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PubMed1998

Competitive forces and academic plastic surgery.

Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.

Academic Medical Centers↗
PubMed1992

Public and private insurer designation of transplantation programs.

In an effort to assure quality and contain costs, several major private health insurers now restrict payment of transplantation procedures to designated programs, often referred to as centers of excellence. These insurers underwrite coverage for over 100 million people. Few transplantation programs meet the criteria set forth by insurers, thus raising concerns about patient access to care. The criteria being used by five private insurers and Medicare were obtained and reviewed. Insurers now designate kidney, heart, liver, heart-lung, pancreas, and bone marrow transplant programs based upon total annual transplant volume as well as one- and two-year patient and graft survival rates. Transplant center criteria vary according to procedure and type of recipient (i.e., pediatric vs. adult). Most insurers require hospitals to perform a minimum of at least 6, and up to 50 procedures annually. Expected one-year patient survival rates may exceed 90% and are often higher than 80%, although standards are usually lower for heart-lung and bone marrow transplantation. In addition, if centers meet the minimum volume and outcome criteria, insurers expect transplant centers to discount per procedure changes by as much as 25%. Patients are often offered incentives to use designated centers with insurers frequently paying travel costs and reducing or waiving copayment amounts. The designation of transplant programs by third-party payers has merit, although program volume requirements may have less validity than individual transplant surgeon and physician experience. Other problems are also apparent. For example, discount pricing is suspect, given the lack of data on actual transplant procedure costs. Also, some insurers intend to regionalize transplant programs, thus unnecessarily limiting patient access to care. Alternatively, the concentration of transplant activity at a smaller number of centers may enhance research opportunities. Nonetheless, transplant professionals, hospital administrators, and patient advocates remain wary of insurer objectives. There is concern that the designation of centers is simply another method by which insurers can avoid paying for transplants.

Costs and Cost Analysis↗
PubMed1996

Who pays for failed organ procurement and what is the cost of altruism?

Our objective was to define medical complications and financial charges generated during the care of potential solid organ donors who fail to donate after consent has been obtained. A retrospective review of financial and medical records of potential organ donors was done at an urban level 1 trauma center. Total hospital stay (T1+T2) for the group was broken down into the interval between admission and diagnosis of lethality (T1) and between diagnosis of lethality and death (T2). Medical complications occurring during the hospital stay and charges generated during each time interval were abstracted. After consent was obtained, 19 of 53 (36%) potential donors failed to donate: 9 of 19 (47%) expired prior to legal determination of brain death; 10 patients failed to progress to brain death and were made DNR. Of these, 9 died within 24 hr, 1 survived 16 days; 6 of the 10 patients did not meet brain death criteria, and 4 were rejected by the OPO for reasons of infectious risks. There were 3.1+/-1.3 medical complications per patient. T1 was less than 4 hr in 16/19 (84%) potential donors and constituted a small percentage of the mean total hospital stay (37+/-10 hr). Charges generated during T1+T2 (33,997+/-25,843) and specifically during T2 (17,385+/-9453) were considerable. These charges were passed on to patients' families or third party payers though care was directed solely at organ procurement after diagnosis of lethality. We conclude that multiple medical complications are encountered in the care of potential organ donors; total hospital stays are short but expensive; more than 50% of charges generated during the total hospital stay arise from care provided after determination of lethality; and the goodwill of families to consent to organ donations of their loved ones appears to carry potential for significant financial burden.

Altruism↗
PubMed2001

Mental health issues in the workplace: a case for a new managerial approach.

Anger, stress, and depression in the workplace are growing concerns among management. Traditionally, health outcomes have functioned under the realm of workplace health professionals. This study assessed whether a traditional worksite health promotion program had an impact on mental health factors. The results suggested that worksite health promotion programs play a limited role in ameliorating work-related mental health outcomes. Rather, management must play a greater role in addressing workplace stress, anger, and depression.

Anger↗
PubMed2003

Privacy and confidentiality: the Health Insurance Portability and Accountability Act in critical care nursing.

Nurses are responsible to protect the confidentiality and security of patients' health information. In the critical care setting, these privacy and confidentiality issues may be even more poignant. If able to carry on with their normal lives after discharge, many of the patients that nurses treat will have some sequelae from their illnesses that could affect their careers, finances, and personal lives. This article reviews the current literature, presents a discussion of confidentiality and security as it applies to uniquely identifiable health information, and offers some "best practices" that can be used in daily practice. Furthermore, the author discusses the Health Insurance Portability and Accountability Act of 1996 and details some reasons why the act is not fully implemented a full 6 years after it was signed into law.

Confidentiality↗
PubMed2002

Health care reform and the pharmaceutical industry: crucial decisions are expected.

For the past 30 years, the largest growing segment of the United States economy is the health care industry. The United States is in a transitional period as American citizens born between 1946 and 1964, the Baby Boomer generation, reach retirement age. In recent years, pharmaceutical costs have been rising faster than the inflation rate, leaving the American public to ask many questions. A major area of interest to policymakers regarding the health care reform agenda is patient spending on pharmaceutical items. Government-funded programs such as Medicare and Medicaid are facing the possibility of running out of funds and require substantive reform. Pharmaceuticals are not covered under the basic Medicare programs. As a result, senior citizens are forced to cover their prescription expenses out of pocket or purchase supplemental insurance plans. This extra expense is leaving many senior citizens across the country struggling to support their ongoing medical needs.

Advertising↗
PubMed2002

Uncompensated care and emergency department utilization: a local study having national implications.

This article provides a comprehensive picture of the manner in which uncompensated care patients utilize the emergency departments (EDs) of two Central Florida hospitals. Specifically, this study assesses the impact of treating uncompensated and primary care patients in ED settings on scarce hospital and community resources. Recommendations are being offered to manage a troubling situation that is occurring with alarming frequency in today's health care system throughout the United States. Special emphasis is placed on recommendations addressing alternative triage and financing models that are considered to be both socially responsible and economically viable. The results of this study suggest strongly that health care organizations must find an alternative to the current trend in ED utilization, in order to meet the primary care needs of patients and not compromise the care provided to those with emergent conditions. The recommendations emanating from this study outline a mechanism that can improve the timeliness of emergency care to those in need, while at the same time, making available primary care resources to those seeking services through an emergency department.

Adolescent↗
PubMedDate not supplied

Consumers devise drug cost-cutting measures: medical and legal issues to consider.

Health care costs in general, and prescription drug costs in particular, are rapidly rising. Between 1996 and 2007 the average annual per capita health care cost is projected to increase from dollar 3,781 to dollar 7,100. [AQ1] The single leading component of health care cost is the cost of prescription drugs (currently 10% of total health care spending, projected to become 18% in 2008). The average cost per drug increased 40% during the 1993-1998 period. Forty-one million Americans have no health insurance, and those who have, have inadequate prescription drug coverage. [AQ2] To cope with this situation, many consumers are trying to economize by doing without the prescriptions or the appropriate doses, buying generics or medicines from Canada or Mexico, or splitting pills of higher doses to take advantage of the pricing policy of drug manufacturers. Some of these approaches are medically and/or legally acceptable, while some are dubious. Most adversely affected are the seniors and poor; for certain groups of seniors prescription drugs account for 30% of their health care spending. The problem must receive prompt concerted attention from consumers, insurers, pharmaceutical companies, and lawmakers before it gets out of hand.

Aged↗
PubMedDate not supplied

A review of current healthcare funding models.

As healthcare expenses grow, concern about how government and private agencies decide to allocate funds for healthcare resources and services also grows. Decisions for healthcare funding are not made arbitrarily but are based on sound ethical principles and practical considerations. This article is a review of 5 ethically based healthcare funding models discussed in the literature that are currently used to justify funding choices. If healthcare professionals and managers are better informed about the ethical reasoning behind funding choices, they could better determine which resource allocation alternatives to support. But where should we spend our resources? Although healthcare professionals have a duty to advocate for all healthcare recipients to receive a fair share of resources, the author concludes that our greater duty as a profession is to the good of society as a whole. Balancing allocation decisions by considering all of the competing healthcare funding models and the ethical bases for them is suggested rather than to advocate too strongly for favored models.

Choice Behavior↗
PubMed2006

Economic causes and effects of AIDS in South African households.

OBJECTIVE: To investigate the magnitude and temporal directionality of associations between illness and death, and income and expenditure, in households affected by HIV/AIDS. DESIGN AND SUBJECTS: A cohort study with repeated measures carried out in 405 households (1913 occupants), known to have HIV-infected occupants and their neighbours, in one rural and one urban area of South Africa. MAIN OUTCOME MEASURES: Monthly adult equivalent income and expenditure. Illness episodes and deaths attributed to HIV/AIDS, tuberculosis and pneumonia. METHODS: Interview surveys of household heads were conducted at baseline and five more times, biannually, providing information on household economics, illnesses and deaths. Regression analyses used marginal structural models and 'before-after' models to analyse changes. RESULTS: In marginal structural models, current or previous AIDS illness was independently associated with 34% [95% confidence intervals (CI) 23-43%] lower monthly expenditure, and current or recent poverty was associated with 1.74 (95% CI 0.94-3.2) times higher odds of an AIDS death. In before-after models, each AIDS death was independently associated with a 23% (95% CI 11-34%) greater expenditure decline over 3 years, and a 100 US dollars higher monthly expenditure at baseline was associated with 0.31 (95% CI 0.13-0.74) times as many AIDS deaths and with 0.41 (95% CI 0.27-0.64) times as many AIDS illness episodes over 3 years. CONCLUSION: AIDS deaths and illnesses predicted declining expenditure and poverty predicted AIDS, suggesting that both welfare and effective treatment are needed.

Acquired Immunodeficiency Syndrome↗