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PubMed2001

[2d Report on increasing volume of diagnostic and interventional heart catheterization in hospitals and private practice in Germany 1990-1999].

Despite all warnings from the German Ministry of Health, the healthcare insurances and the media, the number of diagnostic (DIAG) and therapeutic (PCI) cardiac catheterizations is continuously growing in hospitals and in private practices. From 1997 to 1999, the number of DIAG increased from 478837 to 561623 and PCI from 135925 to 166132. The average number of DIAG per institution decreased from 1482 in 1997 to 1324 in 1999 and the average number of PCI from 535 to 479. The number of DIAG-performing hospitals increased from 256 to 315 and that of DIAG-performing private practices from 67 to 109. The number of PCI-performing hospitals increased from 211 to 278 and the corresponding private practice locations from 43 to 69. In 1999, 18% of all DIAG and 15% of all PCI in Germany was performed in private practice. Since 1994, the average number of DIAG per private practice continuously decreased as well as the average number of PCI per private practice since 1997. This decrease was more pronounced in private practice (DIAG 378/lab and PCI 111/lab) than in hospitals (DIAG 68/lab and PCI 35/lab). Possible reasons for this trend are an increasing number of low volume centers, a more rigid indication for DIAG and PCI due to quality control programs, and the reduction of reimbursement incentives for social healthcare insured patients in private practice. The real optimal need for DIAG and PCI in Germany, however, has to be determined.

Cardiac Catheterization↗
PubMed1996

Hospital response to prospective payment: moral hazard, selection, and practice-style effects.

In response to a change in reimbursement incentives, hospitals may change the intensity of services provided to a given set of patients, change the type (or severity) of patients they see, or change their market share. Each of these three responses, which we define as a moral hazard effect, a selection effect, and a practice-style effect, can influence average resource use in a population. We develop and implement a methodology for disentangling these effects using a panel data set of Medicaid psychiatric discharges in New Hampshire. We also find evidence for the form of quality competition hypothesized by Dranove (1987).

Adolescent↗
PubMed1990

Continuity and change in preferred provider organizations.

This paper presents the results from a national survey of preferred provider organizations (PPOs) that was conducted in 1988. It is based on telephone interviews conducted by the authors with executives in over 170 PPOs in the United States. We compare the survey results with those obtained from similar surveys conducted in 1985 and 1986, allowing us to assess the extent to which PPOs have grown and changed. We found that PPOs have continued to grow at an extremely rapid rate. During the Summer and Fall of 1988, the time in which the survey took place, 37.6 million people were eligible to use PPO benefits, compared to the 16.5 million figure we obtained two years earlier. We did not find, however, that PPOs are moving in the direction of providing more innovative forms of health care cost containment. Most PPOs still rely on discounts from providers and utilization review to achieve savings. There is little trend towards using incentive reimbursement techniques and choosing preferred providers that have shown themselves to be cost-efficient. We conclude that in the coming years PPOs must demonstrate the ability to control rising health care costs. To accomplish this, they will need to put more pressure on providers to use resources more sparingly. Otherwise, they may lose their market share to other forms of managed care.

Capitation Fee↗
PubMed2006

Prevalence and correlates of doctor-geriatric patient lifestyle discussions: analysis of ADEPT videotapes.

BACKGROUND: This study identifies the prevalence and correlates of physician-geriatric patient discussions about physical activity and nutrition lifestyle behaviors. METHODS: Between August 1998 and July 2000, 423 older patient visits to 36 physicians were videotaped in three different primary care settings. The patient sample was primarily white, female, well-educated, and financially sufficient, although 12.7% of the encounters occurred in an inner city clinic. The major dependent variable-lifestyle discussion-is based on observations of physician behavior. Descriptive and multivariate logistic regression analyses were conducted in 2004. RESULTS: Nutrition talk was most prevalent, occurring in almost half the encounters (48.2%) followed by physical activity discussions (39.2%) then conjoint mention (22%). Discussions were significantly less likely to occur in acute visits. While ethnicity, gender, and length of visit were not significantly related, physician interaction style and patient vitality and education were significant predictors in the multivariate analyses. CONCLUSIONS: Given the impact of lifestyle behaviors on myriad health outcomes, the current prevalence rates of physician discussion, while higher than in many previous studies, remain sub-optimal. Practical assessment tools, training in behavioral counseling, and reimbursement incentives are recommended strategies for raising physical activity and nutrition discussion prevalence in primary care settings.

Aged↗
PubMed1998

Pharmacoeconomics: what is it and where is it going?

The use of economic analyses as they pertain to the practice of medicine has become increasingly commonplace. Driven by both changes to reimbursement incentives and the clinical practice of medicine, these analyses have the potential to answer many of the questions posed by the delivery of health care in a fiscally responsible era. As such, the health economist is faced with the increasingly important role of providing data and insights key to the deliberative process of comparing the costs and benefits of medical care. To this end, health economists rely on a number of tools in the practice of pharmacoeconomics. The most common tool is a cost-effectiveness analysis, which compares the clinical effects of alternative therapies (mortality, morbidity) to their net costs. A relatively new tool to the field of clinical economics, the cost per quality-adjusted life-year has the potential of becoming the gold standard in clinical economics for measuring clinical effects if further refinement to measurement technique is achieved. All of these tools have as their outcome the development of a medical decision model or decision tree. These decision trees have four components: disease outcome states; the probability of transition between disease states; the costs, financial benefits, and effects incurred by patients in each outcome state; and risk groups. Data from a wide range of sources, including randomized clinical trials and retrospective analyses of data collected from clinical practice settings, are drawn upon in the development of decision trees. Although economists can help design these models and document the costs and effects of alternative therapies, it is physicians and consumers who will ultimately have to make the decisions that recognize that spending resources on one disease or risk group decreases the resources available to treat other diseases or risk groups.

Cost-Benefit Analysis↗
PubMed1993

Empowering health care improvement: an operational model.

BACKGROUND: The shift from compliance to continuous improvement requires a bridge--empowerment--that enables the creation of an environment in which employees can contribute the full range of their expertise in service to the organization. Leaders are responsible for creating this empowering environment. MODEL: An operational model that describes the nine aspects of empowerment (for example, mission and values, access to information, avenues of influence) can serve as a template for leaders to use to promote an atmosphere of empowerment in their organizations. METHOD: The authors adapted this model as a survey instrument to uncover some hospital success stories that demonstrate several aspects of empowerment in action. The survey was administered at two hospitals. CASE STUDY 1: At Beth Israel Hospital (Boston, Mass), Nutrition Services rated the "mission and vision" aspect of empowerment in their department at an average of 3.5 out of a possible 4.0. The department attributes this high rating to their focus on specific goals that reinforce the larger mission and vision of the hospital as a whole. These goals form the basis for annual employee evaluations. For example, a 1992 patient-focused goal was to provide nutrition counseling and education. The department approached this goal by developing a daily format ("Eat Smart") for the daily hospital cafeteria menu that provided nutritional information. The rationale was to educate employees, who could then bring back information to their patients. Alignment of the department's efforts with the larger mission of the hospital enabled Nutrition Services to extend its influence beyond departmental and professional boundaries. Implementation of other plans at the hospital demonstrate a sustained process of vision development on the part of the executive leadership. CASE STUDY 2: At Robert Wood Johnson University Hospital (New Brunswick, NJ), Support Services gave the "environment of trust and respect" aspect an average rating of 3.7. The key to this success story lies in the upgraded role of the housekeepers as "hosts." The "Pro-Act" restructuring model for patient care delivery creates and upgrades positions to relieve nurses of their task loads. The three nursing services that participated in the survey gave their highest rating to the "access to the education and training" aspect of empowerment. The high quality of professional excellence is supported by tuition reimbursement, incentives for credentials, the extern program and scholarships provided to attract outstanding nursing students to their staff and encouragement of nursing staff at all levels for publication, presentations, and poster sessions. CONCLUSION: These case studies demonstrate how leaders created an environment in which collective learning has become a way of doing business. Given the multifaceted nature of the empowerment model, some may wonder where to begin to focus leadership efforts. It is important to emphasize that the constellation of empowerment aspects constitutes an integral system; the full potential for empowerment arises from synergy among all nine aspects.

Attitude of Health Personnel↗
PubMed1992

Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes.

Previous studies of the impact of varying reimbursement incentives on physician behavior have not explored the simultaneous implications for patients' health outcomes. Using a single group of physicians who provided care for hypertensive patients with either capitation (N = 99) or fee-for-service (N = 66) health insurance plans, physicians' test-ordering behavior and patients' subsequent health outcomes were examined. After controlling for patients' age, severity of hypertension, and level of comorbidity, it was found that patients with capitation health insurance had fewer laboratory tests and lower overall charges than the fee-for-service patients, with no clinical or statistically significant differences in 1-year health outcomes, specifically blood pressure control. The study concludes that capitation can result in reduction in charges associated with management of hypertension, without apparent compromise in proximate health outcomes.

Adult↗
PubMed1995

A call for specific codes for diabetes foot and eye care.

In this report, we propose new International Classification of Diseases (ICD) codes that could be incorporated into computer-based patient records or administrative data to monitor and improve diabetes care. Neither the ICD, 9th Revision, nor its imminent replacement, the ICD, 10th Revision, has specific codes for foot examinations and funduscopic examinations in the asymptomatic person, high-risk diabetic foot status, or clinically significant macular edema. Adoption of official codes for these procedures and conditions implemented in conjunction with computerized databases could be used for surveillance, program planning, and quality of care assessment. Computerized medical records could use the codes to monitor care and issue reminders to patients and providers. Payors could offer reimbursement incentives to encourage compliance with standard recommendations. These codes for care procedures could be linked to outcomes, such as amputations and blindness, to improve our understanding of the etiology of blindness and the relationship between process and outcome. The uniform adoption of these codes would facilitate comparison between health care systems, geographic regions, and nations. The diabetes community should encourage the National Center for Health Statistics to adopt new codes that could be used to monitor diabetes preventive care practices.

Adult↗
PubMed1987

Using information tools to improve hospital productivity.

Because of the new reimbursement incentives placed on healthcare institutions, the efficient and effective use of resources is being emphasized more than ever before. In this new environment, decisions must be made with skill and insight, supported by information tools that analyze and manage productivity. By integrating advanced information technology into hospitals' existing information systems, productivity can become a powerful tool to achieve and maintain a competitive advantage.

Efficiency↗
PubMed1989

Integrating federal health care resources at the local level.

Hospitals throughout the country are increasingly sharing health services, jointly purchasing supplies, and merging. The Veterans Administration (VA)-Department of Defense (DoD) Health Resources Sharing Law of 1982 (PL 97-174) has encouraged much closer relationships between hospitals of these agencies than had existed previously. All VA hospitals within 50 miles of a military treatment facility now have multiservice agreements. Before passage of the law, only a handful of facilities were involved in limited sharing. Closer relationships have led to expanded care for federal beneficiaries at considerable cost savings. In Albuquerque, New Mexico, for example, the VA Medical Center houses the VA and Air Force hospital operations, obviating the need for a separate freestanding hospital. The lack of VA authority to receive reimbursement from the Civilian Health and Medical Program for the Uniformed Services and a lack of a reimbursement incentive for military hospitals to share are identified as factors preventing greater coordination. Even greater local integration of services is likely to occur in the future.

Health Benefit Plans, Employee↗
PubMed2000

Capital structure strategy in health care systems.

The capital structures (the relative use of debt and equity to support assets) of leading health care systems are viewed as a strategic component of their financial plans. While not-for-profit hospitals as a group have maintained nearly constant levels of debt over the past decade, investor-owned hospitals and a group of leading health care systems have reduced their relative use of debt. Chief financial officers indicated that in addition to reducing debt because of less favorable reimbursement incentives, there was a focus on maintaining high bond ratings. Debt levels have not been reduced as sharply in these health care systems as they have in investor-owned hospitals, in part due to the use of debt to support investments in financial markets. Because these health care systems do not have easy access to equity, high bond ratings and solid investment earnings are central to their capital structure policies of preserving access to debt markets.

Capital Financing↗
PubMed1979

Cost of elective surgery and utilization of ancillary services in teaching hospitals.

Measures of surgical utilization studied are the number of elective tests performed preoperatively and the total cost per case. The unit of analysis is a matched pair of patients who underwent the same elective procedure, one a Veterans Administration patient, and the other a municipal or voluntary hospital patient. Federal ownership of the hospital ahd the strongest impact on tests and cost per case. On average, costs for the VA patients were 52 percent more per case. The foreign medical graduate variable had a large positive (inflationary) effect on the number of tests, but a slight downward influence in the cost regressions. The fraction of surgeons with faculty appointments had a strong negative (curtailing) impact on elective testing, but an upward influence on cost per case. Additional variables such as age, average laboratory turnaround time, and fraction of the medical school's students doing their surgical clerkship at the hospital ahd a slight upward influence on utilization. The three policy issues raised in the study involve changing the hospital reimbursement incentives, targeting continuing education programs to categories of staff that need it most, and redistributing faculty and students.

Cholecystectomy↗
PubMed1995

Theory M: A restructuring process.

Through the Nursing Incentive Reimbursement Award (NIRA) Program initiated by the New Jersey Department of Health, a medical center tested, over a two-year time frame, the impact of a staff-developed "Theory M" nursing model. Three nursing units served as control groups and one as the experimental group that incorporated the following features: restructuring of a nursing unit through the redefinition of roles; modifying nurse staffing patterns to change existing ratio of RNs to NAs; incorporating matrix management principles; developing, implementing and evaluating training and educational programs; and renovating a nursing unit.

Health Care Reform↗
PubMed1994

Resolving conflict in a multicultural nursing department.

As a result of the turn toward recruitment from overseas in the 1980s, various challenges must be met and obstacles overcome to achieve harmony among multicultural staffs. A program was implemented to address volatile multicultural issues as part of the Nursing Incentive Reimbursement Award project in New Jersey. Nurses who participated in this sensitive program gave positive feedback, generally reporting that awareness was raised and collegial relationships improved. Specific interventions for dealing with a multicultural staff are offered.

Conflict, Psychological↗
PubMed1997

Rapid hospital discharge following laparoscopy for ectopic pregnancy. A promise unfulfilled?

This study was done to determine whether laparoscopy for ectopic pregnancy in the United States is associated with rapid postoperative discharge, defined as 2 days or less, and to estimate how often ambulatory treatment of ectopic pregnancy occurs without subsequent hospital admission. We used the National Hospital Discharge Survey to estimate the frequency of ectopic pregnancy admissions, operations, and length of hospital stays in 1990. We used the National Ambulatory Medical Care Survey to estimate the number, type, and disposition of office visits for ectopic pregnancy in 1990. According to National Hospital Discharge Survey data, tubal pregnancy led to an estimated 57,000 hospital admissions in 1990. Most (70%) of the 26,000 patients treated with laparoscopy were in the hospital 3 days or more, and most (73%) underwent salpingectomy. The number of ambulatory visits for ectopic pregnancy was too low to estimate reliably according to the standards of the National Center for Health Statistics. We found that laparoscopy was used frequently for the treatment of ectopic pregnancy but was not associated with rapid postoperative discharge. Further research is needed to determine whether these findings persist and whether reimbursement incentives, patient preference, or problems with the diffusion of technology are responsible.

Adolescent↗
PubMed1998

FQHC (Federally Qualified Health Center): harnessing the incentives of cost reimbursement.

Community health centers (CHCs) are federally supported primary care providers to the low-income and uninsured. The federally qualified health center (FQHC) legislation requires states to pay CHCs for Medicaid services on the basis of reasonable cost. The statute generated controversy, particularly in a time when, for most providers, cost-related reimbursement has given way to fixed payments and managed care. This article examines the impact of FQHC on revenue and utilization of CHCs, using data for 328 centers that were in continuous operation between 1989 (the year the legislation was enacted) and 1992, the first year of full implementation. During this period, the CHCs Medicaid revenue grew rapidly. FQHC is estimated to account for under one third of the total increase, while inflation and growth in utilization due to expanded Medicaid eligibility are estimated to account for the other two thirds. At the same time, the change to cost-related reimbursement had a significant increase in total service users and Medicaid recipients receiving care from CHCs. Although some expected that cost-reimbursement would lead to inflationary increase in utilization, this did not occur. There was no statistically significant relationship between the change in payment methodology and changes in encounters per user. The experience of FQHC indicates that, for safety net providers of primary care, cost-related reimbursement is not "inherently inflationary." Results of this study raise the question of whether payment within constraints, but bearing relationship to cost, is not an appropriate approach to developing primary care capitation rates for these providers--and assuring maintenance of the safety net for the uninsured.

Community Health Centers↗
PubMedDate not supplied

Incentives for vertical integration in healthcare: the effect of reimbursement systems.

In the United States, many healthcare organizations are being transformed into large integrated delivery systems, even though currently available empirical evidence does not provide strong or unequivocal support for or against vertical integration. Unfortunately, the manager cannot delay organizational changes until further research has been completed, especially when further research is not likely to reveal a single, correct solution for the diverse healthcare systems in existence. Managers must therefore carefully evaluate the expected effects of integration on their individual organizations. Vertical integration may be appropriate if conditions facing the healthcare organization provide opportunities for efficiency gains through reorganization strategies. Managers must consider (1) how changes in the healthcare market have affected the dynamics of production efficiency and transaction costs; (2) the likelihood that integration strategies will achieve increases in efficiency or reductions in transaction costs; and (3) how vertical integration will affect other costs, and whether the benefits gained will outweigh additional costs and efficiency losses. This article presents reimbursement systems as an example of how recent changes in the industry may have changed the dynamics and efficiency of production. Evaluation of the effects of vertical integration should allow for reasonable adjustment time, but obviously unsuccessful strategies should not be followed or maintained.

Decision Making, Organizational↗