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A disease management program developed by a Wisconsin provider has made impressive inroads in reducing the cost of care for diabetes, asthma, and preterm deliveries, where hospital days dropped by 75%.
The long-term outlook for managed care may be threatened by current capitation-rate-development methods that adjust risk for age, gender, geographic area, income level, and occupation, but not health status. Not only provider payments, but also patient access may be compromised as a result. New risk-adjustment methods that categorize patients into groups based on their current health status and anticipated disease progression allow fairer distribution of the essential components of costs to deliver healthcare services to the at-risk population, and improve upon HCFA's adjusted average per capita cost (AAPCC) rates and recently implemented principal inpatient diagnostic cost group (PIP-DCG) risk-adjustment methodology.
Quality assurance (QA) and risk management (RM) programs are intended to improve patient care, meet accreditation standards, and ensure compliance with liability insurance policies. The purpose of this project was to obtain and disseminate information on whether dental schools integrate QA and RM and what mechanisms have been most effective in measuring accomplishments in these programs. All sixty-five U.S. and Canadian dental schools were sent a twenty-nine-item survey, and forty-six (71 percent) schools responded. The main findings are as follows: 66 percent had a written QA program combined with a QA committee; 95 percent received administrative support; there was wide variation in the makeup of the QA committee; many institutions reported significant changes resulting from the QA program; and over half of the respondents merged QA and RM in some fashion. To develop or maintain an effective QA/RM program, the authors propose the following: obtain active support from the dean; develop goals and mission/vision statements; include trained personnel on the committee; establish wide levels of involvement in the QA program; develop QA measurements to ensure compliance with institutionally developed standards of patient care; and establish continuous cycles of improvement.
Since January 1, 2000 licensed acute care hospitals as well as prevention and rehabilitation hospitals are under legal obligation to implement an internal quality management system. Uncertainty remains, though, about the minimal standards required for these quality systems and which requirements hospitals will have to meet in terms of quality assurance and transparency. The respective provisions of the German Book V of Social Security Code do not define such measures, but leave it to a joint commission of providers and purchasers to agree on fundamental standards and general conditions. This paper aims to outline the development of standards of quality systems for hospitals in the Federal Republic of Germany, considering current trends and tendencies in health care on the basis of legal preconditions, government initiatives and activities of the self-government bodies.
Sexual health appears to be an ideal candidate for a managed clinical network, although there are doubts about whether networks deliver better patient care. With no dedicated staff, clinicians have to put in much of their own time to establish and run a network. For SWAGNET in south-west London, Inclusion is a problem. HIV teams are large and multidisciplinary--everyone needs to be represented.
Industrial engineering applications in the hospital industry first began in 1910. This paper traces the evolution of hospital industrial engineering in five distinct phases. For each of the major phases, this paper presents the contributions made by industrial engineers. Many of the techniques advocated by industrial engineers are now being taught to hospital employees as hospitals introduce total quality management (TQM) within the health-care industry. TQM introduction has meant a new role for industrial engineers, as that of a teacher, coach, and a facilitator. This new role holds much promise for the improvement of quality and productivity in health care.
Strategic management of any business will enable it to prosper in challenging times of change. Strategic planning is not characteristically found only in large corporations. Indeed, small business, such as solo private practices, can gain much from the process. The successful practice is one that is proactive rather than reactive; it has learned to become the beneficiary of change, rather than its victim.
Has managed care taken over medicine in Texas? By Laurie Stoneham, Associate editor David Rogers, MD, remembers what it was like working in his dad's grocery store growing up in Tahoka, Tex. "I feel like I was treated better professionally as a grocery sacker than I am as a physician nowadays. That's hard to tolerate." Dr Rogers is not alone. Many physicians in Texas feel as though something has gone terribly wrong with a profession that's about helping people. Somewhere the sense of fair play has been lost.
BACKGROUND: Despite the high prevalence of urinary incontinence (UI) among older persons and the existence of effective treatments, UI remains underreported by patients and underdiagnosed by clinicians. We measured the occurrence of UI problems in Medicare managed care beneficiaries, frequency of physician-patient communication regarding UI, and frequency of UI treatment. METHODS: We used cross-sectional data from the 2004 Medicare Health Outcomes Survey, which measured self-reported UI (accidental leakage of urine) and UI problems in the past 6 months, 36-Item Short-Form Health Survey health measures, discussions of UI with a health care provider, and receipt of UI treatment. RESULTS: The overall incidence of UI within the past 6 months was 37.3%, consistent with previous estimates. Problems with UI were strongly associated with poorer self-reported health. Mean 36-Item Short-Form Health Survey physical and mental health scores were lower by more than 5 points (on a 100-point scale, P<.001) for respondents with major UI problems when controlling for age, sex, race, Hispanic ethnicity, and major comorbidities. These differences were among the largest of any condition measured. Only 55.5% of those with self-reported UI problems reported discussing these problems during their recent visit to a physician or other health care provider. The rate of patient-reported UI treatment was 56.5% and was lower (P<.001) for older individuals (eg, 46.3% for those aged 90-94 years) or those with poor self-reported health status (50.5%). CONCLUSIONS: Among older persons, UI is common, underdiagnosed, and associated with substantial functional impairment. There appears to be considerable opportunity to mitigate the effects of UI on health and quality of life among community-dwelling older persons.
The critical elements of the change process were designed into the strategic planning process and the pilot project for the Integrated Academic Information Management System (IAIMS) at the University of Maryland. These elements were: Support by the institutional leadership; a critical mass of interested participants from diverse groups across the organization, committed to the project and with ownership of the plan; a motivating level of dissatisfaction with the status quo; the construction of a scenario describing the desired future and an assessment of needs to achieve it; technical and consulting help; a pilot project with replicable features to demonstrate the concept and feasibility of the approach; and participation of opinion leaders initially with later identification of additional opinion leaders who would become part of the pattern of acceptance of the innovation and diffusion of the technology across the campus.
The purpose of this paper is to identify some of the organizational relationships that exist in the Irish healthcare system and to describe a development programme for senior health service managers developed, and being delivered, in the context of these relationships.
OBJECTIVE: This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy. STUDY DESIGN: A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression. RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis. CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.
In a heart failure (HF) disease management program (DMP), 4 patients with advanced HF and low ejection fractions had near full recovery within 4 to 45 months. When discharged to their primary care physicians, all 4 had severe symptom relapse and deterioration of their left ventricular function. Readmission to the HF DMP for a second time resulted in similar improvement in all parameters, as was seen the first time.
Drawing from previous research on individual differences, AIDS, and concerns for face, the author developed and tested a model examining the predictors (knowledge of AIDS transmission, level of homophobia, and concern for face) of AIDS fear and its organizational outcomes (perceived organizational consequences of hiring people living with HIV and attitudes toward disclosure of HIV-related information at the workplace). Data were collected using mail survey. Structural equation modeling was used to examine the relationships among these variables for 160 human resource managers. All of the hypothesized relationships were empirically supported. Implications of the research findings for human resource practices are discussed.
There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient-physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end-of-life care, care needs, and economic burdens. Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P =.02), spend more than 10% of their income on medical care (P =.02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P =.03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P =.59). Despite concerns about the threats of MCOs to the physician-patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.
Obesity is a health issue of epidemic proportions in the United States, creating a health and financial burden for Medicare, Medicaid, and commercial populations alike. While obesity has been linked to an increased risk for any number of health conditions, including heart disease, diabetes, and certain cancers, even a moderate weight loss can mitigate some of the negative medical consequences of unhealthy weight. Obese individuals are often unsuccessful at meeting their weight loss goals for a variety of reasons. Many are increasingly looking to gastric bypass surgery as an easy-fix weight loss solution without fully addressing underlying issues for the original weight gain and failures with previous attempts to lose weight. Because of this, over the past five years an increase in gastric bypass surgeries has resulted in cases with poor outcomes and a subsequent reaction by health plans and employers across the country to eliminate coverage. Others have determined that, while exclusion is not the answer, neither is coverage as standard policies allow. Instead, these groups are opting to implement best practice programs that merge individualized counseling, nutritional education/ planning, and physical activity goals with specific policy changes. Evidence has shown that they are achieving success in managing obesity and its impact on healthcare costs and outcomes.
BACKGROUND: In 1993, Colombia enacted and subsequently implemented a radical reform in its system of providing health care for the poor, moving in a short time from a traditional model of providing health services in public hospitals to a managed competition model in which the government buys health insurance for the poor. This study examines and attempts to draw lessons from the early experience with this reform. METHODS: Information was gathered from document reviews and interviews with key actors at both the national and local levels. Other quantitative data, such as data from existing national surveys and financial operating data, were also used as available. RESULTS: The new system made important achievements in its first few years, including the enrollment of 7 million Colombians (about half of the targeted population) in health insurance plans and improving access to care. Nevertheless, there were substantial problems with the lack of managerial infrastructure and flow of information needed for the new system to function properly. Because of these difficulties, substantial resources were wasted, and insurance coverage did not always result in true access to health care. CONCLUSIONS: Other countries contemplating similar reforms should educate health administrators and the public, and establish solid administrative capacity in advance of implementation. In Colombia, many initial problems still need to be overcome while maintaining and extending the programme's important accomplishments.
This paper examines the popular idea that competition among managed care plans will lead not only to lower prices, but also to improved quality. We explore the likelihood that competition based on quality will occur and that better quality care will result. First, we discuss key elements of competitive theory and then we attempt to apply them to markets for health care coverage and care. We identify the conditions necessary for competition to have the desired effects and assess the extent to which those conditions do or can exist. We conclude that in the USA, many consumers have no choice among plans and, therefore, cannot select one based on quality. Moreover, the evidence suggests that as long as price varies among health plans, consumers who do have a choice will tend to emphasize price, not quality, in making their selections. We conclude with suggestions to increase the likelihood that quality can improve as a result of competition.