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PubMed2004

Images of health insurance in popular film: the dissolving critique.

Several recent films have villainized the health-insurance industry as a central element of their plots. This Article examines three of those films: Critical Care, The Rainmaker, and John Q. It analyzes these films through the context of the consumer backlash against managed care that began in the 1990s and shows how these films reflect the consumer sentiment regarding health-insurance companies and the cost controlling strategies they employ. In addition, the Article identifies three key premises about health insurance in the films that, although exaggerated and incomplete, have significant factual support. Ultimately, the author argues that, despite their passionately critical and liberal tone, these films actually put forward solutions that are highly individualist and conservative, rather than inclusive and systemic.

Attitude to Health↗
PubMed1993

Containing use and expenditures in publicly insured long-term care programs.

British Columbia and Manitoba have the most developed and comprehensive publicly financed long-term care (LTC) programs in North America. For U.S. policymakers, these programs are large-scale natural experiments with public LTC insurance. During the 1980s, both provinces successfully contained the growth of public expenditures on nursing homes, and one province successfully contained the growth of public expenditures on home support services, adjusting for population growth. Because provincial cost-control methods are similar to those that some States already use, it is likely that managers could contain the growth of public expenditures once a publicly insured U.S. LTC program was implemented. The level of public expenditure would depend partly on the level of compensation for LTC sector personnel, which is relatively low in the United States.

Aged↗
PubMed2001

Identifying indicators of laboratory management performance: a multiple constituency approach.

The challenges for laboratory management posed by cost control, managed care, organizational restructuring, information networking and health system integration call for new measures to evaluate how effectively laboratories manage emerging performance expectations. This study identifies the Delphi panel method in achieving consensus on measures of effectiveness and considers a specific application, the identification of indicators of laboratory performance, from the perspective of key constituencies.

Attitude of Health Personnel↗
PubMed1996

Toward cost-effective care for persons with dual diagnoses.

Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.

Behavior Therapy↗
PubMed1982

Variations in physician utilization patterns in a capitation payment IPA-HMO.

Health care utilization data, using measures such as rates of hospitalization, physician visits, and specialty referrals, were collected for individual provider offices in an Individual Practice Association-Health Maintenance Organization (IPA-HMO) that used a capitation payment system to reimburse its primary physicians. Variations in health care utilization patterns between IPA offices were identified and examined for possible associations with other characteristics of these medical practices. As on indirect test of the effectiveness of the HMO's incentive system, it was hypothesized that IPA offices with a larger number of HMO subscriber-patients and those with a longer duration of membership in the IPA would exhibit practice patterns that would conform most with the HMO's cost control objectives. Associations were found between health care utilization measures and characteristics such as the specialty of physicians, but size of HMO patient load and length of IPA membership did not have the predicted effect. The findings of this study serve to identify several questions that need to be addressed in further assessments of the performance of IPAs that follow this general model.

Capitation Fee↗
PubMedDate not supplied

The effect of normative social forces on managed care organizations: implications for strategic management.

Drawing on institutional theory, this study examines how adherence to a number of "institutional" and "technical" environmental forces can influence the business success of managed care organizations (MCOs). The standards studied include: (1) institutional forces: socially accepted procedures for delivering care (access to quality care, availability of information, and delivery of care in a personal manner); and (2) technical forces: industry standards for cost control and efficient use of financial and medical resources. The most significant finding is that successful MCOs must conform to both institutional and technical forces to be successful. MCOs that conform to either one or the other type of standard were no more successful than those that conformed to neither. These findings have several important implications for MCO strategy. First, to be successful, MCO executives must understand the external environment in which they operate. They must anticipate and respond to shifts in that environment. Second, this understanding of the external environment must place equal emphasis on societal demands (e.g., for accessible care and information) and on technical demands (e.g., for cost-efficient care). These findings may well reflect that once managed care penetration reaches relatively high levels, marketshare can no longer be gained through cost-efficiency alone; rather, enrollee satisfaction based on societal demands becomes a key factor in maintaining and gaining marketshare. Institutional theory provides' some strategies for accomplishing these goals. Cost-containment strategies include implementing policies for cutting costs in areas that do not affect the quality of care, such as using generic drugs and reducing administrative excesses and redundancies. At the same time, MCOs must implement strategies aimed at improving conformity to prevailing societal perceptions of appropriate care, including providing patients more freedom to choose their physicians and encouraging and rewarding care providers for being friendly and personable. An MCO should work to inform the public of the organization's efforts to provide high-quality, low-cost medical care in a friendly, convenient manner.

Commerce↗
PubMed1989

National health insurance in America--can we practice with it? Can we continue to practice without it?

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.

Canada↗
PubMed1979

Cost containment through risk-sharing by primary-care physicians.

A new type of independent practice association has been organized to encourage primary-care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician or pediatrician and must be referred by that physician for all specialized care. The primary-care physician authorizes payment from his own account for all care provided to his patients. He shares any dificit or surplus remaining at the end of the year. After four years of operation, United Healthcare has 610 primary-care physicians treating 23,000 patients. Total hospital use during 1978 and 293 bed-days per 1000 patients, as compared with 479 for Blue Cross. The hospital-admission rate per 1000 was 88, as compared with 101 for Blue Cross. Average lengths of stay were 3.3 and 4.7 dyas, respectively. This plan represents another means to control costs in the private medical marketplace.

Consumer Behavior↗
PubMed1996

Managerial responses to Medicaid prospective payment in the nursing home sector.

The United States must soon address long-term care policy. Policymakers have sought cost containment through reimbursement policies that contain incentives for efficiency. Nursing facility administrators were surveyed twice following a significant change in Maine's Medicaid reimbursement policy to determine the effects of the change on their managerial practices. The administrators responded to some of the policy changes as profit maximizers, including instituting cost controls and benefiting from incentives. In other areas, such as staffing, staff pay, and accepting heavy care patients, the administrators did not seem to behave entirely as expected. Insights from organizational theory are useful for explaining some of the other behaviors. As long-term care reform is undertaken, a policy framework should include aspects of the internal environment of nursing facilities, such as administrator goals and organizational structure and mission.

Cost Control↗
PubMed1990

The politics of American health care.

The developments leading to the present American health care organization are traced. It is clear that hospitals have dominated at the expense of primary health care programmes. Health care costs have soared dramatically. There are particular problems inherent in a system shared between federal and state governments and a private health care industry. Attempts to provide a fully (or partially) tax-funded health service in the USA have been bedevilled by a number of factors. These include opposition from labour unions, politicians, vested-interest groups and, in particular, the American Medical Association. As part of its opposition, the AMA politicized itself in 1950. But, in the political literature, American nurses are not portrayed as being very politically active. Reasons for this are explored. The introduction of Medicare and Medicaid programmes is discussed and the legal, social and political implications. Recent attempts in the USA to control costs are assessed and new trends and new problems identified.

American Medical Association↗
PubMed1996

Physician leadership. The time is now.

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.

Communication↗
PubMed1989

The misinformation era: the fall of the medical record.

Medical record information has become less reliable than ever before despite the electronic information revolution in medical care and the authority medical records have been accorded in our society. Long flawed by errors introduced by medical personnel, patients, and machines, medical records have had a further decline in credibility as a result of the loss of confidentiality and the imposition of well-meaning but unrealistic cost-control regulations on medical practice. Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care. Until these deficiencies are corrected, our increasing dependence on medical records should be balanced by increasing skepticism about the value of the information they contain.

Confidentiality↗
PubMed1995

Perinatal regionalization versus hospital competition: the Hartford example.

OBJECTIVES: The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. BACKGROUND: The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. METHODS: The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. RESULTS: The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. CONCLUSIONS: Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Bed Occupancy↗
PubMedDate not supplied

Decreasing NICU Costs in the managed care arena: the positive impact of collaborative high-risk OB and NICU disease management programs.

Costs for preterm and critically ill neonates in a neonatal intensive care unit (NICU) can be astronomical related to the number of inpatient day's accrued and professional ancillary fees. NICU births are often associated with maternal risk factors such as previous preterm or low birth weight delivery, maternal infections, chronic disease states, substance abuse and/or human immunodeficiency virus (HIV) infection. Accordingly, Johns Hopkins HealthCare provides a disease management approach for the prevention of NICU births through "Partners With Mom." This maternity disease management program identifies pregnant women that could potentially generate high-dollar claims. The mission of the program is to reduce hospital/NICU admissions related to pregnancy complications and improve maternal/neonatal outcomes. If an NICU birth does occur, multiple avenues are pursued to control costs. By working in concert with Partners With Mom, the NICU Disease Management Program utilizes a multifaceted approach by tracking maternal risk factors, optimizing levels of required inpatient neonatal care and pursuing other avenues of revenue enhancement.

Case Management↗
PubMed1996

First-line managers: scope of responsibility in a time of fiscal restraint.

Fiscal restraint and government cost control have contributed to the downsizing and restructuring of Canadian health care organizations. As key players in the hospital sector, the role and responsibilities of first-line nurse managers have been significantly affected by these changes. This paper presents data from a survey of 200 first-line nurse managers in British Columbia which investigated the current scope of the first-line manager's role, the number of hierarchical levels within nursing departments, and views on managerial union membership.

British Columbia↗
PubMed1999

Leadership 99. Interview by Terese Hudson.

Cost control, customer service and collaboration among health care sectors rank as top concerns with panelists in H&HN's annual Leadership Report. Efforts to improve community health are a priority, too, but are often frustrated by financial and other constraints. The 16 panelists represent managed care, physicians, and hospitals and health systems.

Attitude of Health Personnel↗
PubMed1990

Trends in laboratory information systems: 1980-1990.

Laboratory information systems are charged with the responsibilities of controlling costs, improving productivity, improving reporting and expanding management control over operations. The LIS that can meet these challenges must allow significant flexibility, interfacing and integration with other systems, efficient operations and enhanced information management. In the current environment of "do more with less," a well-designed, cost-effective laboratory information system is essential to the economic survival of today's laboratory.

Clinical Laboratory Information Systems↗