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PubMed1994

Widespread assessment of risk-adjusted outcomes: lessons from local initiatives.

BACKGROUND: Controlling costs while maintaining quality is a crucial element of national health care reform. Prompted generally by concerns of local businesses, states and regions around the country have already initiated such dual efforts. The central component of these activities is the examination of risk-adjusted outcomes. ISSUES: Publicizing comparisons across providers and using these data for payer contracting have prompted several concerns among many providers, primarily involving reservations about the validity of the risk-adjustment methodologies and the fairness of the outcomes data reports. In contrast, business leaders recognize potential limitations in the data but argue that some information is better than none. They believe that these efforts have already saved money by forcing providers to compete and to justify unusually high costs. Troubling questions arise about whether publicizing their outcomes may prompt providers to avoid especially sick and high-risk patients. Although common themes emerge, each of these initiatives to monitor risk-adjusted outcomes has had to address specific local concerns. The form that these local initiatives take is influenced particularly by relationships between the business and provider communities and their respective visions of how to motivate change in the health care sector. SUMMARY: In some regions, businesses and providers have worked collaboratively, whereas in others relationships have been strained. One major problem in making objective decisions about risk-adjusted outcomes methods is the lack of clear evidence about whether such information truly measures quality of care. Whether a standard national quality monitoring program will satisfy local demands remains unclear.

Consumer Advocacy↗
PubMed2002

Health care in the information society: evolution or revolution?

This brief article is a commentary on the Haux et al. paper on Health Care in the Information Society: a prognosis for the year 2013. The commentary concentrates in particular on the underlying assumptions, which are at the core of the Haux et al. vision for healthcare in 2013. They assume that while there will be a shift towards increased patient-centred, community-based shared care, the underlying healthcare system will remain essentially the same. This commentary suggests that this is a conservative view and indeed questions its validity. Radical financial pressures to control costs as well as demands for equity fueled by more knowledgeable and better informed patients have the potential to bring about fundamental changes, with consequences for the way in which healthcare is delivered and in turn in how information and communications technologies are utilised.

Community Health Services↗
PubMed2002

Prescribing indicators and their use by primary care groups to influence prescribing.

OBJECTIVE: To examine the prescribing incentive schemes used by primary care groups (PCGs); to determine the prescribing indicators used under these schemes; and to assess whether the schemes were seeking to improve the quality of prescribing as well as controlling prescribing costs. DESIGN: Cross-sectional survey. SETTING: A total of 145 PCGs in the London and South-East NHS regions. PARTICIPANTS: Prescribing advisers in each PCG. METHODS: Descriptions of the prescribing indicators monitored by each PCG were obtained from a questionnaire survey of PCGs at the end of the 1999-2000 financial year. Financial information on prescribing and details about the implementation of prescribing incentive schemes for this period became available 6 months later and were obtained by a further questionnaire, follow-up telephone and E-mail surveys. OUTCOME MEASURES: Prescribing indicators, prescribing budgets and spend. RESULTS: One hundred and twenty-one out of 145 (83%) PCGs replied to the questionnaires about prescribing indicators and 129 out of 145 (89%) replied with details about their prescribing costs. The most frequently monitored prescribing indicator was generic prescribing, used by 106 out of 121 (88%) PCGs. The most frequently used clinical areas for prescribing indicators were antibiotics (76% of PCGs), gastro-intestinal prescribing (68%), non-steroidal anti-inflammatories (37%) and cardiovascular prescribing (32%). Seventy-six (63%) schemes also used non-prescribing analysis & cost (PACT) based data for their incentive schemes such as information from prescribing audits and reviews of repeat prescribing protocols. Only 33 (23%) had reached agreement with their practices enabling all prescribing indicator information to be disseminated on a named basis to allow practices to examine each others' prescribing data. CONCLUSIONS: Prescribing incentive schemes usually include targets for improvements in prescribing quality as well as cost. PACT-based data were used for cost control and quality improvement but non-PACT data were almost entirely used to promote prescribing quality improvements. The validity of non-PACT data was questioned as was the choice of some indicators that appeared to have been selected without full consideration of current expert opinion. Further work is needed on which indicators are most likely to act as catalysts to prescribing change.

Drug Prescriptions↗
PubMed1987

Ethical issues in the use of a prospective payment system: the issue of a severity of illness adjustment.

The current Medicare prospective payment system has many positive incentives for hospitals to control costs. Hospitals are increasing outpatient surgery, decreasing admissions, decreasing length of stay, and decreasing use of ancillary services. These are just the effects that Congress and the Health Care Financing Administration hoped for to save the Medicare trust fund. However, there has been evidence of some adverse outcomes including premature discharge, "dumping" sicker patients and patients without insurance, and adverse impact on hospitals with specialty centers. We examine these issues and present a possible solution based on a new Computerized Severity Index.

Cost Control↗
PubMed1985

Maintaining quality of care while reducing charges in the ICU. Ten ways.

We believed that the dilemma of controlling costs yet maintaining quality of care might be approached in 10 ways designed to improve efficiency of care: principles of management, elimination of standing orders, classification of patients, written guidelines, mandatory communication, no repetitive orders, single order for single test, removal of monitoring catheters, constant administrative attention, and feedback. We monitored quality of care using the therapeutic intervention scoring system (TISS), mortality, utilization of bed days in the ICU, and the total hospitalization of 50 patients treated in April 1983 and, 8 months after the interventions, 50 patients treated in February 1984. There were no differences in the patient population, severity, outcome, or days. The total lab bills were $10,000 in 1983 and $6300 in 1984 (p less than 0.01). The total number of tests decreased by 2803 (42%) from 6685 to 3882, or 56 per patient per admission. Calculated ICU laboratory charges per patient decreased $3226 (53%) from $6210 to $2894. In 1983, while patients spent 15% of their hospital days in the ICU, they accumulated 61% of their total laboratory charges. In 1984, ICU days were 19% and ICU laboratory charges were 46% of the total. If the decrease of $3226 per patient is extrapolated to a year's population, this would decrease charges by over $2,000,000 in one 12-bed surgical ICU.

Clinical Laboratory Techniques↗
PubMed1991

An academic medical center's experience with mandatory managed care for Medicaid recipients.

This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.

Academic Medical Centers↗
PubMed1998

Prospective study of the accuracy of the surgeon's diagnosis in 2000 excised skin tumors.

Expeditious yet efficacious removal of skin tumors is a common responsibility for the plastic surgeon. The need to minimize potential risks for mortality or morbidity from undue or excessive surgical resections and to control costs by avoiding unnecessary procedures behooves us to make a precise clinical diagnosis preceding any decision even for such "minor" surgery. Just how accurate these decisions can be expected to be for a typical surgical practice was scrutinized by means of this prospective 4-year study involving the resection of 2058 skin lesions. Each lesion was initially assigned a clinical diagnosis after a brief gross examination and then compared with the pathology report, which was always considered to be the correct answer. Within these parameters, only 65 percent of all tumors were identified correctly preoperatively. Two-thirds of all lesions were benign. Three-quarters of benign lesions were as assumed, and 92 percent of all presumed benign lesions were benign even if incorrectly identified initially, whereas fortunately only 3 percent proved to be malignant. On the other hand, only three-fifths of malignant lesions were identified correctly clinically, yet only 11 percent were benign, implying that most such lesions properly deserved excision anyway. Therefore, approximately 90 percent of all lesions whether benign or malignant were removed appropriately without compromising the patient, but to expect a clinical acumen of 100 percent in this setting may not be realistic. The accuracy of the surgeon in identifying lesions as probably benign was certainly high enough that cost-containment mechanisms designed to deny authorization for their removal probably would be justifiable and difficult to appeal. Any suspicious or equivocal lesions still will require mandatory intervention despite such constraints, because often only histologic examination will allow a definitive diagnosis.

Basal Cell Carcinoma↗
PubMed2002

Pluralism, public choice, and the state in the emerging paradigm in health systems.

Today in developed nations, the public pays for most medical care, with the state and the medical profession or providers determining its nature, form, and level. But there is no well-defined institutional framework for revealing consumer preferences and enabling client choice about the nature and form of public entitlement. This thwarts the efforts of health system reformers to satisfy their clients and consequently promote equity and control costs--the raison d'être of publicly supported care. Consumers can be empowered in the emerging paradigm, however, in which the publicly financed system also contains competing fund-holding institutions that organize and manage the consumption of care (OMCC), such as HMOs and sickness funds. In a system in which individuals are entitled to health coverage, OMCC institutions can play an essential role in both shaping the entitlement and in expressing members' preferences. To do this, the OMCCs need to be financed through capitation and endowed with appropriate constitutional rights on how to use the funds.

Capitation Fee↗
PubMed1992

An overview of allocation and rationing: implications for geriatrics.

Geriatricians are faced with increasing pressure from insurers and the public to control costs. At the same time, subspecialist colleagues, patients, and the courts often demand ever more costly high-technology interventions. This conflict will only intensify given the sustained increase in the percentage of GNP spent on medical care. A number of prominent biomedical ethicists and others have explored rationing of medical care services as one response to these concerns. This is the second in a series of articles in the Journal in response to the Oregon Health Decisions Initiative and is designed to provide (1) a brief ethical perspective on rationing and allocation; (2) an analysis of our present, largely implicit, approach to rationing and allocation; and (3) some suggestions that might move the United States closer to a more coherent and reasonable means of allocating and rationing health care.

Aged↗
PubMed1982

Psychiatry in the general hospital: visualizing the changes.

The general hospital of the future faces the difficult task of maintaining quality of care in light of increasing demands for service and increasing efforts to control costs. Psychiatric units in general hospitals will share this challenge, reflected in such issues as the need to document the cost-effectiveness of services, delineate what circumstances justify the use of inpatient services, and resolve conflicts between (and obtain appropriate reimbursement for) all mental health disciplines. Psychiatry will find it easier to adapt to other changes in general hospital practice, such as the need for greater continuity of care and for varying levels of intensity of care, because of its previous experience in those areas. Through all the changes, psychiatry must continue to speak for the individuality of each patient, not only the psychiatric service but throughout the general hospital.

Cost Control↗
PubMed1987

The new structure of individual practice associations.

There are two types of HMOs: prepaid group practices (PGPs) and individual practice associations (IPAs). Because of rapid change in the HMO industry, the academic literature, which is based primarily on data from the 1970s, is dated in several ways. The literature has focused on PGPs, but IPAs are growing three times faster than PGPs and are likely to dominate the HMO industry in the near future. The literature indicates that a small proportion of an IPA physician's practice is capitated, but such practices often are as much as one-third capitated. And while the literature indicates that IPA physicians are rarely given financial incentives to control cost, such incentives are now common. In this decade IPAs have cut their hospital days per thousand enrollees. Furthermore, IPAs in which individual physicians or medical groups bear some of the financial risk of hospital costs appear to have the same rate of hospital days as PGPs. Additional research is especially needed on cost and quality of care in modern IPAs.

Capitation Fee↗
PubMed1984

Health care and social work services: present concerns and future directions.

This article reviews eight major social-health care issues of the eighties: controlling costs; access to care; changing organizational patterns; solo versus interprofessional care; regulations and accountability; social reform/special interest movements; ethics and values; and changing urban populations. The author formulates how changes in our medical care systems will affect the practice of social work in health care settings.

Cost Control↗
PubMed2003

Insurance coverage and health care consumers' use of emergency departments: has managed care made a difference?

How successful has managed care been in controlling costs and consumers' inappropriate use of health care services? This study compares national data from 1992 and 1996 to determine the effect of managed care on appropriateness of ED utilization. ED utilization was described in two ways as defined in Gooding, Smith, and Peyrot (1996): (1) urgency of visit (urgent vs. non-urgent), and (2) appropriateness of visit taking into account the care provided upon visits (including treatment and diagnostic procedures) and disposition of visit (admit, transfer, and discharge against medical advice). Potentially appropriate visits were the non-urgent cases at which treatment procedures and/or non-routine diagnostic procedures were performed. All urgent visits were defined as appropriate. Study results reveal that consumers' ED misuse changed in complex ways over the period examined. Contrary to our assumptions based on earlier research, the pattern of change was not the same for the two different measures of misuse. Non-urgent use decreased, as hypothesized, but there was an increase in non-urgent use which we have defined as inappropriate (i.e., no treatment and no non-routine diagnostic tests). ED misuse did not decrease more for insured than uninsured consumers, nor more for managed care than fee-for-service consumers. These findings bring into question the efficacy of efforts to address rising health care costs through controlling consumer utilization of services via managed care, efforts mirrored by many fee-for-service indemnity plans. Future research is needed to determine why this consumer misuse of the ED appears to continue and how the recent increase in the marketing of ED services may exacerbate this problem.

Community Participation↗
PubMedDate not supplied

Incremental change in the Australian health care system.

Australia is similar to the United States in that it is a federation of states, its medical profession is well organized and politically powerful, and it has a substantial private sector. Unlike the United States, Australia provides universal access to health care and has controlled its total health care spending to around 8.5 percent of gross domestic product (GDP). This paper reviews the role of private health insurance and recent initiatives to support this; the strategies used to control costs in the fee-for-service sector; and the capacity for experimentation in health care financing within a national system that guarantees universal access.

Australia↗
PubMedDate not supplied

The changing face of managed care.

Managed care plans--pressured by a variety of marketplace forces that have been intensifying over the past two years--are making important shifts in their overall business strategy. Plans are moving to offer less restrictive managed care products and product features that respond to consumers' and purchasers' demands for more choice and flexibility. In addition, because consumers and purchasers prefer broad and stable networks that require plans to include rather than exclude providers, plans are seeking less contentious contractual relationships with physicians and hospitals. Finally, to the extent that these changes erode their ability to control costs, plans are shifting from an emphasis only on increasing market share to a renewed emphasis on protecting profitability. Consequently, purchasers and consumers face escalating health care costs under these changing conditions.

Consumer Behavior↗
PubMed1998

Neonatal hospital lengths of stay, readmissions, and charges.

OBJECTIVE: To evaluate trends in length of hospital stay, hospital charges, and readmission rates of Wisconsin newborns from 1989 through 1994 in light of recent policies requiring earlier discharges after delivery of newborns. METHODOLOGY: Two data sources were used: 1) 1989-1994 Hospital Inpatient Discharge Data from the Wisconsin Office of Health Care Information, and 2) 1994 birth certificate and matched infant mortality data from the Wisconsin Center for Health Statistics. Average lengths of stay and average hospital (delivery and readmission) charges were calculated, and readmission rates were estimated for full-term, premature, and sick newborns. RESULTS: There were 368 955 full-term and 26 668 premature newborns in Wisconsin from 1989 through 1994. The average length of stay decreased by 24% in full-term newborns from 1989 through 1994, while average hospital (delivery and readmission) charges rose over 40% during the same period. Average length of stay for premature infants increased by 24% while their hospital delivery charges increased 214% during the study period. Readmission rates halved, yet charges per readmission doubled for full-term infants. More than twice as many full-term newborns were classified as sick in 1994 (43%) compared with 1989 (19%). CONCLUSIONS: Managed care efforts to control costs of neonatal care through earlier newborn discharge policies may have limited impact. Physicians or hospitals may be compensating for these policies by classifying more newborns as sick, thereby allowing for longer hospital stays to be reimbursed by the insurance carriers. Premature infants, <7% of the total births, account for half of all hospital delivery charges. Efforts to reduce premature births may have a greater impact on neonatal health care costs than efforts to discharge full-term newborns earlier.

Birth Weight↗
PubMed1998

The role of pharmacoeconomic evaluations in disease management.

Disease management is a systematic approach to a health condition or a healthcare intervention that organises preventative, interventional and care approaches throughout the continuum of care and which measures outcomes in terms of populations, not individuals. Disease management's advantage over the current component system is that it stresses prevention over acute treatment of a chronic disease. Patients with better control of their chronic diseases will likely have a decrease in the use of emergency room and inpatient hospitalisation services, thereby improving clinical outcomes of patients. To achieve these goals, disease management uses pharmacoeconomic evaluations and outcomes measures to provide information that helps build formularies and clinical practice guidelines. Several problems exist in integrating pharmacoeconomic studies in disease management models, such as the need for more integrated information systems, standardisation and who should perform these evaluations. Some possible solutions will be addressed in this article. With greater emphasis being placed on controlling costs, the need for pharmacoeconomic evaluations in the design of disease management models will continue to increase in the future.

Cost Control↗
PubMedDate not supplied

Achieving compliance with the European Working Time Directive in a large teaching hospital: a strategic approach.

This paper describes the strategy which achieved European Working Time Directive (EWTD) compliance at the Royal Free Hampstead NHS Trust in medicine and surgery. Compliance with EWTD regulations was assessed by diary card exercise, clinical care assessed through critical incident reports, electronic handover documents and nursing reports, training opportunities assessed by unit training directors, cost controls assessed by finance department analysis, and workload assessed by staff attendance on wards, in casualty and in theatres. There was a change in focus of care to a consultant-led, specialist registrar- (SpR-)driven service extending into evenings and on weekends, coupled with a move to a multi-skilled team for night cover, and to a move from traditional on-call shifts to a full shift system across both medicine and surgery. Compliance with the EWTD was achieved whilst maintaining good standards of clinical care, ensuring training opportunities for doctors in training, controlling payroll costs, removing the need for locums, and reducing workload for both junior doctors and consultants.

England↗