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PubMed1989

An appraisal of organizational response to fiscally constraining regulation: the case of hospitals and DRGs.

Results from analysis of 227,771 discharge abstracts from 68 short-term, acute-care hospitals and from interviews with a stratified random selection of 24 of the 68 chief executives of these hospitals demonstrate that institutions perceive implementation of DRGs as fiscally constraining, especially in light of other resource-constraining conditions (an increase in unemployment resulting in fewer people with hospitalization insurance, in addition to severe cuts in Medicaid rolls and budget). Hospitals responded to DRGs by decreasing the use of affected resources or services available to the hospitalized Medicare patient. In order to survive a more economically stringent marketplace, hospitals no longer protected the traditional core within the Medicare inpatient market. They opted instead to change practices and products at the unregulated margins of the DRG system.

Aged↗
PubMedDate not supplied

[The SUVA (Swiss Accident Insurance Association) statistics and quality control].

Overall quality control in medicine takes place on various levels: Physician--Hospital--Insurer--Authorities, each having different requirements. Comparative standards are rather seldom. A model for a comparative standard for insurer purposes, the medical statistics package SUMEST' is presented. This model is diagnoses oriented and includes parameters for the severity of the accident, cost of treatment and treatment outcome, all based on 5-year data pool results.

Accidents, Occupational↗
PubMed1990

Practice guidelines: a new reality in medicine. I. Recent developments.

There is growing interest in the use of practice guidelines for physicians as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Recent developments at the national health policy level suggest that practice guidelines will play an increasingly prominent role in the practice of medicine. The federal government has created a new US Public Health Service agency with responsibility for practice guidelines. Guidelines have been developed by more than 35 physician organizations and specialty societies. The American Medical Association and the Council of Medical Specialty Societies have endorsed practice guidelines and are organizing specialty societies to set policy on the subject. Academic medical centers have formed a research consortium on practice guidelines. Independent research centers (eg, the RAND Corporation and the Institute of Medicine) are developing methods for assessing appropriateness and setting guidelines. Other groups, such as hospitals, insurers, managed care plans, and private enterprises, are also directly involved. The implications of these developments are far reaching.

Academies and Institutes↗
PubMed1990

The politics of universal access: the Massachusetts Health Security Act of 1988.

This article analyzes the passage of an unprecedented state law, promising every resident access to affordable health insurance. The Massachusetts Health Security Act of 1988 was the product of a set of political and financial pressures that had been developing for nearly a decade. Hospital, insurance, and business interests were unable to reach a new accommodation on hospital payment. This logjam created the opportunity for a policy breakthrough, but did not inherently lend itself to progressive reform. It was consumer activism that forced the traditional powers in health policy to address the interests of the uninsured. By imposing a more public-interest agenda on the process, consumers were able to change the configuration of the stalemate, but could not resolve it. The particular terms of the stalemate, however, made possible a new, more aggressive role for state government in health policy. Unable to satisfy their competing interests within a policy framework that had universal access as a goal, traditionally powerful interest groups found themselves increasingly dependent on the state to broker a new agreement. While the many concessions made to these groups are likely to prove to be the bill's undoing, the unraveling of the agreement will not end the story. The same pressures which led to passage of the Massachusetts law and which are now causing other states to act will continue to exert their effect until a more durable solution is found.

Health Services Accessibility↗
PubMed1992

A controlled auction market is a practical solution to the shortage of transplantable organs.

All attempts relying on pure altruism to meet the demand for transplantable donor organs have failed and continue to fail. The incentive of commercialization of an organ market would seem to be the only practical solution at this time. It is almost impossible to set fixed prices for such priceless items as human organs. The only fair, honest, and feasible approach is the establishment of a free and voluntary national or international auction system under the strict supervision and control of an exclusive, specially created administrative entity free of governmental or other partisan interference. The resultant flow of funds could be enormous and would enhance the welfare of all strata of society. Wealthy buyers would be removed from current waiting lists; the donor pool greatly expanded to perhaps surplus; the resultant money used to relieve the financial burdens on families involved, hospitals, insurance companies--and also used to buy organs for the indigent on waiting lists, pay for surgeries and hospitalization, and thereby increase the income and surgical experience of more surgeons. This proposed new system should include all live as well as brain-dead donors, cadavers and consenting individuals facing purposeful and pointless destruction by judicial execution.

Altruism↗
PubMed1978

Private health insurance plans in 1976: an evaluation.

Private health insures collected a record $39.4 billion in premiums and returned $35 billion in benefits to their subscribers in 1976--a reflection of the steadily rising cost of health care, higher utilization, and the demand for expanded services. The industry experienced a net underwriting loss of $611 million, mainly because claims and operating expenses under insurance-company group business ran 3 percent above premium income. About 77 percent of the civilian population had some form of private hospital insurance, and about the same percentage had some form of surgical insurance. Lesser proportions were covered for other types of care. An estimated 12--13 percent of the population under age 65 had no economic protection against the costs of illness or health-related care--under either a private insurance plan or public program. Although virtually all of the aged were covered by Medicare, some 13--15 million bought private insurance, most of it under plans that covered some or all of the gaps in the Federal program.

Age Factors↗
PubMed1976

The social control of organizations in the health care area.

Available data suggest that the influence and autonomy of health care professionals have been declining. Of course, professional impact remains higher in health care than perhaps any other economic sphere, but the locus of much health care decision making has been shifting from independent professionals to employed personnel of large-scale government, hospital, insurance, and research organizations. The question therefore arises as to what shall replace this previous reliance upon individual professional ethics to assure the society that its newly powerful health care organizations are functioning in a desirable manner. In other words, what are to be the preferred mechanisms for socially controlling health care organizations. This paper traces three dominant belief patterns about how the characteristics of health care organizations and their environments produce desired control. It proposes that belief patterns have emphasized (1) the non-profit motives of many health care organizations; (2) the system of interrelationships that surround health care organizations; and (3) the vast differences among health care consumers. Choices from among these models continue to depend less upon knowledge of organizational functioning than upon political dispositions and social fancy.

Blue Cross Blue Shield Insurance Plans↗
PubMed1978

Physician responsibility for the cost of unnecessary medical services.

Most diagnostic and therapeutic services are ordered by physicians, but physicians practicing under fee-for-service conditions have few incentives to contain the costs of medical care. Without such incentives, effective cost control through mechanisms such as Professional Standards Review Organizations have been disappointing. Several legal approaches might be used to increase physicians' responsibility for the cost of unnecessary services--expansion of tort law, implied contact, redesign of insurance mechanisms, equitable estoppel and informed consent. However, increasing physician responsibility will require uniform but flexible definitions of medical necessity, reliable means for predeterming the need for services and effective penalties or incentives. We propose a peer-review system that would incorporate the sharing of financial risk among physician, hospital, insurer and patient in the fee-for-service sector.

Costs and Cost Analysis↗
PubMed1992

Actuarial status of the Social Security and Medicare programs.

The Boards of Trustees for the two Social Security and the two Medicare Trust Funds recently released their annual reports to Congress detailing the operations of the trust funds during 1991 and their projected financial status for future years. Based on the Trustees' best estimates, the reports show: The Federal Old-Age and Survivors Insurance (OASI) Trust Fund will be able to pay benefits for about 50 years. Congress will eventually need to take action to assure the long-range financing of the program. The Federal Disability Insurance (DI) Trust Fund will be able to pay benefits for only about 5 years and is not adequately financed. As a result, the Board is required to make a separate report to the Congress on the unfavorable financial condition of this trust fund. The Board urges that prompt legislative action be taken to improve the financial integrity of the trust fund, after a review of the disability program. The Federal Hospital Insurance (HI) Trust Fund will be able to pay benefits for only about 10 years and is severely out of financial balance in the long-range. The Trustees urge the Congress to take additional actions designed to control HI program costs either through specific program legislation or as a part of enacting comprehensive health care reform. The Federal Supplementary Medical Insurance (SMI) Trust Fund is financed on a year-by-year basis and, on this limited basis, is adequately financed. The Trustees urge the Congress to take additional actions designed to control SMI costs either through specific program legislation or as part of enacting more comprehensive health care reform.

Budgets↗
PubMedDate not supplied

Gender differences in practice patterns of Ontario family physicians (McMaster medical graduates).

This study examined the extent to which physician gender influences practice patterns. Data came from the Ontario Hospital Insurance Plan billing profiles of general practitioner and family medicine graduates of McMaster University School of Medicine. The women physicians studied were more likely to be certified in family medicine than the men and a higher proportion of their patients were female. Women were more likely to be working part time, billed during fewer months of the year, earned less, and saw fewer patients. They provided greater numbers of services in psychotherapy and counselling and ordered more laboratory tests; associated with this were higher costs per service and per patient. Women offered a less diverse mix of services than men. They provided fewer hospital, emergency room, and intrapartum services and a lower proportion of women included house calls, after-hours work, hospital, emergency room, surgical or intrapartum services in their service mix. Thus these women appeared more likely to restrict their practices to the office setting and to provide a higher proportion of psychosocial care. The overall impact of these sex differences in practice patterns on the health care system requires further exploration.

Family Practice↗
PubMed1988

Medico-economic implications of industrial hand injuries in India.

625 five consecutive cases of industrial hand injuries attending the Employee's State Insurance Hospital, Jaipur, have been studied from 1983 to October 1986. The incidence of injuries was 36 per 10,000 workers per year. 47% were due to entrapment of the hand in active machines, 25% occurred during lifting and transportation of heavy objects and 12% while handling tools. The injuries resulted in residual deficit in 55% of cases and were serious enough to require absence from work of more than four weeks in 48% of cases. On an average 35 days were lost per injured worker. The average economic loss per injured worker was Rs. 6900 (approximately pounds 275) for workers in the wage-range of Rs. 5400 to 19,200 (pounds 216 to pounds 768) per annum.

Accidents, Occupational↗
PubMedDate not supplied

Idiopathic ulcerative colitis in Istanbul: clinical review of 204 cases.

A clinical review of 204 cases of idiopathic ulcerative colitis (IUC) seen in an insurance hospital in Istanbul during a period of nine years is presented. The criteria of diagnosis were based on history and results of rectosigmoidoscopic, biopsy, and barium-enema examinations. In the majority of cases (74 per cent), the disease manifested in the mild form, despite a history of one to five years' duration at the time of diagnosis. These patients usually had single attacks, with recovery in reponse to treatment. The mortality rate for the whole series was 3.9 per cent. Death occurred in eight cases of patients who had the severe form of the disease involving the entire colon, with fulminating courses. One additional death was due to an accident. Treatment consisted of a high-protein, low residue diet, vitamins, rest, sulfa drugs and steroids. Azathioprine, in addition, was used in fulminating cases. Surgery supplemented medical therapy in 19 cases. Indications for surgical treatment were resistance to medical management, cancer, and polyposis. Only two patients (1.0 per cent) were found to have cancer during the follow-up period. These two were operated upon. Idiopathic ulcerative colitis is not a rare entity; with awareness and use of appropriate diagnosis facilities, more cases are being discovered.

Adolescent↗
PubMed1979

Competition in the delivery of medical care.

One approach to reform of the medical-care-delivery system emphasizes the development of constructive competition among providers of health care. In this article we describe competition among providers in Minneapolis-St. Paul, one of the few areas that can provide information concerning the practicality of this type of reform. We have found that competition has helped to reduce hospitalization, contain costs and improve access to medical services. At the same time it has focused attention on consumer satisfaction with medical services, increased the range of consumer choice and given consumers better information about providers. Certain public and private measures could facilitate the development of similar competition in other communities.

Ambulatory Care↗