↗
PubMed1998

Designing an incentive compensation program that works.

To encourage innovation and improve departmental and organizational bottom lines, Winchester Hospital, Winchester, Massachusetts, developed and implemented a middle management and staff incentive compensation plan. Middle managers and staff who participate in projects that provide savings to the hospital are paid a share of the savings. The plan allows staff the option of designing "horizontal" projects, in which a project leader carries out a project individually or with peers, or "vertical" projects, in which a project leader directs a team of key individuals. Increasing numbers of vertical projects have been proposed since the plan's inception in 1994. In addition to increasing the hospital's operating income, the program provides cost-effective, variable compensation, which especially appeals to motivated, high-performing employees; motivates employees to overcome roadblocks; facilitates a team approach that bridges traditional departmental boundaries; and encourages a beneficial and collegial competitiveness among managers.

Cost Savings↗
PubMedDate not supplied

Market-oriented health care reforms and policy learning in the Netherlands.

In this article we analyze the evolution of market-oriented health care reforms in the Netherlands. We argue that these reforms can be characterized as policy learning within and between competing policy programs. Policy learning denotes the process by which policy makers and stakeholders deliberately adjust the goals, rules, and techniques of a given policy in response to past experiences and new information. We discern three distinctive periods. During the first period (1988-1994), the prevailing corporatist and etatist policy programs were seriously challenged by the proponents of a new market-oriented program. But when it came to political decision making and implementation, the market-oriented program soon lost its impetus because it was technically too complex and could not provide short-term solutions to meet the urgent need for cost containment. During the second period (1994-2000), the etatist program regained its previously dominant position. In parallel to a strengthening of supply and price controls, however, the government also persevered in creating the technical and institutional preconditions for regulated competition. Moreover, public discontent over waiting lists and the call for more autonomy by individual providers and insurers strengthened the alliance in favor of regulated competition. This led to the revival of the market-oriented program in a 2001 reform plan. We conclude that the odds of these new post-2001 reforms succeeding are substantially higher than in the first period due to the technical and institutional adjustments that have taken place in the past decade.

Capitation Fee↗
PubMed2001

Cost containment, solidarity and cautious experimentation: Swedish dilemmas.

This paper uses secondary data analysis and a literature review to explore a "Swedish Dilemma": Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay--a policy emphasizing "solidarity"--or must it decide to impose increasing constraints on health services spending and service delivery--a policy emphasizing "cost containment?" It examines recent policies and longer term trends including: changes in health personnel and facilities; integration of health and social services for older persons; introduction of competition among providers; cost sharing for patients; dismantling of dental insurance; decentralization of government responsibility; priority settings for treatment; and encouragement of the private sector. It is apparent that the Swedes have had considerable success in attaining cost containment--not primarily through "market mechanisms" but through government budget controls and service reduction. Further, it appears that equal access to care, or solidarity, may be adversely affected by some of the system changes.

Comprehensive Health Care↗
PubMed2006

Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership.

BACKGROUND: To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery. METHODS: In this single case study, we retrospectively explored how local health-care providers in Amsterdam collaborated for more than 30 years, interacting with the changes to the national health-care system. In-depth analysis of interviews, documents and literature focused on the complex relationship between the activities of this health partnership, its nature and its changing context. RESULTS: The findings revealed that the partnership itself was successful and sustainable over time, although the partnership lost its initial broad explorative nature and narrowed its strategic focus towards care of the elderly. Furthermore, the realized projects--although they enforced integrated care--lost their community-based character. This declining scope of community-based integrated care seems to have been influenced by the incremental introduction of regulated competition in Dutch health care. This casts doubts on the ability of health partnerships to apply a vision of community-based integrated care within the context of competition. CONCLUSION: Collaborating health-care providers can build seamless continuums of care in a competitive environment, although these will not automatically maximize community health with limited resources. Active policies with regard to health system design, incentive structures and population-based performance measures are warranted in order to insure that community-based integrated care through health partnerships will be more than just policy rhetoric.

Aged↗
PubMed1997

The Buyers Health Care Action Group: creating a competitive care system model.

The Buyers Health Care Action Group, BHCAG, representing 26 large self-funded employers, has developed a new approach to the health care marketplace. On January 1, 1997 these companies implemented their plan to promote consumer driven competition at the care system rather than the plan level around clinical quality, service quality and cost. This new approach features increased provider autonomy and accountability, while empowering consumers with information to choose care systems based on their own values. Results to date include availability of 90-95% of community primary care physicians (with almost twice the delivery sites as previous offerings), extensive consumer information about providers and the care systems in which they participate, and a 1997 cost reduction of 9% against expected claims.

Community Participation↗
PubMed1997

Integrating clinical and support process design for effective health services.

With increased capitation and managed care competition, health care systems must demonstrate effective health services with predictable costs, timing, transitions, and health outcomes. By involving patients, payers, and multiple providers, a health care system can design integrated clinical and support processes across the continuum for defined populations. The goals are lower costs, increased payer and patient satisfaction, and improved health status. This article shares examples and experiences from four health care systems that teamed with Premier, Inc., to design an integrated services sequence for defined populations.

Adult↗
PubMed2001

The marginal success of regulated competition policy in the Netherlands.

In the second half of the 1980s the government in the Netherlands adopted a regulated competition policy as part of a comprehensive programme designed to restructure the health care system. The programme was a product of its social and political context, promoted by a group of political entrepreneurs and created to improve efficiency. Despite the initial political support and a long political debate the government had to acknowledge by 1992 that the restructuring would not take place. But changes fostered limited competition between sickness funds and more extensive competition in the small market for supplementary policies. This, however, has not led to sickness funds becoming powerful purchasers that forced hospitals and doctors to improve their efficiency. Rather, they compete for subscribers, become part of large insurance conglomerates, and market more supplementary options. Culturally, health care institutions have become more entrepreneurial, taken up more business concepts, and made the language of markets, products and consumer sovereignty more common. The impact of these changes on the health care system is still unknown, but they create pressure for more health care services, leaving the government with problems that equal those of the 1980s.

Government↗
PubMed2001

Risk sharing as a supplement to imperfect capitation: a tradeoff between selection and efficiency.

This paper describes forms of risk sharing between insurers and the regulator in a competitive individual health insurance market with imperfectly risk-adjusted capitation payments. Risk sharing implies a reduction of an insurer's incentives for selection as well as for efficiency. In a theoretical analysis, we show how the optimal extent of risk sharing may depend on the weights the regulator assigns to these effects. Some countries employ outlier or proportional risk sharing as a supplement to demographic capitation payments. Our empirical results strongly suggest that other forms of risk sharing yield better tradeoffs between selection and efficiency.

Capitation Fee↗
PubMed2003

Risk adjustment in Switzerland.

In Switzerland the new law on Health Insurance, effective since 1996, introduced pro competitive changes in the market of sickness funds. The legislator expected high mobility between sickness funds of both healthy and sick insured as open enrolment was introduced with the new law. That is why the risk adjustment scheme, that was already introduced 1993, was limited until 2005. However, consumer mobility remained low and risk selection strategies are still profitable, since risk-adjustment is based only on demographic variables. This paper describes risk adjustment, consumer mobility, risk selection activities of sickness funds and the impact of imperfect risk adjustment on the development of HMO and PPO models. The paper concludes with a description of the current political and scientific discussion in Switzerland.

Capitation Fee↗
PubMed2004

Health care economics, financing, organization, and delivery.

BACKGROUND: The US health care system is in a state of rapid evolution, with changing payment, organizational, and management structures. To learn how to function optimally in a system in which care is increasingly managed and competitive, today's medical students must understand the structural and economic underpinnings of the system within which they will practice. At the outset of the Undergraduate Medical Education for the 21st Century (UME-21) project, the great majority of medical school curricula were lacking in areas of health care financing and organizational structure. The institutions involved in the UME-21 project sought to address curricular deficiencies in two broad areas: (1) the structure and financing of the US health care system ("health policy") and (2) the manner in which this system is reflected in the organization and activities of health care providers ("care delivery"). This article discusses the development, implementation, and evaluation of the first of the two areas. METHODS: Data were abstracted from written reports provided by each of the UME-21 schools to the project's Executive Committee and sponsor. In selected cases, additional data were obtained by personal communications with project directors and evaluators. Local UME-21 project leaders verified all data presented. RESULTS: Curricular philosophy and teaching methods varied widely, but health policy curricula were predominantly preclinical and didactic in nature. At the school level, much was achieved in terms of student knowledge, curricula were generally well received by students, attitudes toward managed care generally moved in a positive direction, and behavior may have been positively influenced as well. At the project level, many potentially interesting changes exist within the 18 schools and between the UME-21 and other schools, but it is not clear whether or what parts of the health policy curricula were responsible for these changes. Nonetheless, as measured by changes in health policy-related items on the Association of American Medical Colleges Graduation Questionnaire, it appears that UME-21 schools outperformed their non-UME-21 counterparts. All of the UME-21 schools were enthusiastic about their health policy innovations, and this extended across all key stakeholders. Most schools avoided focusing on managed care and instead adopted more neutral themes that introduced the same material. Integrating the new material in conjunction with the more traditional aspects of the curriculum was also an effective implementation strategy. CONCLUSIONS: Health policy should be incorporated into both the preclinical and clinical years. The former emphasizes health care economics as one of the foundations of medical practice, whereas the latter provides the opportunity for its use on a daily basis in clinical settings. However, like any new curriculum, to achieve equal status with the traditional biomedical curriculum, it must be presented in a scholarly, rigorous, and reasonably comprehensive fashion. Mounting a scholarly health policy curriculum requires a wide-ranging, interdisciplinary faculty. If it is to become a central component of the medical school curriculum, creative approaches to faculty recruitment and development will be needed. This will require both careful educational policy formulation and new investment.

Curriculum↗
PubMed2005

Why some market reforms lack legitimacy in health care.

Market-oriented health policy reforms in the 1980s and 1990s generally included five kinds of proposals: increased cost sharing for patients through user fees, the separation of purchaser-provider functions, management reforms of hospitals, provider competition, and vouchers for purchasing health insurance. These policies are partly derived from agency theory and a model of managed competition in health insurance. The essay reviews the course of reform in five countries that had a national health service model in place in the late 1980s: Italy, New Zealand, Spain, Sweden, and the United Kingdom. Special consideration is given to New Zealand, where the market model was extensively adopted but short lived. In New Zealand, surveys and polls are compared to archival records of reformers' deliberations. Voters saw health care differently from elites, and voters particularly felt that health care was ill suited to commercialization. There are similarities across all five countries in what has been adopted and rejected. Some market reforms are more legitimate than others. Reforms based on resolving principal-agent problems, including purchaser-provider splits and managerial reforms, have been more successful, although cost sharing has not. Competition-based reforms in financing and to a lesser extent in provision have not gained legitimacy. Most voters in these countries see health care as different from other parts of the economy and view managerial reforms differently from policies that try to make health care more like other sectors.

Cost Sharing↗
PubMed2005

Effects of New Zealand's health reengineering on nursing and patient outcomes.

BACKGROUND: In 1993, New Zealand (NZ) implemented policies aimed at controlling costs in the country's public health care system through market competition, generic management, and managerialism. The cost control focus was similar to reengineering efforts implemented by other countries struggling with escalating health care costs, particularly the United States. OBJECTIVE: The study's purpose was to examine the effects hospital reengineering may have on adverse patient outcomes and the nursing workforce. RESEARCH DESIGN: The study was a retrospective, longitudinal analysis of administrative data. Relationships between adverse outcome rates and nursing workforce characteristics were examined using autoregression analysis. SUBJECTS: All medical and surgical discharges from NZ's public hospitals (n = 3.3 million inpatient discharges) from 1989 through 2000 and survey data from the corresponding nursing workforce (n = 65,221 nurse responses) from 1993 through 2000 were examined. MEASURES: Measures included the frequency of 11 nurse sensitive patient outcomes, average length of stay, and mortality along with the number of nursing full time equivalents (FTEs), hours worked, and skill mix. RESULTS: After 1993, nursing FTEs and hours decreased 36% and skill mix increased 18%. Average length of stay decreased approximately 20%. Adverse clinical outcome rates increased substantially. Mortality decreased among medical patients and remained stable among surgical patients. The relationship between changes in nursing and adverse outcomes rates over time were consistently statistically significant. CONCLUSIONS: In the chaotic environment created in NZ by reengineering policy, patient care quality declined as nursing FTEs and hours decreased. The study provides insight into the role organizational change plays in patient outcomes, the unintended consequences of health care reengineering and market approaches in health care, and nursing's unique contribution to quality of care.

Adult↗
PubMedDate not supplied

Enhancing performance measurement: NCQA's road map for a health information framework. National Committee for Quality Assurance.

Measuring the quality of health care delivery is one of the most critical challenges facing US health care. Performance measurement can be used to track the quality of care that health plans and medical groups deliver, but effective performance measurement requires timely access to detailed and accurate data. In 1996, the National Committee for Quality Assurance (NCQA) commissioned a report to learn what actions would improve health plans' capacity to electronically report performance data for the Health Plan Employer Data and Information Set (HEDIS). Tracking clinical performance will require not just clinical data stored in information systems, but an integrated health information framework. Seven features are essential to this framework: (1) it specifies data elements; (2) it establishes linkage capability among data elements and records; (3) it standardizes the element definitions; (4) it is automated to the greatest possible extent; (5) it specifies procedures for continually assessing data quality; (6) it maintains strict controls for protecting security and confidentiality of the data; and (7) it specifies protocols for sharing data across institutions under appropriate and well-defined circumstances. Health plans should anticipate the use of computerized patient records and prepare their data management for an information framework by (1) expanding and improving the capture and use of currently available data; (2) creating an environment that rewards the automation of data; (3) improving the quality of currently automated data; (4) implementing national standards; (5) improving clinical data management practices; (6) establishing a clear commitment to protecting the confidentiality of enrollee information; and (7) careful capital planning. Health care purchasers can provide the impetus for implementing the information framework if they demand detailed, accurate data on the quality of care.

Forms and Records Control↗
PubMed2006

Use of board certification and recertification of pediatricians in health plan credentialing policies.

CONTEXT: Health plans conduct credentialing processes to select and retain qualified physicians who will provide high-quality care to their subscribers. One of the tools available to health plans to help ensure physician competence is assessment of board certification status. OBJECTIVE: To determine the credentialing policies of health plans regarding the use of board certification and recertification for general pediatricians and pediatric subspecialists. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted February through July 2005 of credentialing personnel from a US national sample of 244 health plans stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. MAIN OUTCOME MEASURES: Proportion of health plans that require general or subspecialty board certification at initial contract or at any time during association with the plan and recertification to maintain credentialing or to bill as a specialist or subspecialist; percentage of physicians credentialed in each health plan and credentialing goals for each plan regarding the proportion of physicians to be board certified. RESULTS: Response rate was 193 of 244 (79%). Overall, 174 (90%) of the plans do not require general pediatricians to be board certified at the time of initial credentialing, and only 41% ever require a general pediatrician to become board certified. Similarly, only 80 (40%) ever require subspecialists to become board certified in their subspecialty. Although 80 of 192 (41%) report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates. CONCLUSIONS: These findings, although specific to pediatrics, likely apply to other primary care disciplines and raise questions regarding the ability of plans to ensure initial or continued competence of their credentialed physicians. Growing public concern regarding patient safety, as well as demonstrated patient preferences for certified physicians, will likely result in greater emphasis on quality assessments in physician credentialing.

Certification↗