Future directions for the Agency for Health Care Policy and Research

The Agency for Health Care Policy and Research (AHCPR) plays a leading role in health services research. Research efforts to develop practice guidelines, outcomes research, and computer applications have led to improvements in the delivery of care and reduced health care costs. These efforts aid consumers, providers, purchasers, and policy makers in health care decision making. This article cites numerous examples of AHCPR's efforts to increase quality of care and reduce costs.     

Why do states privatize mental health services? Six state experiences. The MEDSTAT Group

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.     

Academic psychiatry and managed care: a case study

An academic department of psychiatry in New York City eliminated the need for behavioral managed care intermediaries by transforming itself from a fee-for-service system to a system able to engage in full-risk capitation contracts. The first step was to require health maintenance organizations to contract directly with the department. The department formed two legal entities, a behavioral management services organization for utilization management and a behavioral integrated provider association. The authors describe these entities and review the first year of operation, presenting data on enrollees, capitation rates, and service utilization for the first three contracts. The fundamental differences in the treatment model under managed care and under a fee-for-service system are highlighted. The authors conclude that by contracting directly with insurers on a full-risk capitation basis, departments of psychiatry will be better able to face the economic threats posed by the cost constraints inherent in managed care and maintain or re-establish their autonomy as care managers as well as high-quality care providers.     

A survey of deliberate self harm services in New Zealand: shouldn't we be doing better?

AIMS: Deliberate self harm is important because it is common, it is associated with suicide and it provides a window of opportunity to provide help to people who do not access the usual mental health services. This survey aimed to describe the management and provision of services in New Zealand public general hospitals for people who deliberately harm themselves. METHODS: A questionnaire asking about deliberate self harm was sent to all 23 CHE's in New Zealand. RESULTS: Nineteen CHE's returned the questionnaire. There was widespread differences in the provision of services and the management of deliberate self harm. For example some admitted nearly everyone who presented whilst others only admitted 20%. Only two CHE's said they kept any computerised records of this population and only six had a psychiatrist responsible for the deliberate self harm service. CONCLUSIONS: Provision for the general hospital management of deliberate self harm is unplanned and disorganised. There should be centrally funded units which monitor deliberate self harm; standards for management of deliberate self harm in the general hospital should be produced; purchasers should use these standards in contracts with providers to insist on better care of this group of patients.     

Preload assessment in patients with an open abdomen

Health care providers and purchasers of health services have an opportunity to improve patient care and potentially save costs through the wise purchase of interactive health communication applications for patients and employees. Purchasing decisions based on evaluation and evidence should drive the design and development of new systems. The cycle of evaluation includes a needs assessment before system development, usability testing during development, and studies of use and outcomes in natural settings. This type of evidence is critical to our understanding of how best to provide health information and decision assistance to patients, employees, and others.     

The neuronal structure of paramamillary nuclei in Bison bonasus: Nissl and Golgi pictures

The Labour government has outlined its plans to 'replace' the competitive internal market with a more collaborative system based on partnership. Agreement amongst purchasers and providers is to be based on co-operation rather than competition. Longer term agreements covering periods of 3-5 years are to replace annual contracts within this new environment. The aim of this paper is to explore the potential economic implications of these policy changes by drawing on the economics of co-operation and the transaction costs approach to longer term contracting. Issues surrounding the role of trust in contractual relationships are explored and the relevance of experience and evidence from non-health care sectors is considered in the context of the NHS. It is concluded that both theory and empirical evidence suggest that co-operation and trust can play a central role in the efficient organisation of contractual arrangements in circumstances similar to those under which the NHS operates. However, we warn against the expectation that the policy changes will produce automatically the scale of benefits predicted by the Labour government, especially as they will have to find a way of extracting reasonable performance from providers under a system of collaboration and long term agreements. They may find they need to tread a fine line between competition and co-operation in order to reap the benefits of both.     

Health information systems and the role of state government

State government entities have created a range of innovative electronic information systems to support their diverse and evolving roles in the health care system. Primary goals of these initiatives include improvement of traditional public health programs, meaningful oversight of providers, simplification of administrative procedures, and support of state purchasing decisions. We establish a taxonomy of state efforts, describing primary capabilities to (1) provide meaningful data to state decisionmakers; (2) disseminate information to purchasers and consumers; (3) coordinate and improve government services; (4) establish mechanisms for electronic transactions; and (5) support telemedicine services. Reductions in the costs of technology and use of the Internet have dramatically increased state capabilities in recent years. Both the successes and failures of existing programs offer important lessons for states that are initiating new electronic communication initiatives.     

Consumer information, patient satisfaction surveys, and public reports

This article describes information useful for consumers and purchasers in making choices about health care services. Two types of information are described, patient satisfaction surveys and public reports about the price and outcomes of health care services such as those published by the Pennsylvania Health Care Cost Containment Council. Patient satisfaction surveys can be used to provide valuable information about health care. The goal of patient satisfaction reporting is to incorporate the patient's perspective to improve care. Public reports about the price and outcome of hospital and physician services not only facilitate consumer and purchaser choice, they also encourage continuous quality improvement by providers.     

When medical group and HMO part company: disenrollment decisions in Medicare HMOs

Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.     

The role of the Agency for Health Care Policy and Research (AHCPR) in improving outcomes of care

This article describes the various outcomes programs supported by the Agency for Health Care Policy and Research (AHCPR). The mission of the agency is to generate and disseminate information that improves the delivery and quality of health care. The agency is charged with helping consumers, providers, purchasers, health plans, and policy makers meet the challenge of improving the quality of health care services while reducing spending. AHCPR has been recognized as funding the development of "gold standard" clinical practice guidelines and the source of unbiased, science-based information on what works and does not work in health care.     

Factors in improved survival from paediatric cancer

OBJECTIVES: The cost of providing services is the traditional criteria used by payers in making selective contracting decisions regarding home care providers in general, and home infusion therapy (HIT) vendors specifically for this analysis. This approach assumes comparable health outcomes, for which adequate measures often are unavailable. In practice, poor quality can result in a need for remedial services. The objective of this research is to develop a method to use health insurance claims data to incorporate the hidden costs of adverse outcomes into an analysis of the costs of a vendor's HIT. METHODS: The Home Infusion Therapy/Relative Benefit Index (HIT/RBI) model incorporates measures of both the cost of providing HIT services as well as the cost of remedial treatment for the adverse outcomes that may result from HIT care, eg, emergency room visits. The data source for the analysis is the health care claims for a sample of managed care patients of national insurer for the period 1990 to 1994. RESULTS: The analysis confirms that adverse clinical outcomes can lead to additional demand for remedial health care with resultant negative financial consequences. When the cost of the adverse outcomes is incorporated into the analysis, vendors who appeared to be low cost on the basis of HIT services, in fact were higher cost vendors, whereas vendors with a high cost of services but with few adverse events were low cost vendors. CONCLUSIONS: Payers should consider both the clinical and economic consequences of providing care into account in selecting vendors. The HIT/RBI model is a useful tool for incorporating the cost of adverse outcomes into a comprehensive comparison of the cost multiple vendors of HIT services.     

Behavioural hyperactivity in rats following postnatal exposure to sub-toxic doses of polychlorinated biphenyl congeners 153 and 126

Over the years, both government and the private sector have used a mix of regulatory controls and competitive market incentives to reduce the rate of spending and minimize excess capacity in health services. Despite these efforts, this study finds an oversupply of five medical technologies in Pennsylvania, which adds costs and raises concern over the quality of care provided by underused facilities. Moreover, as providers compete for network selection, many continue to expand their service capabilities. These findings emphasize the importance of ongoing assessment of the appropriate application, supply, and use of medical services.     

The dynamics of market-level change

Health care exhibits a competitive dynamic today that increasingly resembles that in other service industries. Organizations are becoming larger to achieve scale economies and to increase market power. Vertical integration, whether through ownership or complex contracts, is also being pursued both to seek efficiencies and to improve the bargaining position of the organization. External forces that are driving these changes include more aggressive activities on the part of purchasers to contain their costs, developments in information technology, management innovation in other service industries, and advances in medical technology. Within the health care industry, there is a pattern of organizations taking the initiative to respond to these external forces--often in anticipation of them--and other organizations then responding to the pressures in turn placed on them. Although information on strategies is communicated rapidly throughout the country, what is attempted and what succeeds differs a great deal across communities. The nature of current health care institutions in the community, including the presence of large entities with extensive capital and strong management in a particular segment of the health system and the community's experience with managed care are important factors in the path that change takes.     

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The purpose of this paper is to provide a basis for exploring the relationship between competition and quality in health care by delineating the different institutional, economic and political contexts in which pro-competitive reform was conceived and carried out in different European countries. It begins by distinguishing between national health services and social insurance systems, suggesting that different kinds of system generate different kinds of problem. Different patterns of reform in Italy, Sweden and the UK, and in France and Germany are then reviewed in turn. The paper shows how, since the end of the long boom, health systems in Europe have been exposed to a set of economic, political and ideological pressures. The way these were brought to bear meant that governments in those countries with national health services were much more disposed to radical, pro-competitive reform than others. For them, competition represented a way of managing resource constraint in an increasingly complex and demanding political environment; ideas about quality were marginal to their purpose. The paper then explores the application of competition in different contexts, first among providers and then among purchasers, for which the UK and Germany serve as examples in turn. In each case, competition is only made effective by new forms of managerial direction. Across systems, competition appears less clearly associated with quality than with political control.     

Aims, processes and problems of antenatal education as identified by three groups of childbirth teachers

OBJECTIVE: To establish whether variations exist in the philosophy and approach of three groups of childbirth teachers working in different organisations in the UK. PARTICIPANTS: Two midwifery Parentcraft Sisters working in the UK maternity services, three National Childbirth Trust Antenatal Teachers and two Active Birth Teachers working in the voluntary sector, and two Midwife Teachers. METHOD: Semi-structured interviews were tape-recorded, transcribed and analysed using a grounded theory approach to identify common categories. FINDINGS: All three groups of teachers identified similar aims for antenatal education, with the need to build clients' confidence in their ability to give birth and care for their babies as the most important. However, the process by which the various teachers attempted to realise their aims appeared to be very different. IMPLICATIONS FOR PRACTICE: In order to ensure the prioritization of antenatal education with purchasers and providers, childbirth teachers need to define more clearly the criteria by which it can be audited.     

一种基于区块链智能合约的软件服务交易方法

随着软件服务交易模式由提前付费向“先服务后结算”转变,软件即服务（SaaS）所依赖的订阅模式面临着软件服务金融化与法律化的挑战—既无法按实际使用量进行金融支付,也难以通过法律形式规范服务提供方、消费方、交易平台之间权利义务关系。据此,本文将智能法律合约（SLC）引入到服务计算平台中,提出一种服务即合约（SaaSC）架构。在法律化方面,SaaS+SaaSC的组合支持SLC软件订阅合约中设立服务注册、发现、定制化三种条款,从交互动作、服务状态、状态转移流程等方面规范了各方当事人在服务注册、发现与消费三阶段的交互行为;在金融化方面,将服务接口声明添加到智能法律合约中,借助智能合约自动执行和检查条款实现了细化到服务接口调用级别的精准计费模式。进一步,以天气预报服务作为案例实现了基于区块链智能合约的在线软件服务获取、交付及合约化支付,验证了SaaS+SaaSC方案的合理性和有效性,表明软件服务合约化是一种新的可行技术路线。      

The U.S. home infusion market

Medicare legislation stimulated the development of home care services but also resulted in fragmentation of service components. In the 1980s, prospective pricing and diagnosis-related groups, and resulting pressures to reduce inpatient length of stay, prompted additional growth of the industry. Even so, in 1995 home care represented only 3% of total national expenditures on health care. The annual growth rate of the home infusion industry dropped from 64% in 1982-86 to 24% in 1986-93. While revenue per patient for home infusion is expected to decrease under managed care, an increasing number of patients will support continued market growth. The home infusion market is highly competitive, with only a few large national providers and many small local providers. In 1996, 29% of acute care hospitals provided or were developing a home care program. Community pharmacists' options in the home infusion area include independent services, partnerships, joint ventures, contracts with hospitals, and franchises. The home infusion market is being integrated into alternative sites, such as ambulatory infusion centers (AICs), as providers attempt to diversify to maintain managed care contracts. AICs provide infusion therapy and nursing to noninstitutionalized, nonhome-bound patients. Untapped sources for future growth of the infusion market include long-term-care facilities. More consistent studies of the home care market are needed. Despite slowed growth in recent years, home care has a strong market in the United States.     

How Relational are Construction Contracts?

For many years, the construction industry has relied on formal contracts to define and enforce the obligations and rights of contracting parties. Legal scholars have suggested that, based on their transaction characteristics, there are three different forms of contracts: classical, neoclassical, and relational. Of these, which form is more appropriate for use in construction projects? With increasing awareness of the importance of teamwork in construction, there is clear evidence of a rising trend in adopting a partnering approach to construction project delivery. For projects that seek to achieve a partnering relationship, relational contracts that value relationships, trust, and communication appear to be the appropriate form of contract. This paper discusses the application of relational contracts in construction by examining the fundamental question “How relational are construction contracts?” The degree of relationalism is assessed using a relational index comprising eight factors: cooperation, organizational culture, risk, trust, good faith, flexibility, the use of alternative dispute resolution, and contract duration. It was found that in the traditional design–bid–build form of delivery, the main contract and domestic subcontract forms are more relational than those of the nominated subcontract and the direct labor contract. The study was conducted in Hong Kong.     

Quality assurance from the viewpoint of medical management by health insurance

Legal requirements of SGB V make provisions for quality assurance (QA) activities in relation to inpatient and outpatient care. Available contracts between health providers and institutions covering costs presently regulate QA in three distinct areas in surgery: inpatient and outpatient care, Fallpauschale (fee for case) and Sonderentgelte (fee for service), and out-patient surgical treatment. MDK as a medical counselling and review agency working on behalf of health insurance companies has a more or less well defined role in the organization (board membership) and actual work (evaluation and probing) of external QA. Its participation and competence derive from legal authorization (SGB V) and hence from its given assignments: review of indication, economical aspects and quality of services provided--each on a single case basis and on a more general basis, nursing care, hospital budgets and finally planning capacity for hospital care.