Reengineering: deja vu all over again

There is growing interest among hospitals in reengineering. It promises dramatic improvements in performance: Costs will be reduced while work processes, productivity, and patient care will all improve. A review of the health care literature on reengineering shows that little evidence exists to support its claims. This article critiques the existing literature on reengineering and addresses the conundrum hospital executives encounter when faced with the decision to adopt a new management technique--such as reengineering--in the absence of proof of its efficacy.     

Reaching out: marketing strategies for organ donation awareness

The current competitive health care environment has intensified the need for data that provide a snapshot of the realities of clinical practice. As decision making moves from a clinically based perspective to one grounded in scientific data, health care providers are increasingly being challenged to document the extent of a problem and the effectiveness of its management. This is especially true with pressure ulcers, which are viewed as high-volume, high-risk problems in most health care settings. Moreover, in long-term care facilities, regulatory agencies have designated the development of pressure ulcers as an indicator of quality of care provided to patients. Thus, it is essential that data related to the scope and severity of pressure ulcers in a facility be gathered accurately. The aim of this article is to describe a methodology for determining prevalence and incidence of pressure ulcers that accurately measures the effectiveness of preventive intervention. The importance of risk assessment and of clear operational definitions of the population and a case will be addressed.     

Capitation. Theory, practice, and evaluating rates for gastroenterology

Capitation risk contracting has the potential to combine insurance functions with medical care functions. Success depends on a careful consideration of the capitation rate and a thorough understanding of all capitation contract issues. Proper incentives to physicians in a specialty network stimulate a major reengineering effort to squeeze the inefficiency out of the system. Within the network, true peer review can effectively diminish variability in medical care. Such variability leads to increased cost without benefit to health status. The superior medical management of a capitated specialty network can create added value by coordinating more cost-effective and appropriate evaluation and therapy.     

The blending of competitive and regulatory strategies: a second opinion

A comparison of the 10 states that as of 30 June 1994 witnessed the highest and lowest percent of health maintenance organization market penetration, and the findings reported in the Dartmouth Atlas of Health Care in the United States, both illustrate dramatic differences among the various states in the distribution, utilization, and cost of hospital and other health services. This article thereafter focuses on the implications of these findings in the context of the states eventually blending competitive and regulatory strategies to constrain hospital expenditures-a conceptual framework that is consistent with Americans being advocates of pluralism when organizing and financing their health care system.     

The costs of schizophrenia

Schizophrenia is regarded as the most expensive mental illness because of its specific symptoms and characteristics (e.g. early onset, often chronic course, high rates of readmission to hospital treatment, high rate of disabilities and extensive rehabilitative interventions), which prove to be extremely costly. Despite this, studies on the financial aspects of schizophrenia or the provision of care for schizophrenic patients has become an issue of psychiatric research only since the beginning of the reform of mental healthcare. Early cost studies had been conducted in the United States (US) during the fifties. Since then, they have grown in number not only in the US and in Great Britain, but also on the Continent of Europe. On an international level, comprehensive literature concerning methodology has attempted to establish cost studies as an integral part of mental health services research. Germany, however, is far behind international developments. Although the fundamental lack of empirical data on costs both in psychiatry as a whole and in schizophrenia had already been ascertained in a large national survey called "Psychiatrie-Enquête" in the mid-seventies, little has changed since then. One reason for these possibly great methodological problems is associated with the assessment of cost data in fragmented community mental health care networks, which in Germany include the additional obstacle--unlike abroad--of non-availability of access to data from case registers. Psychiatric case registers are not permitted in Germany because of very strict data protection laws. Despite the problems in methodology, there is an urgent need in Germany to remedy the lack of cost data for schizophrenic-patient care. The pressure of curbing costs in health care will probably force the German mental health care services to provide detailed cost data with regular reports in the future.     

Provision of psychotherapy under managed health care: A growing crisis and national nightmare.

Managed care was intended to save money by eliminating unnecessary services. However, for both physical medicine and mental health care, it is easier to save money by simply cutting needed services. This is what is happening in managed care in the US today. However, data exist for arriving at reasonable procedures to provide real help and still be cost-conscious, a fact that is being ignored by managed care companies. The German national health system covers up to 300 sessions of psychotherapy if needed, but only 3% of their outpatient medical costs are used for such psychotherapy. Unfortunately, the American managed care systems aim at short-term cost savings, even if it means higher costs in the long run (or making patients go outside the managed care health plan for help or forgo getting psychological help at all). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Focus groups reveal perils and promises of managed care for nurse practitioners

Decades of practice and research suggest that nurse practitioners (NPs) provide cost-effective and high-quality care. Managed care's emphasis on prevention and cost savings led some policy makers to view NPs as a way to meet the need for primary care providers. However, access to and utilization of NPs has increasingly been controlled by managed care organizations (MCOs) through their selection of providers for primary care panels. This study employed qualitative methodology to examine NPs' experiences with MCOs. Three focus groups, comprising 27 NPs in New York and Connecticut, revealed NPs' mixed reactions to managed care and a range of sentiments regarding NPs' efforts to be listed as primary care providers. The results reflected NPs' concerns about their perceived "invisibility," as well as their sense of "invincibility" in the ways in which NPs are responding to the barriers posed by MCOs. They identified barriers to, as well as ways to facilitate, being listed by MCOs, and described the importance of NPs working individually and collectively in negotiating with MCOs.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

Roles of advanced practice nurses in oncology

Managed care is a process of health-care management that integrates financing, cost-containment strategies, and business principles with the delivery of health care. Managed care's rapid transformation of specialty practices, such as oncology, is redirecting classic nursing functions toward market initiatives that value the design of care/case management systems and the implementation of multidisciplinary "patient-centered" care models. As health-care systems continue to evolve, advanced practice nurses (APNs) are redefining their roles and enhancing their skills to meet the demands of the marketplace. Advanced practice nurses are defined as registered nurses who have met advanced educational and practice requirements and are prepared at the graduate level. This paper will identify the four established APN roles: nurse practitioner (NP), nurse anesthetist, nurse midwife, and clinical nurse specialist (CNS), as well as highlight the nurse practitioner and clinical nurse specialist as the leadership APN roles within oncology practice. The adaption to managed care has identified new functions and created opportunities for these APN specialties that are being viewed both competitively by other oncology health-care providers and creatively by managed-care organizations. The integration of these emerging roles within the new advanced nursing market and their contributions to oncology care are also discussed.     

A point of view: why point-of-care places are not free marketplaces

Current wisdom holds that health care is a business and "as such must abide by market principles." Most nurses are not well enough versed in economic theories to credibly critique health care delivery decisions based on economic theories. The relationship of market principles to health care realities is described in basic terms to encourage nurses to "optimize patient care and influence health care policy." Physicians, who control all access points to the health care system, have enjoyed a 40-year market dominance that is "rapidly being replaced by insurance companies and for-profit investors." Providers' decisions to treat or not to treat are strongly influenced by whether the patient is in a fee-for-service or capitated payment environment.     

Charity and community: the role of nonprofit ownership in a managed health care system

As American medicine has been transformed by the growth of managed care, so too have questions about the appropriate role of nonprofit ownership in the health care system. The standards for community benefit that are increasingly applied to nonprofit hospitals are, at best, only partially relevant to expectations for nonprofit managed care plans. Can we expect nonprofit ownership to substantially affect the behavior of an increasingly competitive managed care industry dealing with insured populations? Drawing from historical interpretations of tax exemption in health care and from the theoretical literature on the implications of ownership for organizational behavior, we identify five forms of community benefit that might be associated with nonprofit forms of managed care. Using data from a national survey of firms providing third-party utilization review services in 1993, we test for ownership-related differences in these five dimensions. Nonprofit utilization review firms generally provide more public goods, such as information dissemination, and are more "community oriented" than proprietary firms, but they are not distinguishable from their for-profit counterparts in addressing the implications of medical quality or the cost of the review process. However, a subgroup of nonprofit review organizations with medical origins are more likely to address quality issues than are either for-profit firms or other nonprofit agencies. Evidence on responses to information asymmetries is mixed but suggests that some ownership related differences exist. The term "charitable" is thus capable of a definition far broader than merely the relief of the poor. While it is true that in the past Congress and the federal courts have conditioned the hospital's charitable status on the level of free or below cost care that it provided for indigents, there is no authority for the conclusion that the determination of "charitable" status was always so limited. Such an inflexible construction fails to recognize the changing economic, social and technological precepts and values of contemporary society. -Circuit Court of Appeals, District of Columbia, Eastern Kentucky Welfare Rights Organization v. Simon (1974).     

Review of a general practice attachment for accident and emergency training

The changes occurring in the health care delivery system afford ideal opportunities for call centers to expand their essential functions. Two obvious and timely services that can be adapted to the call center are outcomes management and disease management. These services benefit from the central role that telephonic nurses can play in clinical assessment and data collection and analysis. Other new services, such as gate-keeping functions, may also be relevant to call centers. The information and technology specialization of expert clinicians who practice "sightless" nursing make call centers the new clinical epicenter in the service capabilities of health care networks.     

The quest for value in health care

Purchasers and consumers of health care will increasingly refine their definitions of "quality" and the "cost" associated with treatment. The beneficial relationship of these concepts is "value." In the new era of managed care, those providers who offer the best value will succeed. Low-value producers will fail. Understanding buyer perceptions and expectations of value will become increasingly important as markets mature and integrated systems vie for dominance.     

Combining a global health budget with a market-driven delivery system: Can it be done?

Two correlated problems, rampant escalation of health-care costs and the lack of access to health care for many Americans, challenge long-term solutions to our health-care crisis. Historically, free markets have provided the most effective method of controlling costs. Although the current health-care system is highly competitive, it falls far short of being a truly competitive marketplace emphasizing competition around cost and quality. A health-care system based on managed competition in which the marketplace is structured to create competition on cost and quality provides great promise for regulating health costs. Erosion of health-care benefits under our current system of employer-based health insurance threatens the effectiveness of any market-based solution. The 21st Century Health Care Act combines the cost-effectiveness and universal access derived through a single revenue spigot with the power of a market approach created by managed competition. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Reengineering of Construction Management Process

Applying the business process engineering philosophy, this study focuses on developing a construction management process reengineering (CMPR) method to improve the efficiency of construction management. The CMPR method includes four phases, namely, process representation, process transformation, process evaluation, and reengineering activity. Using CMPR, inefficient operations within a construction company working process can not only be identified, but a new rational operation process can also be developed to improve management efficiency. In this way, the competitive ability of a construction company is also increased. This study argues for the need of a new research agenda in construction management in general. This is illustrated by information technology within construction—in particular, by examining the potential application of the reengineering philosophy. The research possibilities are identified and tested based on the implementation of the CMPR method. To some extent, this study establishes a new agenda of process reengineering for future research.     

Human onchocerciasis in Africa

In the United States, the traditional public utilities, power and telecommunications, along with health care, are being deregulated and becoming increasingly competitive, especially on price. Regulation of the public utilities has occurred for the past century not simply because they have been monopolies, but, more importantly, because they are "industries affected with the public interest," that is industries which: 1. provide an essential service, 2. benefit from public prequisites, and 3. would cause great public harm if mismanaged. Consequently, the presence of competition in these industries does not negate the need for regulation. Regulation of these industries is best understood as being along the three sides of a "triangle of public interests"--quality, public accountability, and universal service. Examples are provided of these types of regulation in power and telecommunications, even in current "deregulatory" legislation. Health care reform activists in the United States have lately paid attention mostly to the first two legs of the triangle; they are encouraged to focus creatively on the third leg--universal health care.     

Shoe-surface interaction and the reduction of injury in rugby union

Medical schools, teaching hospitals, and managed care organizations have a vested interest in shaping the knowledge, skills, and attitudes of the next generation of physicians who must adapt to significant changes in the financing and delivery of health care. This article summarizes the rationale for educational partnerships between managed care and academic medicine based on a review of three decades of well-documented experimentation in the literature. Discussed are some of the most important characteristics of the successful partnerships being forged in the current healthcare environment based on new kinds of relationships between faculty and non-university clinician educators. What had been referred to in previous decades as the "teaching-HMO" is now being complemented by community-based links between academic health centers and managed care plans. Several public and private sources have been generous in providing venture capital to support many of these innovations. However, their continued operation will depend on models for health care networks that can identify and manage the revenue and costs associated with the missions of education, clinical services, and research.     

An approach to reducing the adverse effects of broken appointments in primary care systems: development of a decision rule based on estimated conditional probabilities

A method is presented for adjusting the scheduling of appointments in ambulatory health care centers to reduce the deleterious effects of broken appointments. The essence of the methodology calls for scheduling and "expected number" of patients for a given clinic session. This "expected number" is calculated from estimated probabilities of appointment breaking, conditioned on patient characteristics which are deemed to be related to appointment-breaking rates, and on which number appointment within a specified time period is being made for the patient. The two ill effects of appointment breaking that are considered here are the diminution of efficiency of operation and interference with continuity of patient care. Ways of using this methodology to ameliorate each of these effects are outlined, with one of these way serving to alleviate both effects. This method is meant to be of quite general applicability, although its development was motivated by the problems of a localized particular situation.     

Collaboration--in a variety of ways--creates health care value

This is an opportune time for physician/nurse partnerships as the health care community moves from systems that treat sickness to systems that are responsible for the health of the community. No one profession has all the answers to the problems facing health care today. Providers working collaboratively have the potential to find solutions as long as they keep in mind that the patient is the ultimate purpose for their being. Value will be added by health care professionals who allow consumers better access to information and more involvement in their care.