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Case management at what expense? A case study of the emotional costs of case management.

Case management, which has its historical roots in community and public health, seeks to coordinate care, decrease costs, and promote access to appropriate levels of service. The case management system in this case study underscores the potential negative outcomes that can result from ignoring the holistic approach represented by an implemented case management system as a cost control mechanism. These negative outcomes not only include those expenditures of resources usually included when describing costs of care, but include those emotional costs of the system, patient, and care managers. Several needed system changes are identified and recommendations provided.

Case Management↗

The true costs of nursing care. A simple approach provides more accurate accounting of nursing services.

Since the prospective payment system mandated that they define and control costs more efficiently, healthcare organizations have separated nursing care from fixed overhead and reevaluated cost-containment restraints. Nursing objectives and daily data collection help to assign patients to one of four classes, from routine to continuous care. Providers can use these four classifications to monitor nursing productivity and allocate labor, employing such set variables as hours per patient day, indirect care, constant time, productive and nonproductive time, and profit margin. The result of this system is variable billing that more accurately reflects the true cost of nursing care. This proposed system of more open cost accounting makes patients and families more knowledgeable consumers. Administrators reviewing such cost breakdowns can evaluate nursing and other departments more effectively and market specific services more competitively. The system shows that nursing can be a profit, not a cost, center, which increases nurses' commitment and satisfaction. Organizations should encourage nurse managers to incorporate business into their traditional role. Cost accounting within nursing makes identified costs more manageable and increases efficiency throughout the organization.

Accounting↗

Maximizing the benefits of health care information systems.

Information systems can improve cost control, increase the timeliness and accuracy of patient care and administration information, increase service capacity, reduce personnel costs and inventory levels, and improve the quality of patient care. However, experience shows that most of these benefits will not occur automatically following system implementation. Operational problems may exist that diminish information timeliness, accessibility, and accuracy; policies and procedures may not have been sufficiently tailored to reflect the realities and intents of the systems; and personnel tasks may not have been adequately restructured. In order to realize the full potential of information systems, health care organizations must plan for and implement strategies that are designed to maximize such benefits. This paper describes a method for developing benefits maximization strategies. The processes used to define strategies and their outcomes are presented.

Cost-Benefit Analysis↗

Taking medicine back: Dx and Rx for orthopedic surgeons.

The present day practice of medicine is cause of considerable malaise for physicians. This article will invoke the ancient proverb, "Physician Treat Thyself". In other words this article addresses the problems from a diagnostic and therapeutic perspective, working toward a permanent cure. The history of medical practice groups, in-office surgery, and ancillary services is reviewed. The co-morbidity of health maintenance organizations, Evaluation and Management requirements, and cost shifting are mentioned. Finally a list of symptoms and the appropriate therapeutic measures are administered to control costs, increase income, and re-establish some form of authority in the practice of medicine.

Delivery of Health Care↗

Computerized cost analysis for the nursing skills laboratory.

Cost control and accountability are requirements in the academic world of the 1990s. The author describes a computerized cost analysis system in the nursing skills laboratory that enables administrators to determine the cost of teaching skills, increases efficiency level of teaching by the faculty, and provides data for budgeting and ordering expendable medical supplies.

Budgets↗

Nutrition support team recommendations can reduce hospital costs.

Providing nutrition support may be costly to hospitals under the prospective payment system. A nutrition support team, however, can be effective in controlling costs. To demonstrate the importance of the nutrition support team and to quantify the potential cost savings that can be achieved, a retrospective review of the effect of our team on hospital costs was conducted for the 12-month period of October 1989 to September 1990. The team supervises but does not regulate the use of total parenteral nutrition (TPN). During this time period, 176 patients received TPN. In 14 patients, the use of TPN was inappropriate, representing $65,349 in excess costs. After the cost of providing enteral nutrition to these patients (estimated at $2,430) was deducted, a net loss of $62,919 occurred. Nutrition support team action saved an additional $45,186 in hospital charges when recommendations to discontinue TPN were eventually heeded. Nutrition support team approval before TPN is initiated would achieve cost savings.

Academic Medical Centers↗

The economic burden of Barrett's esophagus in a Medicaid population.

OBJECTIVE: To estimate the overall healthcare expenditures of patients with Barrett's esophagus in the West Virginia Medicaid population. METHODS: West Virginia Medicaid-paid claims data for the period January 1, 1995, to December 31, 1999, were used for the study. The population included all individuals eligible for West Virginia Medicaid during the study period except for Medicare eligible- and Medicaid managed-care recipients. A prevalence-based approach was used to determine the cost of illness for Barrett's esophagus. RESULTS: The total cost of illness for Barrett's esophagus more than tripled, from $182399 in 1995 to $623864 in 1999, with approximately a 4(1/2)-fold increase in medical and more than a threefold increase in pharmacy costs. The average cost of treating Barrett's esophagus was found to be approximately $1207 per patient in 1999. Overall, pharmacy costs accounted for >66% of the total costs. Controlling for age, gender, and number of comorbidities, patients with Barrett's esophagus incur 21.2% higher overall costs than patients with gastroesophageal reflux disease and 62.4% higher overall costs than the general Medicaid population. CONCLUSIONS: The increasing prevalence of and resource utilization for Barrett's esophagus provide a framework for further analysis and implementation of policies aimed at appropriate allocation of resources for the state's Medicaid program.

Barrett Esophagus↗

Regulations vs. ideals: a case history of a hospice closure.

The cost of health care and health insurance and the increasing number of Americans without access to basic health services has become a primary issue in today's society. Leading politicians, economists, planners, and private individuals recognize the essential need to re-design the system and provide coverage to all Americans. However, the history of programs strangling in the red tape created by inflexible regulatory efforts to set standards, monitor performance, and control costs, thereby denying access to individuals they were specifically designed to serve, points to the need for an equally new approach to planning such a system. The authors have attempted to illustrate, through the case history of the closure of a hospice serving a poor socioeconomic area of New York City, the need for government regulators, program planners, and caregivers to recognize and define common goals and develop flexible and cooperative working relationships.

Facility Regulation and Control↗

Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment.

Financial analysis of 391 joint replacement operations performed during 1996 determined that almost 80% of the hospital cost for joint replacement procedures was generated in the operating room, nursing units, recovery room, and pharmacy during the first 48 hours of hospitalization. Attempts to control or reduce the hospital cost of joint replacement operations should focus on these specific areas of opportunity.

Arthroplasty, Replacement, Hip↗

Sowing the seeds of reform in 1994.

The prospects for reforming health care financing revolve around five questions: (1) Will Congress mandate universal coverage? (2) Will Congress require employers to pay most of the cost of employee coverage? (3) Will Congress authorize effective limits on health care spending? (4) What role should regional health alliances play in the reformed system? (5) How much change in health insurance arrangements can be implemented over the remainder of this decade? The author argues that the prospects are slight for quickly implementing reforms as sweeping as those that President Clinton has proposed. But prospects are good for beginning a process that will lead to universal coverage and effective cost controls. The key is the creation of regional alliances.

Cost Savings↗

Critical pathways: an integrated documentation tool.

A multipurpose six-page, three-fold flow sheet improves patient outcomes, meets JCAHO standards and facilitates easy tracking of a patient's progress. The flow sheet is divided into nursing process, expected patient outcomes, critical pathway and variance report. Outcomes management is an effective process to control costs and improve patient outcomes.

Documentation↗

Cost effectiveness of quality control in bacteriology.

The cost effectiveness of quality control in bacteriology stipulated by regulators is not established. The authors evaluated 111 surveillance procedures applied to 54 different operations; 100 had been performed in the authors' lab between 1965 and 1980, 91 of which had been performed 50 times. Forty-six conformed to CLIA requirements (CLIA-P). Thirty-seven others were CLIA-P, which had been modified (CLIA-PM) by reducing frequency and extent because few or no deficiencies had been observed. Eight others were devised by the authors (HH-P). The number detecting deficiencies, the per cent, and the mean per cent of deficiencies detected were: CLIA-P, 31, 67%, 3.5%; CLIA-PM, 8, 22%, 2.1%; HH-P, 8, 100%, 8.8%. Compliance with CLIA would cost HH $20,700/year (3.4% of total bacteriology laboratory cost). HH-P would cost an additional $9000/year. Discontinuation of CLIA-P not detecting deficiencies would reduce HH costs by $2900/year. Application of other low yield CLIA-P only to new lots of selected dehydrated media and fresh batches of selected reagents would reduce cost further by $2000/year.

Bacteriology↗

Variable budget: a management tool for laboratory financial planning and control.

There is no exact or perfect method of establishing a variable budgeting system. What needs to be done is to design a system that best fits the needs of your own particular situation. Meet with your supervisory staff. Agree which costs should be considered fixed, which are to be considered step-variable. Once this is accomplished, design your management reports to accommodate the desired results. Certainly, the variable budget concept will provide laboratory management with a more realistic report for cost control and departmental performance analysis.

Budgets↗

Cost-effectiveness of hospice care.

Is hospice cost-effective? What is perfectly clear is that hospice care overall provides different care than conventional care for the dying. There is much more home care, aimed at goals of comfort, dignity, and remaining at home, and that care is distributed over longer periods of time. There is less hospital care and less anticancer therapy. Nonhospice oncologic care provides more hospital services, particularly in the last month of life, and more effort to directly attack the malignant disease. There will always be those individuals whose goals and medical condition at a particular time make one type of care the best choice for that person. Current research strongly supports hospice care as cost-saving in the last month of life. The overall effect of hospice care on costs appears to be weakly positive. This is despite the fact that hospice benefits under Medicare include absence of co-payment, medications for the primary condition, and substantially more supportive services, which represent extra value and decreased out-of-pocket expenses to the consumer. A factor strongly favoring the development of cost-effective programs is the fact that most hospices began and developed as capitated systems of care. Thus the benefits derived from providers working with patients to control costs have accrued over time. The not-for-profit structures led savings to be put back into patient care, allowing more help for families and patients. An unresolved bias of available research is the question of the extent to which hospice patients are self-selected at the time of entry for their low interest in intensive and expensive services. The most positive estimates of cost-savings in hospice have required case-mix or time-of-entry adjustments to demonstrate savings. There is little support for cost-savings in the raw data comparing total costs in hospice and conventional care groups. However, there is also no evidence that hospice care adds to costs of care for the dying. Differences in outcomes between hospice- and conventional-care have been modest. Satisfaction with care has often been higher in hospice care, but care giver burden may also be higher. Other outcome measures have been inconsistently affected. The task of measuring differences is a difficult one. Hospice patients themselves are largely unavailable for measurement during the most critical periods of care, and proxy measures of benefit are necessary. Families also tend to be grateful (or critical) around the death of a loved one; this is related to complex family relationships and emotions not likely to be influenced by any health care program. It should also be noted that the task of measuring the success of hospice care has largely used measures originally developed for understanding the impact of conventional oncologic care. The tools for understanding the effects of spiritual counseling or homemaker assistance are much less well developed. The initial goals of the Medicare hospice benefit appear to have been met: a choice is available that responds to the needs and concerns of many dying people and their families, at no additional cost to the taxpayer. In addition, millions of families have received the benefit of the lower out-of-pocket costs for health services and medications. They have benefited from the broader definition of health which made simple, continuous support services such as homemaking and personal care available at no charge. The question of hospice cost-effectiveness would seem to be a question of the past. Other questions offer even more substantial challenges to continuing hospice care as it is now offered and into the future. There are no data to allow a critique of the current structure of hospice services, or to support the link between individual components of service and outcomes. This leaves the hospice concept open to considerable manipulation.(ABSTRACT TRUNCATED)

Cost-Benefit Analysis↗

The impact of DRGs on the cost and quality of health care in the United States.

The prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears to have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.

Diagnosis-Related Groups↗

How to reduce absenteeism: a comparative analysis.

One way for hospitals to control costs and increase productivity is to reduce absenteeism. This study evaluates the comparative effectiveness of seven prevalent absentee-control programs. Three are reward programs (bonus, buy back, and personal recognition); three are disciplinary programs (disciplinary action, no-fault, and year-end review); and one combines reward and discipline (paid leave bank). Data from 464 hospitals located in 42 states are analyzed. Statistical significance was obtained by using an ANOVA (p less than .05). The results suggest that a paid leave bank offers the most promise for controlling absenteeism. The data show no significant difference in levels of absenteeism among hospitals that use a mix of reward and disciplinary programs from those that use only reward or only disciplinary interventions. Implications of the findings are subsequently addressed.

Absenteeism↗

A case management tool for occupational health nurses: development, testing, and application.

1. Case management is a process of coordinating an individual client's health care services to achieve optimal, quality care delivered in a cost effective manner. The case manager establishes a provider network, recommends treatment plans that assure quality and efficacy while controlling costs, monitors outcomes, and maintains a strong communication link among all the parties. 2. Through development of audit tools such as the one presented in this article, occupational health nurses can document case management activities and provide employers with measurable outcomes. 3. The Case Management Activity Checklist was tested using data from 61 firefighters' musculoskeletal injury cases. 4. The activities on the checklist are a step by step process: case identification/case disposition; assessment; return to work plan; resource identification; collaborative communication; and evaluation.

Adult↗

Prostate cancer screening. Appropriate choices? Investigators of the American Cancer Society National Prostate Cancer Detection Project.

Early detection of prostate cancer has produced distinct stage migration of prostate cancer to earlier, more curable disease through optimized combined use of digital rectal exam (DRE), transrectal ultrasound, and prostate specific antigen (PSA). Currently available and emerging data can be assessed according to the World Health Organization's established criteria. As a significant public health problem, prostate cancer meets almost all the criteria for screening. While concerns about incomplete natural history, progression rates, and the need for better prognostic factors are valid, important social and public health issues also need to be considered. If future expenditures for terminal cancer care are minimized via reductions in therapy choices or coverage, no economic benefit for prostate cancer screening should exist. Narrow-focused attempts at cost reduction could inappropriately discourage high risk groups from participating in early detection programs, thereby eliminating the greatest potential benefit. Conversely, the greatest immediate cost-control issue for prostate cancer care in the United States could be the marked increased detection in men older than 75 years of age. Current cost savings are possible with improved public health education about the appropriateness of early detection in the oldest age groups or those with significant preexisting medical conditions. Prostate cancer control perhaps requires a tailored approach of screening in high risk groups and more appropriate "case finding" in the lower risk, general population. The initial combination of PSA and DRE can result in early detection, which is both ethical and economic, for individual patients consulting with informed physicians.

Aged↗