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PubMed1993

Economic impact of cost-containment strategies in third party programmes in the US. Part II.

This is the second article in a 2-part series that examines the economic impact of several different strategies used to control costs in third party programmes. This article investigates 5 different methods: (a) formularies; (b) capitation; (c) drug utilisation review; (d) prior approval; and (e) drug product selection. The published literature indicates that use of formularies decreases drug expenditures, but these savings may be offset by expenditures in other areas of healthcare programmes. Capitation, though less well studied than other strategies, may show some effectiveness in reducing costs by increasing generic dispensing and promoting switching from prescription drug to over-the-counter. Drug utilisation review, as a systematic programme of claims data review, has been shown to yield positive economic return in a variety of areas, including both impersonal and face-to-face educational interventions with healthcare practitioners. Prior approval and drug product selection both result in savings when examined in isolation from other aspects of healthcare. Cost-shifting, administrative costs and costs incurred because of possible decreased access to care have yet to be fully accounted for.

Capitation Fee↗
PubMedDate not supplied

Where does the US experience of managed care currently stand?

After an historical review of the advent of managed care in the USA, this article presents cost-control mechanisms, changes in the medical practice and consequences on patient health. The article also explains the development of the HMO using the transaction costs theory and the subsequent orientations of the US health care system.

Cost Control↗
PubMed2001

A comparison of breast cancer secondary prevention activities and satisfaction with access and communication issues in women 50 and over.

BACKGROUND: Between 1950 and 1990, the incidence of breast cancer increased about 52% and the mortality rate increased 4%. Prevention programs (mammograms and clinical breast exams) can positively affect both cost control and mortality rates. Balancing the costs of preventive screening against the potential savings is a part of an ongoing debate centering on the age at which women should have yearly mammograms. Yet, if all agencies agree that women aged 50 and over should receive yearly mammograms, then why are so many women aged 50 and over not being screened? METHODS: Using previously validated instruments, this study surveyed residents of Spokane County, Washington. Respondents (1,850 returned of 2,600) were compared over time by demographic characteristics and by insurance type to identify any significant differences between those who had preventative screens and those who did not. Issues involving access to screening and communication with healthcare providers were also examined. RESULTS: Factors that affect whether women receive preventative screening include insurance type, provider type, long waiting times, and poor communication among the doctor, the staff, and the patient. CONCLUSION: The most important determinant to whether preventative screening is being conducted is the relationship between the patient and their healthcare provider.

Breast Neoplasms↗
PubMed2006

Tonic dopamine: opportunity costs and the control of response vigor.

RATIONALE: Dopamine neurotransmission has long been known to exert a powerful influence over the vigor, strength, or rate of responding. However, there exists no clear understanding of the computational foundation for this effect; predominant accounts of dopamine's computational function focus on a role for phasic dopamine in controlling the discrete selection between different actions and have nothing to say about response vigor or indeed the free-operant tasks in which it is typically measured. OBJECTIVES: We seek to accommodate free-operant behavioral tasks within the realm of models of optimal control and thereby capture how dopaminergic and motivational manipulations affect response vigor. METHODS: We construct an average reward reinforcement learning model in which subjects choose both which action to perform and also the latency with which to perform it. Optimal control balances the costs of acting quickly against the benefits of getting reward earlier and thereby chooses a best response latency. RESULTS: In this framework, the long-run average rate of reward plays a key role as an opportunity cost and mediates motivational influences on rates and vigor of responding. We review evidence suggesting that the average reward rate is reported by tonic levels of dopamine putatively in the nucleus accumbens. CONCLUSIONS: Our extension of reinforcement learning models to free-operant tasks unites psychologically and computationally inspired ideas about the role of tonic dopamine in striatum, explaining from a normative point of view why higher levels of dopamine might be associated with more vigorous responding.

Animals↗
PubMed2006

Early effects of the prospective payment system on inpatient rehabilitation hospital performance.

OBJECTIVE: To assess changes in utilization and financial performance for inpatient rehabilitation facilities (IRFs) that shifted from Medicare's cost-based payment system to the IRF prospective payment system (PPS). DESIGN: A pre-post nonequivalent comparison group design. The intervention group included IRFs that changed to the PPS in fiscal year 2002. The comparison group included IRFs that were paid under the cost-based system. SETTING: IRFs in the United States. PARTICIPANTS: Final sample included 120 IRFs, with 26 IRFs in the comparison sample. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcome measures included utilization (length of stay [LOS], total discharges, Medicare discharges) and financial performance (revenue, expenses, profitability, Medicare payment and cost). RESULTS: PPS IRFs experienced a smaller decline in LOS, whereas Medicare cost per discharge increased at a lower rate. PPS IRFs reduced operating costs per discharge, whereas profit margin had a greater increase. CONCLUSIONS: IRFs under PPS implemented cost controls that lead to lower operating costs below the fixed payment to profit under PPS. Discharge growth for PPS IRFs was similar to the comparison group. PPS facilities did not implement a strategy that attempted to admit more patients to increase Medicare payments.

Costs and Cost Analysis↗
PubMed1997

Tonsillectomy and adenoidectomy pathway plan of care for the pediatric patient in day surgery.

The care of children undergoing tonsillectomy and adenoidectomy (T&A) in the day surgery setting can be costly, due in a large part to the length of stay after surgery. A clinical pathway standardizes the length of stay and, therefore, directly controls costs associated with outpatient T&A. A T&A pathway plan of care was developed at one institution to (1) decrease the cost of the procedure, (2) improve parent/patient satisfaction, and (3) maintain or improve the quality of care.

Adenoidectomy↗
PubMed1979

The competitive response of Blue Cross and Blue Shield to the health maintenance organization in Northern California and Hawaii.

The health maintenance organization (HMO) can provide an alternative to the predominant form of health care delivery in the United States, fee-for-service. Although market penetration of the HMO is relatively low in most parts of the country, the HMO has achieved a significant market share in a number of states. This paper examines the competitive response of Blue Cross and Blue Shield to the introduction of the HMO in two geographic regions with significant HMO activity, northern California and Hawaii. The evidence obtained from extensive interviews indicates that Blue Cross and Blue Shield plans have responded to HMO competitive pressure by establishing their own HMOs and by altering traditional procedures. HMO competition has stimulated Blue Cross and Blue Shield to make greater cost control efforts and to offer larger benefit packages. These results can have important policy implications for the role that HMOs are to play in cost containment.

Blue Cross Blue Shield Insurance Plans↗
PubMed1981

Physicians pivotal to successful cost containment efforts.

Medical staffs are involved in a variety of activities to lower health care costs in their institutions and communities. The various mechanisms for medical staff participation in and accountability for cost-effective management of hospital resources are explored in the following report on the National Symposium on the Role of the Medical Staff in Controlling Costs.

Cost Control↗
PubMed1978

HSAs and PSROs: can the odd couple learn to live together?

The Health Policy Program, UCSF School of Medicine, has conducted a two-year study of possiblities for cooperation between Health System Agencies (HSAs) and Professional Standards Review Organizations (PSROs). This paper, which is based on that study, focuses on two areas in which it may be impossible for either program to do its work properly without help from the other. HSAs cannot do health planning without the kind of data that can only be generated by the PSRO network. In turn, it may be hopeless for PSROs to try to change utilization practices unless HSAs can hold down the supply of beds and services. In spite of their interdependence, cooperation to date between HSAs and PSROs has been limited by their different membership, by restrictions on release of PSRO data, and by ineffectual HSA tools to control supply. With increasing government cost-control pressures, HSAs and PSROs are likely to find it necessary to work together as their activities begin to impact on each other.

Health Systems Agencies↗
PubMed2001

Activity cost analysis: a tool to cost medical services and improve quality of care.

This paper suggests an activity-based cost (ABC) system as the appropriate cost accounting system to measure and control costs under the microstatistical episode of care (EOC) paradigm suggested by D. W. Emery (1999). ABC systems work well in such an environment because they focus on activities performed to provide services in the delivery of care. Thus, under an ABC system it is not only possible to accurately cost episodes of care but also to more effectively monitor and improve the quality of care. Under the ABC system, costs are first traced to activities and then traced from the activities to units of episodic care using cost drivers based on the consumption of activity resources.

Accounting↗
PubMed2003

[Costs, costs and more costs: which one should we use?].

A cost is not an intrinsic feature of a product in the same way as temperature is for water and air. It is a calculation based on theory and convention. Costs may be characterised by their object (an hospital admission, a hospitalization day, a diagnostic related group, a treatment phase), their contents (costs directly attributable to the patient, controllable costs, including not only departmental operating costs but also costs resulting from the department's activity, full costs including administrative and infrastructure overhead costs), the point of reference from where the costs are considered (from the point of view of the family, the health professionals suppliers, the buyers, the health care system, or society) and the time when the costs were calculated. The cost framework which must be considered in any economic evaluation must relate to the budgetary concerns of the party whose involvement is sought in a health care project. There is no all encompassing study in this field; an evaluation performed for one type of contributor must only consider this party's point of view.

Cost of Illness↗
PubMed1987

Rate setting and hospital cost-containment: all-payer versus partial-payer approaches.

This article explores the relative cost-containment potential of hospital rate-setting programs that differ in the extent of payer coverage. While the analysis has implications for the impact that Medicare's prospective payment system (PPS) may have on overall hospital costs, this study is based on a comparison of all-payer and partial-payer state systems in the pre-PPS era. Data on hospital costs are drawn from the 1982 and 1983 American Hospital Association's Annual Surveys of Hospitals. The data confirm that all types of mandatory rate-setting systems are effective systems of cost control. The findings suggest that all-payer approaches may have some short-run advantages in terms of reducing the growth in hospital costs but that, as of 1983, they had not attained a lower level of costs (measured on a per-admission basis) than partial-payer systems.

Cost Control↗
PubMed1997

Variations in living donor graft rates by dialysis clinic: effect on outcome and cost of chronic renal failure therapy.

OBJECT: Examination of nephrology practice variations in living donor renal grafts to determine their influence on organ supply, quality, and cost of chronic renal failure therapy. MATERIALS: Saskatchewan chronic dialysis, cadaveric, and living donor renal grafts in 1983-1994 inclusive. RESULTS: Saskatchewan has three dialysis (I, II, III) and one transplant clinic. In the period the renal graft incidences/million population by these dialysis clinics by organ source were; Cadaveric: 23.1, 23.2, 21.1 (p = ns). Living: 5.4, 21.7, 8.3 (I or III vs II p < 0.000, I vs III p < 0.061). Total: 28.7, 44.7, 29.4. Living donor series A is 79 grafts in patients under age 60 with primary renal disease. Series B is 20 grafts in patients with secondary renal disease or over age 59. Series A ten-year actuarial patient survival is 92% and B 44%. Series A ten-year actuarial graft survival (including regrafts) is 77% and B 39%. Rehabilitation rate in patients with functioning grafts is 88.5%. Province-wide extension of the Clinic II living-donor graft rate in 1983-1994 would have produced 160 more renal grafts or 59% of those receiving chronic dialysis in 1994. The annual maintenance for a graft with the initial grafting cost taken over five years was $10,825 and the dialysis cost $40,100. CONCLUSIONS: (1) nephrology practice variations caused a 2.5-4.0-fold difference in living donor renal graft rates, indicating patient education by the attending nephrologist influences the living donor transplantation rate, (2) with such education the combined living donor and the cadaveric organ supply virtually meets graft demand, (3) living donor renal grafts yield a better quantity and quality of life and better cost control than dialysis with their annual cost being one-quarter that for dialysis.

Actuarial Analysis↗
PubMed1997

[Risk management to control increased and more costly malpractice suits].

Considerable increase of premium for risk-insurance demands now risk management (RM) in German hospitals. RM is more than quality management and has other goals. The method we are using to analyse the risk in hospitals is given in detail. By this way we cover the main groups of potential personal damage of patients and reasons and fundamentals to sue the hospital. There is no total quality management (TQM) in hospitals without RM in the medical field. RM can be successful only with the awareness of medical and nursing staff for risks and liability claims. In our experience there is a lot of potential damages and sources of liability demands even in hospitals which seem to be well managed.

Cost Control↗