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PubMed1991

Forces of change in the health care system. Implications for cancer care in the 1990s.

Dramatic changes will occur in the health care system during the 1990s which will profoundly affect the delivery of care for cancer. Perhaps the most important factor is the aging of the population. As the proportion of people who achieve old age increases, the absolute prevalence and incidence of cancer will increase despite improved treatment techniques. This phenomenon will increase health care expenditures despite ongoing efforts to control costs. Second, there will be continuing efforts at cost control and increased emphasis on quality assurance and outcomes by third party payers. Providers will be scrutinized and compared with one another. The large payers of the nation's health care bills will demand proof of outcome and cost leading to bidding by providers and payment only to those who have the best outcome for the least money. Third, there will be an increasing emphasis on prevention and screening, in public health policy, an approach that may conflict with personal freedom. Fourth, there will be increasing deliberations and questions about the ethics of the health care system and treatment decisions. There will be continuing debate about the need for a rationing of health care and the right of individual privacy versus the states' right to preserve life. These changes will impact on all health care professionals whose practice includes patients with cancer.

Cost Control↗
PubMed1994

Government participation in physician negotiations in German economic policy as applied to universal health care coverage in the United States.

Systems of universal health care coverage in western industrial societies have usually established some form of government participation in negotiations over physician payment as a means of controlling costs. In the Federal Republic of Germany, a mixed private and public body. Concerted Action in Health Care sets a 'target' for physician and 'sickness fund' negotiators. This indirect form of government participation is effective in 'linking' fees with utilization during negotiations, avoiding inflationary trends inherent in fee-for-service systems. This target-setting factor is a necessary complement to negotiation of a 'pool' of money, wage level and technological adjustment factors, as contained in a model of German economic health care policy. These four elements of economic policy are recommended as cost control measures for office-based physician payments under conditions of universal health care coverage in the United States. Indirect government participation through setting 'targets' for negotiations is seen as consistent with established American institutional practices.

Cost Control↗
PubMed1986

The aging enterprise: in whose interests?

This paper revisits the aging enterprise in the context of the new competitive business ideology. Public policy has created an aging enterprise that assures that the needs of the aged will be processed and treated as a commodity. The medical-industrial complex, which comprises the most significant part of the aging enterprise, is a primary beneficiary of the recent reformulation of values and expectations vis-a-vis the state and the private sector. The new business ideology in health is aimed not only at controlling costs but, more importantly, at establishing health care as a market good like any other. Issues of access to needed services are raised for Medicare and Medicaid beneficiaries and for the uninsured. Budget cuts, medical cost control, and the market ideology are resulting in greater fragmentation, privatization, and corporatization of services, as indicated by the author's research on the private nonprofit health and social services sector in a sample of 8 states and 32 communities. In this paper, age-segregated politics and policies in the United States are challenged to utilize grass-roots political efforts that cross age and class barriers. Single-interest aging-based policies are criticized as a form of selfish separatism that could supplant an important and vitally needed intergenerational and coalition strategy.

Aged↗
PubMed2005

Consumer directed health care: ethical limits to choice and responsibility.

As health care costs continue to escalate, cost control measures will likely become unavoidable and painful. One approach is to engage external forces to allocate resources--for example, through managed care or outright rationing. Another approach is to engage consumers to make their own allocation decisions, through "self-rationing," wherein they are given greater awareness, control, and hence responsibility for their health care spending. Steadily gaining popularity in this context is the concept of "consumer directed health care" (CDHC), which is envisioned to both control cost and enhance choice, by combining financial incentives with information to help consumers make more informed health care decisions and to appreciate the economic trade-offs of those decisions. While CDHC is gaining attention in the popular press, business publications, and academic journals, it is not without controversy about its relative merits and demerits. CDHC raises questions regarding the ethical limits of consumer responsibility for their choices. While the emphasis on consumer choice implies that autonomy is the ruling ethical principle in CDHC, it must be tempered by justice and beneficence. Justice must temper autonomy to protect disadvantaged populations from further widening disparities in health care access and outcomes that could arise from health care reform efforts. Beneficence must temper autonomy to protect consumers from unintended consequences of uninformed decisions. Thoughtful paternalism suggests that CDHC plans offer choices that are comprehensible to lay consumers, limited in their range of options, and carefully structured with default rules that minimize potential error costs.

Bioethics↗
PubMed1997

Management tools and organization as key factors towards quality care: reflections from experience.

Health care organization in French hospitals has become an increasingly important issue, as efforts to ensure better cost control have increased financial constraints, as patients have demanded ever better results and quality, and as nurses' expectations for better working conditions have grown. Organizing a health care unit requires an articulation between individual efforts--necessary both for gathering accurate information on each patient and for providing patients with personalized care--as well as an integrated system of various logistics, specialized services such as nursing care, custodial care, technical examinations, and administrative procedures. Coordination between these different components continues to be a significant challenge to hospitals, as each category has developed independently its own specialty and sense of autonomy, resulting in different professional rationalities, cultures, approaches, and sometimes conflicting behaviour. Pointing out these difficulties is not sufficient to solve the problem, however, and since the management tools currently in use (activity measurements, procedures used to develop choices and judgements) are often kept in place for external reasons, they may actually perpetuate these behaviours. This paper is a set of reflections derived from a long period of experience and research in the management of French hospitals and health management institutions. It reports that the financial reforms implemented in budgeting procedures for French hospitals, and the efforts to control costs better in the national health insurance system, have resulted in new types of behaviour in physicians, nurses and health care managers, as well as the need for information that deals not only with health care activities but also with quality.

Cost Control↗
PubMed1994

Understanding the choices in health care reform. The Health Care Study Group.

This commentary is the joint product of a group of concerned scholars, many of them long associated with this journal. It assesses the debate over health care reform with the goal of minimizing the many myths and misunderstandings that exist. We address eight issues most likely to engender confusion: (1) the question whether cost control and universal coverage are contradictory goals, (2) the definition of universal coverage, (3) sources of bureaucracy in a reformed health care system, (4) the meanings of "competition" and "regulation," (5) the difference between short- and long-term measures to control costs, (6) subsidization of universal health care, (7) the role of medical care professionals in decision making about the delivery of services, and (8) the meaning of "choice" for patients and caregivers.

Competitive Medical Plans↗
PubMedDate not supplied

A report from the front line: policy & politics in health reform.

With federal action on health care reform at a standstill, states are faced with the choice of waiting for Washington or moving ahead. But states will have a hard time taking action in the face of economic problems and the need for additional revenues to address the problems of the uninsured. Grass roots advocacy is essential to put health care reform on the political agenda at all levels. Key elements of reform include allocating responsibility for payment and establishing methods of cost control. States have achieved limited success in controlling costs and expanding access but a federal framework is necessary if real progress is to be made.

Cost Control↗
PubMed2000

Movement toward individual health benefit accounts.

There are strong pressures for employers to pursue defined contribution health benefits with individual health benefit accounts such as Medical Savings Accounts (MSAs), Health Care Reimbursement Accounts (HCRAs), and Comprehensive Individual Medical Accounts (CIMAs). Health care consumers are becoming more assertive. The political backlash against managed care is eroding provider-based cost control mechanisms. Health insurance premium inflation is intensifying. Advocates of the movement toward individual health benefit accounts view them as a means of restoring autonomy to the physician-patient relationship and controlling costs. Opponents are concerned that individual health benefit accounts of any type will segment insurance markets, benefiting the healthy and wealthy at the expense of the chronically ill and the poor. Can these accounts be designed so as to achieve their positive effects and minimize negative effects?

Community Participation↗
PubMed2003

Mission possible: creating a technology infrastructure to help reduce administrative costs.

Controlling administrative costs associated with managed care benefits has traditionally been considered a "mission impossible" in healthcare, with the unreasonably high cost of paperwork and administration pushing past the $420 billion mark. Why administrative costs remain a critical problem in healthcare while other industries have alleviated their administrative burdens must be carefully examined. This article looks at the key factors contributing to high administrative costs and how these costs can be controlled in the future with "mission possible" tools, including business process outsourcing, IT outsourcing, technology that helps to bring "consumerism" to managed care, and an IT infrastructure that improves quality and outcomes.

Cost Control↗
PubMed1997

Components of the costs of controlling quality: a transaction cost economics approach.

This article identifies the components that contribute to a healthcare organization's costs in controlling quality. A central tenet of our argument is that at its core, quality is the result of a series of transactions among members of a diverse network. Transaction cost economics is applied internally to analyze intraorganizational transactions that contribute to quality control, and questions for future research are posed.

Cost Allocation↗
PubMed1990

Practice standards: implications for the internist.

Pressure for national standards of medical practice is increasing from cost control initiatives, medical malpractice liability, and the desire to simplify complex practice problems. Good standards need to be academically sound, focused enough to be clinically useful, yet flexible enough to allow for the realities of practice. Standards have already been created by several professional societies, including anesthesiology and cardiology in internal medicine. Although physician education is primary, controlling the use of expensive new technologies is an unwritten but important secondary goal. While standards have reduced malpractice liability in some professional groups, some clinicians are concerned that standards will be too academic and unrealistic. Currently, third-party payers are watching the development of practice standards but are hesitant to use them as criteria for determination of reimbursement. The federal government has a major interest in practice standards as a means of both monitoring quality of care and controlling costs. A number of agencies are studying the development of standards and their implications for use. Recent articles questioning the usefulness of common diagnostic tests and even the routine physical examination have raised concern among internists that restriction of practice and reimbursement will follow. Some evolving standards, such as screening for breast cancer, seem to ignore the realities of clinical practice and may generate more cost than they save. Internists need to provide input as standards are developed to guarantee appropriateness and feasibility.

Costs and Cost Analysis↗
PubMed2007

The impact of managed care enrollment on emergency department use among children with special health care needs.

BACKGROUND: Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED). OBJECTIVE: We sought to determine whether a managed care program can reduce ED use for children with chronic health problems. SUBJECTS: We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months. METHOD: We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use. RESULTS: Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V. CONCLUSIONS: A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness.

Adolescent↗
PubMed1989

The prospects for prepaid long-term care: the Arizona Medicaid experiment.

Arizona is adding long-term care to its prepaid, capitated alternative to Medicaid. This article discusses the potential for this major cost-control experiment. Experience suggests that those able to quality for long-term care will fare better than the poor did in the previous system. However, limiting eligibility will be the primary means of controlling costs; significant price competition is not likely to develop. The bidding process will serve more to transfer risk to contract providers than to improve program efficiency. Potential cost savings will be more than offset by an increased identification of need.

Arizona↗
PubMed1994

The integrated inpatient management model's clinical management information system.

The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.

Ancillary Services, Hospital↗
PubMed1989

Why it's time for a national health program in the United States.

The United States lacks a coherent national health program. Current programs leave major gaps in coverage and recently have become more restrictive. Influential policies that have failed to correct crucial problems of the health-care system include competitive strategies, corporate intervention, and public-sector cutbacks with bureaucratic expansion. A national health program that combines elements of national health insurance and a national health service is a policy that would help solve current health-care problems. Previous proposals for national health insurance contained weaknesses that would need correction under a national program. Based on the experiences of other economically advanced countries, a national health program could provide universal entitlement to health care while controlling costs and improving the health-care system through structural reorganization. Current proposals for a national health program contain several basic principles dealing with the scope of services, copayments, financing, cost controls, physician and professional associations, personnel and distribution, prevention, and participation in policy making. Support for a national health program is growing rapidly. Such a program would help protect all people who live in this country from unnecessary illness, suffering, and early death.

National Health Programs↗
PubMed1992

Controlling transcription costs.

Understanding what transcription costs and controlling the costs are two interrelated subjects, yet two very different subjects. Understanding what it costs is critical for your budgeting activity. Controlling the cost is essential for your management effectiveness.

Budgets↗