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PubMed1998

Accountability for quality in managed care.

BACKGROUND: It is often difficult to understand where responsibility lies for monitoring and improving quality in managed care. From 1996 through 1998 a group of individuals convened by the Institute of Medicine's (Washington, DC) National Roundtable on Health Care Quality developed a model of accountability for the quality of care provided by managed care organizations (MCOs). Each of three overarching forms of accountability (professional, market, and regulatory) has a set of tools for imposing accountability and-because accountability relationships are not self-enforcing-sanctions for failures of accountability. PROFESSIONAL ACCOUNTABILITY: Fiduciary relationships in medicine are an essential part of any quality accountability mechanism, and it will be important to maintain the strength of the professional model in the changing health care system. Yet it is not easy to preserve the strength of the professional model in an MCO environment in which professionals are not dominant, and there is likely to be increasing pressure to weaken their autonomy. MARKET ACCOUNTABILITY: The primary assumption of market accountability is that consumers will select options based on perceived value to them and will make new choices based on their information and experience. Market accountability requires choice among competing providers and information to inform choice. In health care, however, individuals rarely have the information they need and often do not have choice. Accountability for quality generally has not been a major feature in contracts. REGULATORY ACCOUNTABILITY: There is a widespread perception of defects in a market-based health care system. Many believe there is a need for a regulatory structure to correct market failures. The use of regulation to impose accountability for quality requires that a regulatory framework, penalties for violations, and effective enforcement mechanisms are all established. PUBLIC GOODS: The model of accountability for quality in managed care does not promote public goods such as education, research, public health, or care for the uninsured. Indeed, the locus of responsibility to the community when markets fail to supply these public goods is controversial. Nevertheless, such responsibility should be considered by MCOs and policy makers. COLLABORATION TO IMPROVE QUALITY OF CARE: Given market-driven models of health care financing and delivery, it might be feasible and desirable to encourage collaboration among MCOs to improve quality, whether at the national or local market level. The health professions in general, and the medical profession in particular, are and must be accountable to society for providing leadership in the development of knowledge about effective medical care, in defining high-quality care, and in advocating for and improving the quality of care. CONCLUSION: Establishing effective accountability for quality involves multiple entities and many different kinds of accountability relationships. The three forms of accountability interact, and all operate at once.

Accreditation↗
PubMed1996

What is accountability in health care?

Accountability has become a major issue in health care. Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities. The concept of accountability contains three essential components: 1) the loci of accountability--health care consists of at least 11 different parties that can be held accountable or hold others accountable; 2) the domains of accountability--in health care, parties can be held accountable for as many as six activities: professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and community benefit; and 3) the procedures of accountability, including formal and informal procedures for evaluating compliance with domains and for disseminating the evaluation and responses by the accountable parties. Different models of accountability stress different domains, evaluative criteria, loci, and procedures. We characterize and compare three dominant models of accountability: 1) the professional model, in which the individual physician and patient participate in shared decision making and physicians are held accountable to professional colleagues and to patients; 2) the economic model, in which the market is brought to bear in health care and accountability is mediated through consumer choice of providers; and 3) the political model, in which physicians and patients interact as citizen-members within a community and in which physicians are accountable to a governing board elected from the members of the community, such as the board of a managed care plan. We argue that no single model of accountability is appropriate to health care. Instead, we advocate a stratified model of accountability in which the professional model guides the physician-patient relationship, the political model operates within managed care plans and other integrated health delivery networks, and the economic and political models operate in the relations between managed care plans and other groups such as employers, government, and professional associations.

Delivery of Health Care, Integrated↗
PubMed1998

The role of outputs and outcomes in purchaser accountability: reflecting on New Zealand experiences.

Recent reforms in a number of countries' health systems have led to the separation of funder, purchaser and provider roles and the strengthening of funders' and purchasers' positions relative to providers. One of the aims of such reforms is to improve accountability. This paper reports on experiences in New Zealand where, in addition to improving the accountability of providers, purchaser accountability has also been a key policy issue. Attempts have been made in New Zealand to develop a funder-purchaser accountability framework based on a mix of outcomes, outputs and inputs. This paper discusses the roles that each might play in contracts and accountability relationships between funders and purchasers. The paper concludes that holding purchasers accountable for outcomes is likely to prove difficult and controversial, because of problems of attribution and because New Zealand funders in recent years have played an important role in determining the priority outputs and inputs which must be purchased. The paper suggests that accountability is more appropriate at the output and process level, in addition to holding purchasers accountable for the ways in which they make decisions and undertake contracting roles. Holding purchasers accountable for purchasing outputs and processes, however, requires greater commitment on the part of the funder to setting priorities more clearly; specifying the range and level of outputs to be purchased and the terms of access to those services; and funding services to this level. The international attention currently being paid to the development of practice guidelines and priority criteria also suggests that holding purchasers accountable for a form of inputs may become an increasingly common practice in future. From 1 July 1998, New Zealand will introduce a priority criteria system for determining access to elective surgery; accountability is thus becoming focused on inputs in the form of patient characteristics. This approach will greatly assist in promoting accountability.

Contract Services↗
PubMed1998

Individual social security accounts: issues in assessing administrative feasibility and costs.

Whether to add individual accounts (IAs) to the Social Security system is a highly political issue. But almost lost in the debate so far have been any practical considerations about how to administer such accounts. Any discussion of whether to create individual accounts must also address the basic but critical questions of how they would work: Who would run them? What would they cost? Logistically, are they even possible? This EBRI Issue Brief provides an overview of the most salient administrative issues facing the current Social Security reform debate--issues that challenge proponents to carefully think through how their proposals could be implemented so as to achieve their policy goals. The options and difficulties in administering IAs raise concerns that cut across ideology. The object of this report is neither to dissuade the advocates nor support the critics of individual accounts. Rather, it is to bring practical considerations to a political debate that has largely ignored the pragmatic challenges of whether IAs would be too complex for participants to understand or too difficult for record keepers to administer. The major findings in this analysis include: Adding individual accounts to Social Security could be the largest undertaking in the history of the U.S. financial market, and no system to date has the capacity to administer such a system. The number of workers currently covered by Social Security--the largest single entitlement program in the nation--is at least four times higher than the combined number of all tax-favored employment-based retirement accounts in the United States, which are administered by hundreds of entities. Direct comparisons between employment-based retirement savings plans and Social Security reform are tenuous at best. Social Security covers workers and businesses that are disproportionately excluded from employment-based plans. Because of these differences, a system of individual Social Security accounts would be more difficult to administer than employment-based plans, and total administrative expenses would be larger relative to benefits. Credit-based systems such as the current Social Security program are less difficult to administer than cash-based systems, which must account for every dollar. Inherent in the "privatization" debate is generally the presumption that IA benefits would be based on cash contributions and investment returns. The current credit-based system tolerates small errors in wage reporting, because they rarely affect benefits. But every dollar counts in a cash-based IA system. To ensure that benefits are properly provided, an IA system would require more regulation, oversight, and error reconciliation than the current Social Security program. Social Security individual accounts cannot be administered like 401(k) plans without adding significant employer burdens--especially on small businesses. Under the current wage reporting and tax collection process, it would take at least 7-19 months for every dollar contributed to an individual's account to be sorted out from aggregate payments and credited to his or her IA. This 7-19 month "float period" could result in substantial benefit losses over time. Options for preventing such losses involve difficult trade-offs, such as increased government responsibility, increased complexity, greater employer burdens, and/or investment restrictions for beneficiaries. If legally considered personal property, the IAs of married participants could pose significant administrative challenges. Social Security today must obtain proof of marriage only at the time spousal benefits are claimed. But some IA proposals would require contributions to be split between spouses' individual accounts, requiring records on participants' marital status to be continuously update to ensure that contributions are correctly directed. Also, dealing with claims on individual account contributions in divorce cases could place IA record keepers in the middle o

Aged↗
PubMed1988

Computerized accounting for the dental office. Using horizontal applications general ledger software.

Remember that computer software is designed for accrual accounting, whereas your business operates and reports income on a cash basis. The rules of tax law stipulate that professional practices may use the cash method of accounting, but if accrual accounting is ever used to report taxable income the government may not permit a switch back to cash accounting. Therefore, always consider the computer as a bookkeeper, not a substitute for a qualified accountant. (Your accountant will have readily accessible payroll and general ledger data available for analysis and tax reports, thanks to the magic of computer processing.) Accounts Payable reports are interfaced with the general ledger and are of interest for transaction detail, open invoice and cash flow analysis, and for a record of payments by vendor. Payroll reports, including check register and withholding detail are provided and interfaced with the general ledger. The use of accounting software expands the use of in-office computers to areas beyond professional billing and insurance form generation. It simplifies payroll recordkeeping; maintains payables details; integrates payables, receivables, and payroll with general ledger files; provides instantaneous information on all aspects of the business office; and creates a continuous "audit-trail" following the entering of data. The availability of packaged accounting software allows the professional business office an array of choices. The person(s) responsible for bookkeeping and accounting should choose carefully, ensuring that any system is easy to use, has been thoroughly tested, and provides at least as much control over office records as has been outlined in this article.

Accounting↗
PubMed1990

The status and validity of accounts obtained at interview: a contrast between two studies of families with a disabled child.

Within the qualitative perspective, data generated in the interview context present particularly difficult problems of interpretation. The status and validity of respondents' accounts is unclear. One dimension underlying their production is that between public and private domains, and their corollaries in speech, 'public' (ought-type) accounts and those reflecting a 'private', and potentially much less acceptable, reality. This paper contrasts two apparently similar studies of families with a disabled child which resulted in entirely different sociological accounts of their situation. The data on which each was based almost exactly mirrors the distinction between public and private accounts. The first, Voysey's influential study, is a 'glowing' account of the way parents make sense of the problem by reference to 'official' versions of the situation and adjust, relatively unproblematically, to it. The second, the author's epilepsy study, is a 'gloomy' account of parents struggling to cope with the problem in an 'official' vacuum, within which doctors in particular are strongly criticised. Because the accounts on which the sociological account is based are not separable from the different research stances adopted by the investigators, it is not possible to know what status and validity to ascribe to them. In the epilepsy study, on the principle of triangulation, an attempt was made to validate parents' negative evaluation of doctors by reference to an observational study of medical encounters. In major respects, this confirmed their version of the situation. It is suggested that attention to the type of accounts produced in interview, together with the use of triangulated data-sets, goes some way towards resolving the problem of their status and validity for a sociological account.

Adaptation, Psychological↗
PubMed2003

Representing childhood cancer: accounts from newspapers and parents.

We present an analysis of newspaper accounts and parents' accounts of childhood cancer. Newspaper accounts construct cancer as a threat to the entitlements and category-bound activities of childhood. Newspaper discourses around children with cancer are predominantly eulogising, constructing children as courageous, stoical and inspirational. Parents are characterised as confederates in the 'battle' against cancer; as fund-raisers; and as guardians of their children's identities. Little attention is given to parents' own needs. Parents' in-depth interview accounts suggest that newspapers are selective and privilege certain types of representations. Parents' accounts, like those in newspapers, construct childhood cancer as an assault on the rights of childhood. Parents also characterise themselves as having a range of obligations founded on dominant discourses about parenting. However, parents' descriptions bear little resemblance to newspaper accounts. Rather than the cheerful, uncomplaining and 'brave' newspaper representations of children, parents report that children can be distressed, anguished and difficult to manage, especially when being encouraged to submit to painful and frightening medical interventions. Parents themselves experience a range of quality of life impairments, including severe role strain, but find it difficult to voice these because they have to negotiate prevailing discourses about the duties of parenthood. Parents' accounts do not allow unproblematic access to some external reality; these accounts are just as constructed as newspaper accounts. Both newspapers and parents may draw on common discourses about parenting, childhood and illness, but newspapers are more likely to represent children in idealised ways and to marginalise parents as resources solely for their child's benefit.

Adult↗
PubMed2000

Personal account retirement plans: an analysis of the survey of consumers finances.

This report is based on data from the Federal Reserve Board's triennial Survey of Consumer Financies (SCF), which provides the most comprehensive data available on the wealth of American households. The most recent SCF data are for 1998, and this report tracks information from the 1992, 1995, and 1998 surveys. The percentage of families with a participant in a pension plan from a current job increased from 38.8 percent to 41.0 percent over this six-year period. If one focuses exclusively on those families with a worker and in which the head is under age 65, the percentage for 1998 increases to 56.8 percent. The previously documented trend toward defined contribution plans was confirmed and the significance of 401(k)-type plans for those families participating in a pension plan more than doubled, from 31.6 percent in 1992 to 64.3 percent in 1998. The percentage of family heads eligible to participate in a defined contribution plan that did so increased from 73.8 percent in 1995 to 77.3 percent in 1998. Of those families choosing not to participate in a defined contribution plan, 40.3 percent were already participating in a defined benefit plan. Overall, "personal account plans" represented nearly one-half (49.5 percent) of all the financial assets for those families with either a defined contribution plan account, IRA, or Keogh, in 1998. This was a significant increase from 43.6 percent in 1992. The average total account balance in personal account plans for families with a plan in 1998 was $78,417, an increase of 54 percent in real terms over the 1992 balance of $50,914 (expressed in 1998 dollars). For families participating in a defined contribution plan, IRA, or Keogh in 1998, 52 percent of the overall average was attributed to IRA/Keogh balances (43 percent from IRAs alone), and 44 percent of the average was from account balances in defined contribution plans with the current employer. There is a marked tendency for lower-income families to have larger percentages of their total personal account plan retirement portfolio in IRAs, although this trend appears to be fading with time. The impact of rollovers on the average total account balance for all individual account balances appears to be quite large: $152,451 for those with at least one rollover, versus $78,471 for all families participating in at least one personal account plan, regardless of whether they have had a rollover. The vast majority of the rollovers would appear to be going to IRAs, as opposed to a defined contribution plan with a new employer.

Aged↗
PubMed2006

Insurance choice and tax-preferred health savings accounts.

We develop an infinite horizon utility maximization model of the interaction between insurance choice and tax-preferred health savings accounts. The model can be used to examine a wide range of policy options, including flexible spending accounts, health savings accounts, and health reimbursement accounts. We also develop a 2-period model to simulate various implications of the model. Key results from the simulation analysis include the following: (1) with no adverse selection, use of unrestricted health savings accounts leads to modest welfare gains, after accounting for the tax revenue loss; (2) with adverse selection and an initial pooling equilibrium comprised of "sick" and "healthy" consumers, introducing HSAs can, but does not necessarily, lead to a new pooling equilibrium. The new equilibrium results in a higher coinsurance rate, an increase in expected utility for healthy consumers, and a decrease in expected utility for sick consumers; (3) with adverse selection and a separating equilibrium, both sick and healthy consumers are better off with a health savings account; (4) efficiency gains are possible when insurance contracts are explicitly linked to tax-preferred health savings accounts.

Choice Behavior↗
PubMed2005

Accounting principles, revenue recognition, and the profitability of pharmacy benefit managers.

OBJECTIVES: To contrast pharmacy benefit management (PBM) companies' measured profitability by using two accounting standards. The first accounting standard is that which, under Generally Accepted Accounting Principles (GAAP), PBMs are currently allowed to employ. The second accounting standard, seemingly more congruent with the PBM business model, treats the PBM as an agent of the plan sponsor. DATA SOURCES: Financial Accounting Standards Board (FASB) Emerging Issues Task Force Issue 99-19, U.S. Securities and Exchange 10-K filings and financial accounting literature. SUMMARY: Under GAAP record keeping, the PBM industry profitability appears modest. Using currently applied GAAP, the PBM treats all payment from the plan sponsor as revenue and all payment to the pharmacy as revenue. However, the PBM functions, in practice, as an entity that passes-through money collected from one party (the sponsor) to other parties (dispensing pharmacies). Therefore, it would seem that the nature of PBM cash flows would be more accurately recorded as a pass-through entity. When the PBM is evaluated using an accounting method that recognizes the pass-through nature of its business, the PBM profit margin increases dramatically. CONCLUSION: Current GAAP standards make traditional financial statement analysis of PBMs unrevealing, and may hide genuinely outstanding financial performance. Investors, regulators, pharmacies, and the FASB all have an interest in moving to clarify this accounting anomaly.

Accounting↗
PubMed2004

Accounting- versus economic-based rates of return: implications for profitability measures in the pharmaceutical industry.

BACKGROUND: Accounting-based profits have indicated that pharmaceutical firms have achieved greater returns relative to other sectors. However, partially due to the theoretically inappropriate reporting of research and development (R&D) expenditures according to generally accepted accounting principles, evidence suggests that a substantial and upward bias is present in accounting-based rates of return for corporations with high levels of intangible assets. Given the intensity of R&D in pharmaceutical firms, accounting-based profit metrics in the drug sector may be affected to a greater extent than other industries. OBJECTIVE: The aim of this work was to address measurement issues associated with corporate performance and factors that contribute to the bias within accounting-based rates of return. METHODS: Seminal and broadly cited works on the subject of accounting- versus economic-based rates of return were reviewed from the economic and finance literature, with an emphasis placed on issues and scientific evidence directly related to the drug development process and pharmaceutical industry. RESULTS: With international convergence and harmonization of accounting standards being imminent, stricter adherence to theoretically sound economic principles is advocated, particularly those based on discounted cash-flow methods. Researchers, financial analysts, and policy makers must be cognizant of the biases and limitations present within numerous corporate performance measures. Furthermore, the development of more robust and valid economic models of the pharmaceutical industry is required to capture the unique dimensions of risk and return of the drug development process. CONCLUSIONS: Empiric work has illustrated that estimates of economic-based rates of return range from approximately 2 to approximately 11 percentage points below various accounting-based rates of return for drug companies. Because differences in the nature of risk and uncertainty borne by drug manufacturers versus other sectors make comparative assessments of performance challenging and often inappropriate, continued work in this area is warranted.

Accounting↗
PubMed1999

The construction of mental accounts in benefits decision making.

Mental accounting describes the psychological creation of separate accounts or budgets for categories of decisions. This process simplifies complex budget decisions in ways that significantly affect consumer behavior (Kahneman and Tversky 1981, 1984) and has been incorporated into economic theory (Shefrin and Thaler 1988). The impact of mental accounts on benefits decisions is likely to be significant. The creation of these accounts is context dependent, and prior work has demonstrated that the source and timing of payments affects the allocation of resources into mental accounts. Results from this work demonstrate that other normatively unimportant factors of the choice such as presentation order impact the construction of mental accounts. These results describe mental accounting biases within the context of health care benefits and demonstrate that the construction of mental accounts is highly unstable and easily manipulated within this domain.

Chi-Square Distribution↗