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PubMed1995

Organ transplantation criteria represent insurer dilemma.

In its simplest form, technology assessment, as used for coverage decision making, involves an analysis of published data regarding the safety and effectiveness of a technology, either on its own merits or in comparison with a competing technology. However, while the medical literature, and thus technology assessments, typically focus on a well-defined population, a positive coverage policy almost immediately creates pressure for broadening patient selection criteria. A variant on this phenomenon is the patient selection criteria for organ transplantation. These criteria are based not only on the scientific merits of the procedure but also on frequently ill-defined notions of the most appropriate allocation of a scarce resource, which in turn is determined by supply and demand at individual transplant centers. In these cases, the payer may defer to the patient selection criteria of the individual transplant center. However, the situation arises when a patient, rejected at one transplant center, "shops" and finds another center that has more favorable selection criteria. How, then, can the payer resolve these discrepancies and establish consistent policy guidelines? Should allocation of scarce donor organs be part of a technology assessment and coverage decision? The case of liver transplantation will be used here to illustrate the insurer's dilemma.

Eligibility Determination↗

PubMed1995

Negotiating successful managed care contracts.

The goal in managed care contracting is to create a coherent framework for treatment and payment decisions that is as unintrusive, flexible, and cooperative as possible for both payers and providers. That goal rarely is achieved with a generic contract that ignores the circumstances and interests unique to a particular payer and provider. This article highlights a number of key issues that arise in managed care contracting in general and offers several practical suggestions for resolving those issues.

Contract Services↗

PubMedDate not supplied

Integrated delivery systems/networks in the uncertain future. Strategic stakeholder management, Round One continued.

This article presents an analysis of Round One data with a focus on integrated delivery systems/networks (IDS/Ns). These complex, multifaceted organizations are growing in importance in the turbulent health care industry. The emergence of these multi-organizational forms requires that all health care industry organizations--medical groups, hospitals, payer organizations, suppliers--adapt to the ever-increasing demands placed on them as the industry experiences revolutionary changes. The findings presented in this article were compiled from the responses of 580 health care industry experts about the uncertain future facing health care executives. These respondents represented virtually every health care organizational form, including medical groups, physicians, hospitals, payer organizations, academic researchers, pharmaceutical firms and other health care industry suppliers. Each of these health care respondent panels answered hundreds of questions pertaining to both the present (1994) and the future (1999). These analyses seek to describe the different relationships between medical groups, their stakeholders and IDS/Ns, and how they will change over the years of 1994 to 1999. We also present experts' perceptions and predictions about five other key stakeholders of medical groups--managed care organizations, governments, employers, system hospitals and patients.

Costs and Cost Analysis↗

PubMedDate not supplied

Subcapitation: sharing risks and rewards with community physicians.

The continuing growth of managed care and payers' growing preference for working with integrated systems require medical groups of all sizes to examine their options. A Cincinnati multispecialty group developed a network--in partnership with community physicians--that may serve as a model for other evolving managed care markets. To provide geographic coverage and cost effectiveness, the group created a network of more than 350 primary care and specialty physicians to serve as the delivery system for three capitated payers. The system is based on subcapitation and aligned incentives. These enable the multispecialty group to deliver a wide array of specialty services cost effectively and allows subspecialty and primary care groups to benefit from this tie to a multispecialty provider. The groups approached to participate in the subcapitated network were selected carefully and chosen according to objective criteria. The system provides incentives for physicians to increase their efficiency and to work cooperatively to improve patient care processes. The subcapitated network physicians are represented on many of the system's quality improvement committees and have generally found the arrangement to be favorable.

Capitation Fee↗

PubMed1991

Market forces can boost quality, lower costs.

Competitive market forces may do more to ensure healthcare quality than government regulatory attempts. Independent research can show that healthcare quality drives profits and increases market shares. Greater market shares increase volumes, and increased volumes can lead to lower costs per case. These improvements may better position providers for payer contract negotiations, especially as payers are encouraging providers to assume more risk. Ultimately, however, a public more informed about costs and outcomes may be necessary for market forces to reduce national average costs per case.

Cost Control↗

PubMed1993

Adapting to the ANSI 835 transaction set.

Adapting to the American National Standards Institute (ANSI) 835 Health Care Claims Payment/Advice format--the first nationwide, all-payer electronic standard for healthcare claims--requires an approach tailored to the individual provider's system. Providers have four options for receiving ANSI 835 claims payments. They include: direct transmission from payers, value added network services (VANs), banks with electronic data interchange capabilities, and paper reports. Providers' claims processing systems vary enormously in the formats they use and in their capacities to transmit and receive claims payments electronically. Author Romo reviews factors that providers need to consider when refining internal capabilities and selecting external processors to accept the 835 format.

Accounts Payable and Receivable↗

PubMed1995

The need to manage and reconcile capitation payments.

As capitation becomes a more common method of paying providers, healthcare financial managers must determine if these payments are being made correctly. The reconciliation process under capitation contracts is new for most financial managers. Standard industry conventions for payers and providers are needed to reduce the associated administrative costs for this type of payment. Recent efforts to create an American National Standards Institute (ANSI) X12 capitation payment standard have focused on provider information needs under capitated payment agreements. A solution is at hand if providers and payers can agree on a standard for reconciling capitation payments.

Capitation Fee↗

PubMed1996

Setting limits through global budgeting: hospital cost containment in Rhode Island.

In 1974, hospitals in Rhode Island have participated in annual negotiations with state officials and representatives from Blue Cross to determine the allowed increase in statewide hospital costs (the "Maxicap") for the next fiscal year, based on projected increases in hospitals' revenues, changes in patient volume and operating expenses. Individual hospital budgets may be above or below the Maxicap as long as the total increase in hospital costs for all hospitals in the state does not exceed the negotiated amount. At a time when regulatory solutions are increasingly under fire, continued support for Rhode Island's approach to hospital cost containment from third party payers, providers and public officials stands in stark contrast to other states where rate setting was either dismantled or discredited as a cost control strategy. A negotiated global cap on hospital expenditures offers an alternative to formula-based state rate-setting methodologies which could be incorporated as part of an all-payer reimbursement methodology or as an incremental step towards more comprehensive reform.

Blue Cross Blue Shield Insurance Plans↗

PubMed1996

Improving patient care delivery with integrated case management.

Providers and payers in an integrated delivery system can increase the coordination and cost-effectiveness of the services they provide by developing a strong case management program. Integrated case management can provide the common thread for developing and meeting joint goals, such as reduced lengths of stay, cost-per-case reductions, decreased admission/readmission rates, and increased patient satisfaction. Providers and payers should design and integrate their case management services to allow for greater sharing of resources and integration of patient care goals and incentives.

Case Management↗

PubMed1997

Looking to save millions each year? Try global pricing.

Global pricing is gaining in popularity as managed care payers look for efficient and innovative ways too provide care. Properly structuring global deals requires physician-hospital organizations to accurately define what services they are efficient at providing and also proving to the payer that they have the administrative and clinical ability to effectively manage global deals.

Capitation Fee↗

PubMed1997

The Cleveland Health Network: a new integrated delivery system.

CHN and its subsidiary CHN MCO have significantly impacted the Cleveland market place in the two years since their inception. CHN will continue to expand geographically with hospital and physician partners who are committed to providing quality care in the most cost-effective manner. Medical management will continue to be the central focus and over-riding success of the CHN MCO, making this organization extremely attractive to the payer market. The integrated CHN and its medical management focus could become a model for other integrated delivery systems. As the market place continues to experience an increase in managed care and more consolidation of healthcare providers (and in some cases, mergers with payers), more integrated delivery systems will emerge. Senior- and mid-level administrators and managers with operational responsibilities need to take into consideration how their patient access systems will need to be modified to meet the demands of managed care through the formation of integrated delivery systems. How patients access the systems is of critical importance in ensuring financial success, ease of access for the patient, and tracking of appropriate medical care.

Community Networks↗

PubMed1997

Looking for win-win contracting? Tap new 'bricks and mortar' of health care.

Negotiating a win-win contract with payers is based on three factors for hospitals and physicians: predicting utilization rates based on demographic information; identifying treatment guidelines that generate the best outcomes at the lowest price; taking a "partnership" mindset when working with payers and when hospitals and physicians work together.

Contract Services↗

PubMed1997

Super PHOs provide clout and added efficiencies.

Joining or forming a super PHO can increase the attractiveness to payers through broader geographic coverage and also generate administrative efficiencies for the individual PHOs. The key is to make sure the organization adds value to the managed care product and is not just a cartel to leverage payers.

Efficiency, Organizational↗

PubMed1997

Getting in harmony. As markets change, hospitals struggle with pricing.

When it comes to tinkering with pricing strategies, hospitals are no more immune from mistakes than other corporations. Blame it on the changing healthcare market. Before managed care began taking root, most payers accepted hospital rates without much fuss. Now haggling over price discounts is the norm, and payers usually have the upper hand at the negotiating table.

Cost Control↗

PubMed1997

Integrating clinical and support process design for effective health services.

With increased capitation and managed care competition, health care systems must demonstrate effective health services with predictable costs, timing, transitions, and health outcomes. By involving patients, payers, and multiple providers, a health care system can design integrated clinical and support processes across the continuum for defined populations. The goals are lower costs, increased payer and patient satisfaction, and improved health status. This article shares examples and experiences from four health care systems that teamed with Premier, Inc., to design an integrated services sequence for defined populations.

Adult↗

PubMedDate not supplied

Standardizing medical data.

Congress passed The Health Insurance Portability and Accountability Act of 1996 in the doldrums of last Summer, and promptly charged the National Committee on Vital and Health Statistics to begin working on the regulations that will help providers, payers, and all members of the public adhere to the spirit of the law. What does this legislation portend for the health care industry? Standardization of information systems will play a large role in assuring the portability of health care insurance from one employer and payer to another in this legislation. Accountability, too, will depend on those same data standards to allow comparisons of processes and outcomes of care across health plans, providers, communities, states, and regions. In fact, without standardized data describing patients and their treatments, there can be no comparisons of their outcomes of care, or the processes used to treat them.

Career Mobility↗

PubMedDate not supplied

Creating value-focused healthcare delivery systems: Part three--Core competencies.

Value is created through the delivery of high-quality, cost--effective healthcare services. The ability to create value from the providers' perspective is facilitated through the development and implementation of essential, customer-focused core competencies. These core competencies include customer relationship management, payer/provider relationship management, disease management, outcomes management, financial/cost management, and information management. Customer relationship management is the foundation upon which all core competencies must be built. All of the core competencies must focus on the needs of the customers, both internal and external. Structuring all processes involved in the core competencies from the perspective of the customer will ensure that value is created throughout the system. Payer/provider relationship management will become a crucial pillar for healthcare providers in the future. As more vertical integration among providers occurs, the management of the relationships among providers and with payers will become more important. Many of the integration strategies being implemented across the country involve the integration of hospitals, physicians, and payers to form accountable health plans. The relationships must be organized to form "win/win" situations, where all parties are focused on a shared vision of creating value and none of the parties benefits at the expense of the others. Disease management in creating value requires that we begin examining the disease process along the entire continuum. Not only must providers be able to provide high-quality acute and chronic care, but they must also begin to focus more heavily on programs of prevention. Value is created throughout the system through reducing the prevalence and incidence of disease. Only through managing the full continuum of health will value be created throughout the healthcare delivery system. Outcomes management ensures that the outcomes are the highest quality at a cost-effective price. Outcomes must not only be compared to best practices, but to what is possible. Providers must constantly strive to enhance the quality of the services. Financial/cost management ensures that care is cost-effective and that a marginal profit is maintained to allow continued investment in new technology and continuing medical education to enhance the quality of care and lifestyles for all stakeholders. Information management is the binding element, or keystone, in providing value-focused care. Through the collection, storing, transfer, manipulation, sorting, and reporting of data, more effective decision-making can occur. Integrated MIS allows information to be generated about the cost-effectiveness of treatment regimens, employee productivity, physician cost-effectiveness, supply utilization, and clinical outcomes, as well as patient information to be readily available throughout the healthcare system. Having this information available will allow providers to become more cost-effective in the delivery of care, which results in perceived higher value for the services. Customers demand value. Value is created by meeting the needs and demands of the customers through the delivery of cost-effective, high-quality healthcare services that are easily accessible and meet with high patient satisfaction. Providers who can demonstrate their ability to provide the services in this manner will create a competitive advantage in the marketplace and will be perceived as the value provider of choice by loyal customers.

Cost Control↗

PubMedDate not supplied

Effect of insurance coverage on the relationship between asthma hospitalizations and exposure to air pollution.

OBJECTIVE: Based on the assumption that people without health insurance have limited access to the primary care services needed to prevent unnecessary hospitalizations for asthma, the authors hypothesized that insurance is a factor in the strength of the association between hospital admissions for asthma and exposure to air pollution. They tested this hypothesis with 1991-1994 data from central Los Angeles. METHODS: The authors analyzed the effect of insurance status on the association between asthma-related hospital admissions and exposure to atmospheric particulates (PM10) and ozone (O3) using hospital discharge and air quality data for 1991-1994 for central Los Angeles. They used regression techniques with weighted moving averages (simulating distributed lag structures) to measure the effects of exposure on overall hospital admissions, admissions of uninsured patients, admissions for which MediCal (California Medicaid) was the primary payer, and admissions for which the primary payer was another government or private health insurance program. RESULTS: No associations were found between asthma admissions and O3 exposure. An estimated increase from 1991 to 1994 of 50 micrograms per cubic meter in PM10 concentrations averaged over eight days was associated with an increase of 21.0% in the number of asthma admissions. An even stronger increase--27.4%--was noted among MediCal asthma admissions. CONCLUSIONS: The authors conclude that low family income, as indicated by MediCal coverage, is a better predictor of asthma exacerbations associated with air pollution than lack of insurance and, by implication, a better predictor of insufficient access to primary care.

Air Pollutants↗