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PubMed1989

Managed health care.

The fundamental components of managed-care plans are described; the development of managed-care programs is discussed; and the impact of managed care on pharmacy services and the price, quality, and accessibility of health care are reviewed. Health care can be considered to be managed when at least one of the following fundamental components is present: prospective pricing, "UCR" (usual, customary, and reasonable) pricing of services, peer review, mandatory use review, benefit redesign, capitation payments, channeling, quality criteria, and health promotion. The managed-care industry consists of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and managed fee-for-service plans. Managed-care reimbursement principles involve transferring some or all of the impetus for controlling use of services to the health-care provider. Means by which this is done include prospective pricing, services bundling, price discounts and negotiated fees, and capitation financing and reimbursement. Financial risk-sharing arrangements with providers--including hospitals, physicians, pharmacies, and home-care companies--are necessary for any managed-care plan to attain true control over its service costs. Use-review and use-management services are also fundamental to containing health-care spending. These include retrospective, concurrent, and prospective reviews of the necessity and appropriateness of medical services. Use management, like services bundling and prospective pricing, has been more effective in reducing costs of hospital inpatient services than costs associated with ambulatory care. Per case payments and services bundling have made individual charges for items irrelevant to hospital revenue. This has forced hospital pharmacy managers to become more sensitive to cost management. Drug formularies, improved productivity, and use of prescribing protocols are means by which hospital pharmacies have controlled costs. However, since shorter hospital stays are not associated with a linear decline in the need for drug therapy, reducing pharmacy operating expenses in proportion to the decline in hospital occupancy is probably not possible. Community pharmacies have responded to managed care by forming pharmacy services administrative organizations. Application of managed-care principles has reduced the use of inpatient hospital services by Medicare beneficiaries, helped HMOs and PPOs to lower prices for some services, reduced use of hospital services by HMO members, and redirected some inpatient hospital care to alternate-care providers.(ABSTRACT TRUNCATED AT 400 WORDS)

Capitation Fee↗
PubMed2000

MSOs revisited.

Explore the source record for details and available documents.

California↗
PubMed1993

Managerial effectiveness and the public sector. A Health Service example.

Attempts to address the question of managerial effectiveness in the UK's National Health Service, with particular reference to doctors holding managerial positions as clinical directors. Emphasizes a systems framework as a model for analysis of the concept of effectiveness. Identifies and discusses the importance of various managerial inputs (for example, managerial behaviour) and outputs such as objectives in business plans. Highlights the difficulty of establishing outcome measures in a service organization. Contrasts this approach with an alternative subjectivist approach which questions the validity of objective measures of effectiveness. The two approaches are not necessarily incompatible but require a convergence in the philosophical assumptions underpinning analysis. May be relevant to medical managers and other professionals acting as managers in service organizations.

Employee Performance Appraisal↗
PubMed1990

[Comparative study on head nurses' perception to own role and staff nurses' role expectation to their head nurse between university hospitals and general hospitals].

The organization of nursing department significantly effects the hospital management. Especially, the head nurse is one of the most important position because head nurse is a first-line manager in the hospital level, a middle manager in nursing service organizations level and the top manager in each nursing unit level. This study was attempted to show the ideal model and rule by compare head nurses' role perception with staff nurses' role expectation according to two types of hospital. The survey was conducted among 94 head nurses and 233 staff nurses who are working at 5 different University Hospitals over 600 beds and 93 head nurses and 218 staff nurses who are working at 12 different General Hospitals between 100-300 beds in Seoul. The data was collected in a period from 8th September to 13th October in 1989 and the instrument used for this study was based on Han's one and referred back to many literary sources and revised. The collected data was analysed by computer using S.P.S.S. program as a Mean, Percentage, Cronbach's alpha, Chi-Square, t-test and ANOVA. 1. The study was compared to the difference of the two subject group's general characteristics according to a type of hospital. As a result, there were significant differences in age, educational background and career. 2. This Study was compared to the difference of the two subject group's role perception and role expectation about each question according to a type of hospital. The result of this comparisons as follows: First, These were the most important issue between both groups: "Head nurse has to know about her staff's events and problems and then help them to solve that promptly" Second, These were the least important issue between both groups: "Head nurse has an interview with patient's family and visitors", "Head nurse is interested in her staff's privacy". 3. This study was compared to the differences of each role areas according to a type of hospital. As a result, there were no significant differences both two subject groups except nursing manager role in staff nurses' group (t = -2.893, df = 449.0, p = 0.004). 4. This study was tested to the difference of the two subject groups according to general characteristics. As a result, All of that there were no significant differences.

Hospitals, General↗
PubMed1999

Moral authority, power, and trust in clinical ethics.

Moral concerns about the authority, power, and trustworthiness of physicians have become important topics in clinical ethics during the past three decades. These concerns have come to greater prominence with the increasing involvement of large-scale private institutions in the organization and delivery of medical services, especially managed care organizations, and with the increasing involvement of government in the payment for and organization and delivery of medical services. When physicians act as the agents of large institutions or governments. the power of physicians over their patients increases. The purposes of this article are (1) to reflect briefly on the historical origins of the moral problem of physicians' power in medicine, and (2) to introduce the articles in the 1999 annual number of the Journal of Medicine and Philosophy on topics in clinical ethics.

Delivery of Health Care↗
PubMed2005

Treatment outcomes in 4 modes of orthodontic practice.

BACKGROUND: This study is a continuation of a previously published report on the outcome of orthodontic treatment provided in offices representing different modes of practice. METHODS: The sample consisted of duplicate pretreatment (T1) and posttreatment (T2) dental casts of 348 patients from traditional private orthodontic practices (5 offices, 134 patients), company-owned practices (5 offices, 107 patients), offices associated with practice-management organizations (2 offices, 60 patients), and general dental practices (2 offices, 47 patients). Methods were used to obtain random, representative samples from each office, starting with lists of patients who were treated consecutively with full fixed orthodontic appliances. The dental casts were measured by 2 independent judges who used the unweighted PAR score. RESULTS: Good interjudge agreement was shown on the initial casts, but the agreement was not as strong on the final casts. CONCLUSIONS: The measurements showed that treatment outcomes were generally satisfactory, although some significant differences between offices and management modes were shown.

Adolescent↗
PubMed1999

Creativity: the fuel of innovation.

Market-leveled changes occurring in the health care industry require new and creative models of organization, management, and service delivery. One of today's primary management challenges is the development of organizational cultures that value innovation, change, and creativity. The adoption of an ethic of innovativeness allows the organization to stretch the limits of individual and collective knowledge, skill, and ability to meet complex consumer needs. Creativity within organizations is influenced by management practices in conjunction with creativity-relevant work group skills. A common wisdom exists that professional nurses are creative in finding solutions for complex patient care needs. The expansion of this creativity within organizational systems will allow for the evolution of professional nursing practice, improvement in care delivery, and organizational performance.

Creativity↗
PubMed1998

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Adolescent↗