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We have developed a quantitative "score card" for measuring the quality of 130 managed care organizations. This tool is currently being used in California as part of a large scale CQI process. When quality data are compared to cost data, we observe a negative correlation between cost and quality, consistent with the industrial model that better quality and lower cost can go hand in hand.
The New York State Department of Health has created a data warehouse to analyze and evaluate the Medicaid managed care program. Online query tools and reports, grouping tools such as Diagnostic Related Groups, and measurement tools such as Health Plan Data and Information Set (HEDIS) measures have been incorporated into the data warehouse. Other public health data sets including birth certificate data have also been integrated. The result is a powerful data set that can analyze information quickly and efficiently, with built-in data intelligence. Developed over time, this system can provide states, health insurance companies, and health data consortiums a roadmap on how to implement an integrated data warehouse solution.
This article describes ways to develop a Case Management System that includes the principles of care planning by using an interdisciplinary team across the continuum of health services.
This article reports on a study assessing the impact of a clinical guideline for the active management of labor. Modest changes were noted in the process of care with minimal impact on outcomes. Results might have been enhanced if more systems had been in place and if provider training had involved more comprehensive discussion and feedback on each of the components.
Case management models have been categorized many different ways, but classification into two generic models is proposed here: an interrogative model that relies on intense oversight with expected cost reduction and a patient advocacy model that relies on a brokering arrangement for services in the best interest of the patient. A randomized trial in an elderly, functionally impaired population resulted in the implementation of a patient advocacy model and suggests that this model results in increased service use and costs, but that increased survival rates may justify the additional cost.
Day Surgery (DS) and prehospitalization emerged in Italy--as it had previously in the United States and other European countries--as able to improve healthcare and reduce costs. The purpose of this study was to evaluate the impact of the Nurse Case Manager (NCM) Model on patients undergoing DS procedures. The study assessed the intensity of pain, anxiety, and stress factors, and the level of discomfort experienced. The quasi-experimental study design involved two groups of patients (at two different DS hospital centers): one using the NCM model (Ward A) the other based on team nursing (Ward B). All patients undergoing DS for (a) varicose veins, (b) inguinal hernia, (c) breast biopsy, and (d) hemorrhoids were included. A valid questionnaire interview based on 22 questions was used (1) the morning before surgery, (2) the evening after surgery, and (3) 48 hr after the operation, by telephone. Of the 145 patients that were involved, 66 were from Ward A (45.5%) and 79 from Ward B (54.5%). When patient care was based on the NCM Model (Ward A), it seemed that (a) the pathway before DS was more efficient; (b) they perceived lower levels of perioperative anxiety and pain; and (c) they recognized the DS center as a unique point of reference for all postoperative problems.
OBJECTIVES: To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems. DATA SOURCES/STUDY SETTING: Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities. STUDY DESIGN: This is an observational study with data collection over a six-year period. DATA COLLECTION/EXTRACTION METHODS: The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions. PRINCIPAL FINDINGS: The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results. CONCLUSIONS: General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.
BACKGROUND: Photographic images provide vital documentation of preoperative, intraoperative, and postoperative results in the clinical dermatologic surgery practice and can document histologic findings from skin biopsies, thereby enhancing patient care. Images may be printed as part of text documents, transmitted via electronic mail, or included in electronic medical records. OBJECTIVES: To describe existing computer software that integrates digital photography and the medical record to improve patient care and practice management. CONCLUSIONS: A variety of computer applications are available to optimize the use of digital images in the dermatologic practice.
Author reports on empirical study of medical directors at Blue Cross Blue Shield Plans regarding their awareness of and response to issues of pain management and palliative care for their insured populations.
The objective of this article is to describe the proceedings of a workshop organized by the Centers for Disease Control and Prevention (CDC) to 1) summarize current preventive care practices for people with diabetes in managed care organizations (MCOs) in the U.S., 2) understand the strengths and barriers to diabetes-related health services research in MCOs, and 3) highlight the major research questions and approaches to improve diabetes-related research in these organizations. Review and synthesis of presentations and discussions are provided. MCOs have considerable potential to enhance diabetes health services research because of their access to large diverse populations, novel health service interventions, and availability of data systems that link patients, health care providers, health care use, and health outcomes. Barriers to improved MCO-based research include confounding by concurrent interventions and secular trends, lack of control groups for rigorous evaluation of interventions, and the heterogeneous structures of MCOs. Future research, particularly if conducted in a collaborative environment, has the potential to improve the understanding of trends in health services, improve the understanding of characteristics of MCOs, and evaluate complex interventions directed at patients, health care providers, and systems of care.
Case management, a strategy to co-ordinate the services and care required by groups of patients, evolved in the US and is becoming increasingly popular in this country. The author explains what it involves, but warns that the evidence from the US of its advantages is very weak.
After presenting the quality model adapted by the health authorities, the authors refer to the development of quality methodology to the present day, and the importance of the self assessment of Quality focusing on the one according to the European Foundation For Quality Management (EFQM) adapted by healthcare organisations. Each criteria of the EFQM model is presented and its potential as a motivation for change by means of self assessment is discussed.
Hospitals often have looked to industry as a source of solutions to business problems. In recent years, they have begun to adopt a concept that has been used by manufacturers for more than 50 years--product line management (PLM). One characteristic of PLM is the designation of a product champion whose responsibility it is to promote the product both inside and outside the organization as well as to view for organizational resources to support the product. This article presents the findings of an exploratory study that indicates that although many hospitals are successfully utilizing PLM, a number of barriers to the implementation of this concept remain.
Managed care means a system of providing health care that includes: the selective association of providers in a community, the requirement that patients use these providers if they are to receive insurance coverage, and the active intervention by an outside agent in the doctor-patient relationship to control the health care delivery process.
TIMY is the ideal management system for novice data-entry personnel as well as for the research staff, nurses, and physicians at our facility. Access to data through the use of menus and security systems makes TIMY a user-friendly database. It has excellent data export capabilities so that more complex data analysis can be performed using dedicated software such as SPSS/PC, BMDP, or SAS. This provides great flexibility as well as the power needed for the study of complex data sets.
Employers, who pay for much of the healthcare in this country, are not waiting for government to restructure the healthcare system. In this cover story, PROFILES examines how two firms formed their own managed care networks to control healthcare cost and quality, and what hospitals did to become players. By understanding the employer' point of view, hospital marketers can better anticipate their needs and develop a marketing strategy to form closer relationships with employers, provide quality care at a lower cost, and increase their market share.
The managed competition approach was originated by Alain Enthoven, a professor at the Stanford University Graduate School of Business, in the late 1970s, and has since been refined by Enthoven and a group of colleagues meeting in Jackson Hole, Wyoming. This outline was presented by Enthoven at hearings on cost control in health care reform held by Senator Edward Kennedy (D-MA) in December 1992.
Physiotherapy needs to change to be relevant and appropriate to the delivery of health care in the future: departments in acute units will become smaller as therapists' expertise is required in the community. Sue Jackson, Physiotherapy Manager, North Staffordshire Hospital, describes the first steps in this culture change--and other professional and human resource issues.