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PubMed1993

The German health care system: model or mirage?

Rising costs have spurred America's leaders to look abroad for a model upon which to pattern reform of our health care system. On the surface, at least, Germany would appear to have an ideal system combining universal access, high quality, free choice of physicians, and cost control. Germany has been particularly effective in curbing pharmaceutical and administrative expenses, and has avoided the progressive imbalance between primary care providers and medical specialists seen in America. However, Germany lags behind the US in emphasizing preventive services and in shifting services to the ambulatory setting. Also, an oversupply of physicians, lack of incentives to limit the volume of services, and a global budget cap have combined to induce physicians to do more while their incomes were falling sharply relative to those of other workers. Although selected elements of the German health care system could be beneficial to America, full-scale adoption of the German system is neither realistic nor desirable.

Cost Control↗
PubMedDate not supplied

Value-based health care. Part I: Physicians reestablishing clinical autonomy.

Clinical decision-making was once the sole purview of physicians, but no longer. Medical judgment has been usurped by third parties in the name of cost control. To reestablish this rightful authority, physicians must organize to assume the financial risks for their patients' health, using objective, clinical information to deliver superior quality outcomes. To successfully manage their patients' clinical and financial risks, physicians need to: (1) establish a structure independent of the hospital medical staff for outpatient contracting; (2) secure a capital partner that supports their independent, clinical decision-making; and (3) be leaders in acquiring and effectively using clinical information that accurately risk-adjusts and integrates both inpatient and outpatient data for all episodes of care. Physicians who acquire these skills will secure premium contracts from purchasers who are demanding value-based health care delivery.

Capital Financing↗
PubMed1998

Access to medical care under strain: new pressures in Canada and Australia.

Health policy changes intended to achieve cost control in OECD countries run the risk of reintroducing financial barriers to health care. However, although the problems faced are similar, different countries are dealing with the situation in different ways. For example, Canada and Australia, which share many similarities, have taken quite different policy paths in the last decade: Canada has preserved universal access, whereas Australian policy is promoting a two-tier system through the provision of public subsidies for private insurance. The evidence is that country-specific factors such as institutional arrangements, attitudes, and values intersect with economic and financial factors to shape policy outcomes. Moreover, the Canadian and Australian experiences suggest that in relation to access issues, attitudes and values are the key policy determinants.

Australia↗
PubMed1996

Health care system reforms in western European countries: the relevance of health care organization.

The problems within the health care systems of western European countries, and their current attempts at reform, can be analyzed by comparing those countries having national health care service (NHS) systems with those having social security systems. There are important differences in the structures, processes, and outcomes of these two types of health care systems, and thus in the problems they face. Greater cost control, equity, and, possibly, efficiency in improving the population's health are the advantages of NHS systems; however, public satisfaction is lower than in social security systems. Attempts to overcome this trade-off between the outcomes of the two types of health care systems are the main goal of the reforms. To achieve this goal, there has been a trend toward convergence of NHS and social security systems. For the NHS systems of Latin-rim countries, however, which have received less political commitment and public support than those elsewhere, this means a return to the former social security systems--a trend that may reintroduce the problems associated with these types of systems but without any evidence that public satisfaction will increase.

Cost Control↗
PubMed1985

Ten testing questions: five years later.

Five years ago, as the marketplace approach to health care policy started to gain popularity, important questions about the effects on the public welfare demanded (but did not receive) answers. Today these questions are as pertinent as when the author first posed them in 1980: How can we say that health care is a basic right and yet also support policies that put the consumer at risk? Since most hospitals still exist fundamentally to serve the public rather than to turn a profit, how can they reasonably be subjected to a policy strategy that favors survival only for the most prosperous? Without federal health planning, how can limited capital development funds be distributed rationally? What should replace cost as the method of paying hospitals? Will the public accept a cost-control strategy that puts physicians in control of the flow of dollars? How can graduate medical education be financed in the years just ahead? How can we adapt the services of the community hospital to the public's radically changing needs? How can medical and social services be effectively integrated, both inside and outside of hospitals? How can we ration health services equitably and humanely? What is the appropriate level of government for the financing of health services for the aged, the poor, and the disabled? No consensus on these issues exists among either the public or health care professionals, and government is unlikely to take the lead role in initiating a rational decision-making process. Until such consensus is reached, budget-cutting will be the primary activity of health care policymakers.

Cost Control↗
PubMed1995

The relationship between hospital charges and a modified Parsonnet risk score.

Health care now consumes approximately 14 percent of the U.S. Gross National Product (GNP). The amount of money spent on health care in America per capita and as a percentage of GNP far exceeds that of any other industrialized country. Currently, the financial burden of health care is being shouldered by government and business. The expenditure of billions of dollars of corporate profits on health care progressively undermines the global competitiveness of American business. These economic realities have emerged as the dominant driving force in health care reform. Cost control efforts to date have focused on strategies to limit inpatient hospital expenditures. The DRG prospective payment system is designed to reimburse a fixed sum based on the diagnostic category of the patient. The DRG payment is essentially independent of underlying patient characteristics that can potentially drive up expenditures. The work reported in this article was done to develop a descriptive formula that could be used to predict resource consumption in the care of patients. The financial viability of a hospital depends on its ability to predict expenditures, allocate resources, and choose its service areas correctly. Errors in financial forecasting in the era of prospective payment will result in financial failures of entire institutions.

Age Factors↗
PubMed1986

Cost savings achieved through cephalosporin use review and restriction.

Attempts to control costs associated with antimicrobial therapy and surgical prophylaxis with injectable cephalosporins in a 335-bed, acute-care, county teaching hospital are described. An ABC analysis of our pharmacy inventory revealed that 11.8% of the annual pharmaceutical budget was represented by cefamandole and that this agent was used primarily for surgical prophylaxis. Initial attempts to replace cefamandole with cefuroxime met with unexpected resistance from the department of surgery and were unsuccessful. A cost analysis revealed that annual savings in supply and personnel costs of $115,819 could be realized if cefazolin were substituted for cefamandole. Substitution of cefazolin resulted in an additional cost savings of $40,000 above our original proposal involving cefuroxime. Persistent efforts of the department of pharmacy aided the effective implementation of this alteration in cephalosporin prescribing practices.

Cephalosporins↗
PubMed1992

Swedish health care in perspective.

The evolution and current problems of the Swedish health services are placed in an international comparative perspective with other industrially developed democratic states as to cost control, distribution of facilities and personnel, management of waiting lists for services, and differences in use of services. All of these countries are experiencing the same aforementioned problems differing mainly in degree. It is suggested that Sweden as well as other countries needs to reconceptualize the meaning of equality of access relative to the apparent emergence of private insurance as waiting lists grow for quality of life procedures such as lens and hip replacement. A concept of a basic service for everybody and so-called luxury service for those who wish to buy it needs to be faced in political debate. It is clear that government is unable to finance and supply the range of demand of a consumption good represented by a modern medicine. In so far as Sweden has been regarded as a model it appears that no country is a model anymore. The complexities of a modern health service has overwhelmed all countries and can be regarded as a sublime loss of innocence.

Cost Control↗
PubMed1994

GUIDe (Guidelines for the Use of Intensive Care in Denver): a community effort to define futile and inappropriate care.

Several issues force us to critically evaluate futile or inappropriate intensive care. These issues include cost control, quality of care, and professional and family integrity. The debate has progressed along three avenues: ethical discourse, prognostic scoring systems, and debate in the courts. Despite these arenas of discussion, a consensus about futile or inappropriate care has not been reached. The healthcare profession and the public need to work together to forge a consensus. We describe one model that facilitates this political process. Guidelines for the Use of Intensive Care in Denver (GUIDe) is a consortium of metropolitan Denver hospitals and other healthcare institutions whose goal is to develop guidelines for the use of futile or inappropriate intensive care. The building of consensus starts with subcommittees (adult intensive care, neonatal intensive care, and long-term care) that present proposals at plenary sessions. Other subcommittees (public liaison and legal subcommittees) facilitate dialogue with the public. Feedback from the plenary sessions, the greater medical community, and the public lead to proposal revisions. We expect to present hospitals with actual guidelines in approximately 3 yrs.

Colorado↗
PubMedDate not supplied

Automating clinical practice guidelines: a corporate-academic partnership.

Implementation of guidelines offers one of the largest opportunities for quality improvement, utilization review, and cost control for the health-care enterprise. If guidelines could be implemented on a large scale, their adoption could result in $100 billion in annual savings as well as improve the quality of patient care. However, infrastructural barriers impede progress. Collaboration between the Laboratory Medicine Health Services Program at the University of Alabama at Birmingham, Columbia-Presbyterian Medical Center, and the Cerner Corporation, funded by the National Institute of Standards and Technology as part of the Advanced Technology Program involving ¿Information Infrastructure for Healthcare,¿ is focused on developing and delivering: 1) methods for creating operational forms of guidelines; 2) an effective computer-based architecture for implementing guidelines in clinical practice; 3) methods for packaging guidelines for wide distribution; 4) methods for testing the efficacy, safety, and acceptability of guidelines; and 5) a model for collecting, aggregating, and normalizing data from disparate systems. This hypothesis-driven research program is focused on laboratory medicine-based guidelines as a tool for developing, testing, and evaluating methods that can be implemented widely.

Academic Medical Centers↗
PubMed1993

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

Community Participation↗
PubMed2006

[What place can the health executive hold in the internal contract process?].

The current context of cost control relative to health expenditures forces hospitals to wonder about their management style. Therefore, the question of the efficiency of the health system is raised. Would the formalization by contract bring the beginnings of an answer? This is what its growing development within numerous public health establishments leads one to suppose, thus signing an evolution towards some new "medical and administrative" governance. Through this article, I therefore suggest to you a questioning on the essence of the contractual method, its stakes, its limits and especially a projective approach on the consequences of this management method considering the "health executive" function. As the stake in this reflection is to highlight the fact that if the health executive has a place acknowledged in the internal formalization by contract, its competence will constitute an increase in value in the contractual process. Indeed, this questioning seems important to me and this, all the more as the ordinance dated May 2, 2005 including "various arrangements relative to the functioning of public health establishments and modifying the public health code", stipulates that public hospitals should resort to the method of internal formalization by contract in setting up centres of activity and this, at the latest, before December 31, 2006.

Contract Services↗
PubMedDate not supplied

Econotherapeutics.

A program that represents the efforts of a hospital pharmacy management company to control drug costs is described. The program, Econotherapeutics, was developed in response to a changed health care reimbursement system that focused on the costs of products rather than the revenue generated by these products. For antimicrobial agents, a hospital-specific antibiogram is used to encourage cost-effective prescribing. A pharmacist intervention program, medical staff presentations, drug usage evaluation, management systems, and educational programs for pharmacists are all essential parts of the program. Centralized data gathering has allowed cost comparison of specific antimicrobial agents so that differences between variable cost estimates and costs based on actual use can be evaluated. Actual dose and dosage interval were used to calculate average cost per treatment day in a 121-hospital sample. Our cost data support the choice of cefotaxime over ceftriaxone.

Anti-Bacterial Agents↗
PubMed1996

Health service structures, management and professional practice: beyond clinical management.

At the heart of the operation of the health system is the relationship between managers and the various professionals who provide clinical services. While there is an inherent conflict between these two groups, this conflict has been avoided in the past by the managers playing a supporting rather than a controlling role. However, the current demands of cost-control are placing managers and professionals into direct conflict; a situation that many organisations are addressing by putting clinicians into management roles. This measure has had initial success in some situations, but it is argued that this success will be limited because clinical departments are not able to address many of the broader issues that affect the performance of health services. This paper proposes an alternative approach that will enable these broader issues to be effectively addressed, and also reduce the structural conflict.

Australia↗