All that glitters is not always gold: Medical offset effects and managed behavioral health care.

This article urges caution in using broadly predicted medical offset effects in marketing managed behavioral care services. Three analyses of a health maintenance organization population who were provided managed mental health services showed that the use of simple percentage change in cost and use of hospital care may give deceptively positive results. The use of such methods may eventually undermine rather than support the credibility of managed care contracts for professional psychology. Results are discussed in the context of professional psychology's future role in guiding quality assurance and cost-effectiveness studies in regional, multiprofessional primary practice groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Teaching hospital costs: implications for academic missions in a competitive market

CONTEXT: As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. OBJECTIVE: To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). DESIGN: Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). SETTING AND PARTICIPANTS: A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. MAJOR OUTCOME MEASURES: Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. RESULTS: In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. CONCLUSIONS: The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.     

Basaloid squamous cell carcinoma: a distinctive human papilloma virus-related penile neoplasm: a report of 20 cases

OBJECTIVE: To estimate the costs and benefits to community pharmacies of converting a traditional practice into one based on pharmaceutical care. SETTING: Community-based ambulatory care pharmacies. PRACTICE DESCRIPTION: Community pharmacy. PRACTICE INNOVATION: Pharmaceutical care. MAIN OUTCOME MEASURES: Costs incurred and revenues received. DESIGN: Twenty-five community pharmacies that had made the transition from traditional practice to one based on pharmaceutical care returned a survey providing data on the costs and revenues associated with the transition. RESULTS: Mean total cost of making the conversion for the 25 pharmacies was $36,207. The largest cost component associated with the transition was personnel, which had a mean cost of $16,512 per pharmacy. Mean revenues received for pharmaceutical care by these 25 pharmacies was $3,687, mainly for disease management services. Pharmacies that spent more on the conversions, and used brochures and physician detailing as well as consultants and franschises, tended to be more successful in generating revenues from pharmaceutical care. CONCLUSION: Most pharmacies that have made the conversion to pharmaceutical care have not experienced an increase in profits as a result of that conversion. More effort needs to be directed toward improving the flow of revenues obtained from providing pharmaceutical care.     

Unlicensed assistive personnel in the perioperative setting

The present climate in health care, including a tendency toward more managed care and capitation systems, has caused hospital administrators and perioperative managers to reexamine traditional work systems and their associated costs. Some decisions around work redesign may be financially driven or based on the decreased availability of qualified professionals in the job market. The use of an increased number of unlicensed assistive personnel (UAP) in hospital settings has become a common redesign strategy to address both issues. In the perioperative setting, some traditional roles are well established for UAP. Today, changes associated with downsizing, cost containment, and increasing technology have opened up new opportunities to explore ways to integrate UAP roles into the perioperative setting.     

Collaborative use of informatics among hospitals to benchmark medication use processes

BACKGROUND: In spring 1995 pharmacists representing each of the 23 member hospitals in Synernet, a hospital cooperative in Maine, decided to collaborate in developing a multihospital medication use evaluation (MUE) program. The committee set up task forces for adverse drug reaction reporting and prevention, MUE plans, and medication error reporting and prevention, for exploration of opportunities to eliminate duplication of efforts, compare performance, and share best practices. PLANNING THE PROGRAM: The members retained a consulting firm to manage the SynRx medication use program from conceptualization through implementation. Modules--on individual drug dosing, switching from intravenous to oral administration, pharmacists' clinical recommendations, and surgical antibiotic prophylaxis--were designed so that participants could adopt the entire plan as a turnkey procedure by inserting their hospital name in the appropriate blanks, modify it to more closely fit their own organizations, use portions of it for inclusion in their current plans, or not use it at all. The goal was to build in maximum flexibility to accommodate the variations in the participating hospital pharmacies and their respective hospitals. RESULTS: Early program benefits include improvements in medication event reporting, documentation of the measured aspects of medication use, delivery of care processes, and administrative efficiency. LESSONS LEARNED AND CONCLUSIONS: The participants, consultants, and programmers involved in the SynRx program learned firsthand the complexity and magnitude of hospital medication use processes. Yet it is possible to overcome the wide variability in systems among hospitals to create standards that allow for more meaningful comparisons of medication use.     

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 effect of physician practice organization on efficient utilization of hospital resources

OBJECTIVE: This study examines variations in the efficient use of hospital resources across individual physicians. DATA SOURCES AND SETTING: The study is conducted over a two-year period (1989-1990) in all short-term general hospitals with 50 or more beds in Arizona. We examine hospital discharge data for 43,625 women undergoing cesarean sections and vaginal deliveries without complications. These data include physician identifiers that permit us to link patient information with information on physicians provided by the state medical association. STUDY DESIGN: The study first measures the contribution of physician characteristics to the explanatory power of regression models that predict resource use. It then tests hypothesized effects on resource utilization exerted by two sets of physician level factors: physician background and physician practice organization. The latter includes effects of hospital practice volume, concentration of hospital practice, percent managed care patients in one's hospital practice, and diversity of patients treated. Efficiency (inefficiency) is measured as the degree of variation in patient charges and length of stay below (above) the average of treating all patients with the same condition in the same hospital in the same year with the same severity of illness, controlling for discharge status and the presence of complications. PRINCIPAL FINDINGS: After controlling for patient factors, physician characteristics explain a significant amount of the variability in hospital charges and length of stay in the two maternity conditions. Results also support hypotheses that efficiency is influenced by practice organization factors such as patient volume and managed care load. Physicians with larger practices and a higher share of managed care patients appear to be more efficient. CONCLUSIONS: The results suggest that health care reform efforts to develop physician-hospital networks and managed competition may promote greater parsimony in physicians' practice behavior.     

The impact of physician involvement in managed care on efficient use of hospital resources

OBJECTIVES: This research assesses the impact of managed care on the physician's efficient use of hospital resources. It examines three questions. (1) Does a higher percentage and volume of managed care patients in the physician's hospital practice lead to more efficient utilization? (2) Do physicians shift cost to nonmanaged care patients in an effort to compensate for lower reimbursement for managed care patients? (3) Are there threshold effects in the percentage and volume of managed care patients treated by physicians? METHODS: The study combines patient discharge data from the state of Arizona with physician and hospital data for a 2-year period. Random effects maximum likelihood (REML) regressions were performed for four different diagnosis classifications to examine the effect of the physician's managed care caseload on mean-adjusted charges and length of stay. RESULTS: The findings suggest that physicians with high percentages and volumes of managed care patients in their hospital practice are more efficient in using hospital resources. The findings also suggest that physicians may compensate for the lower reimbursement from managed care patients by increasing their resource use among non-health maintenance organization patients. CONCLUSIONS: Finally, there appears to be a threshold effect of managed care activity on the physician's hospital utilization in one of the conditions studied.     

Managed care and open-heart surgery facilities in California

More than 25 percent of hospitals in California that offer open-heart surgery performed fewer than the number recommended by minimum volume guidelines in 1991. This DataWatch examines the characteristics of these hospitals and the patients they treat. The analysis suggests that the market share of these providers has remained constant over recent years, despite substantial growth in managed care. Simple explanations--for example, that these hospitals are serving isolated geographic markets or are hospitals in transition--do not explain the phenomenon. Medicare beneficiaries represent approximately half of the patient volume at these facilities. Health maintenance organizations (HMOs) are more likely to send their enrollees to high-volume facilities.     

The impact of managed care on clinical research: a preliminary investigation

Rapid growth in managed care enrollment is likely to affect clinical research at the nation's academic medical centers (AMCs). Our site visit interviews indicate that managed care has not markedly reduced coverage for research-related care. However, market competition in some areas has limited AMCs' ability to subsidize research activities with clinical revenues. As they gain market share, managed care organizations will have a growing influence on research priorities. Therefore, it is important for the academic community to work with managed care leaders to identify areas for collaboration and an agenda for moving forward in the future.     

Magnetic resonance imaging (MRI) scans

A Research Network Based in London, Ont., aims to improve hospital care by having hospitals share information. The research points out the ways some hospitals do things differently. Dr. William Sibbald, who heads the network, says that if hospitals overcome some of the variations between them, they may be "able to save money and become more efficient."     

Factors Affecting the Use of Precast Concrete Systems in the United States

The use of precast concrete systems offers several advantages such as speedy erection, higher quality, lower project cost, better sustainability, and enhanced occupational health and safety. In spite of these advantages, the share of precast concrete systems in the U.S. building construction market is very low. The factors behind this low market share are discussed in several studies. This study aims to identify the current factors that affect the use of precast concrete systems, compare them with the ones that prevailed in 1995, and figure out what has changed through the last 11?years in the American precast concrete industry. The findings of an extensive survey indicate that most of the dominating barriers to the extensive use of precast concrete systems in 1995 are either eliminated or drastically reduced, while some of them still prevail. Practitioners should be well informed about the factors that affect the use of precast concrete systems if these systems are to be used more extensively.     

Reactive oxygen species in human semen: investigations and measurements

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.     

Dynamic cost shifting in hospitals: evidence from the 1980s and 1990s

The purpose of this paper is to determine whether dynamic cost shifting occurred among acute care hospitals during the period from the early 1980s to the early 1990s and, if so, whether market factors affected the ability to shift costs. Evidence from this study of California acute care hospitals during three time intervals shows that the hospital did practice dynamic cost shifting, but that their ability to shift costs decreased over time. Surprisingly, hospital competition and HMO penetration did not influence cost shifting. However, increasing HMO penetration (measured as the HMO percentage of hospital discharges) did decrease both net prices and costs for the early part of the study, but later was associated with increases in both.     

Caring for Cambodian refugees in the emergency department

BACKGROUND: Platelet utilization has steadily increased throughout the past three decades. At the same time, there has been very little study of the current transfusion practices. STUDY DESIGN AND METHODS: A survey was conducted of institutional members of the American Association of Blood Banks (hospitals) that were actively involved in the care of pediatric and/or adult hematology and/or oncology patients. Inquiries were made relating to the extent of prophylactic versus therapeutic use of platelets, criteria used for prophylactic transfusion of platelets and type, and dose of platelets used. Data were analyzed according to patient age and type of hospital. RESULTS: Of 786 responding hospitals, 630 (80.2%) provided sufficient data for analysis; 126 of that 630 provided care for pediatric patients. The majority (60.9%) of responding hospitals had a minimum of four hematologists and/or oncologists. Eighty-four percent of hospitals reported transfusing some apheresis platelets. The dose of platelet concentrates most frequently used for adults ranged from 6 to 10, with pools of 10 more commonly used in community hospitals. More than 70 percent of hospitals reported transfusing platelets primarily for prophylaxis: 60 percent of hospitals set the threshold platelet count for prophylactic platelet transfusion at 20,000 per microL, with approximately 20 percent each transfusing at higher and lower levels. A platelet count of 50,000 per microL was most frequently required for performance of a minor invasive procedure. CONCLUSION: The data from this study show that the majority of institutions use prophylactic platelet transfusion in both pediatric and adult hematology and/or oncology patients. However, there is considerable variation in platelet transfusion practice.     

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).     

Medical management of obesity

CONTEXT: Since the initiation of managed health care, little information has been available on whether family planning agencies are seeking ways to serve (and obtain reimbursement for serving) the growing number of clients who are managed care enrollees. METHODS: A 1995 mail survey sought information from a nationally representative sample of publicly funded family planning agencies about the agencies' involvement with managed health care plans and related clinic services, policies and practices. Completed surveys were received from 603 agencies, for an overall response rate of 68%. RESULTS: One-half of all publicly funded family planning agencies had served known enrollees or managed care plans. One-quarter (24%) had served managed care enrollees under contract, while others sought out-of-plan reimbursement for services provided to enrollees (13%) or used other sources to cover the cost of these services (12%). Family planning clinics administered by hospitals and community health centers were more likely than other types of clinics to have contracts to provide full primary-care services to managed care enrollees, whereas Planned Parenthood affiliates were more likely to have contracts that covered the provision of contraceptive care only. Clinics administered by health departments rarely had secured managed care contracts (10%), and only 36% reported even serving managed care enrollees. CONCLUSIONS: The challenges presented by managed care, and agencies' responses to these challenges, vary according to the type of organization providing contraceptive care. Family planning agencies need to seek relationships with managed care organizations based on those services that their clinics can best supply.     

Hospital employment trends in California, 1982-1994

During the 1980s California hospitals responded to selective contracting, growth in managed care, and the Medicare prospective payment system (PPS) by controlling their level of spending. This DataWatch examines whether these hospitals achieved these savings by changing the number and/or the mix of hospital employees. We examined employment trends because wages represent the largest component of hospital budgets and because the number and mix of personnel can be changed in the short run. Analysis of the California Health Facilities Cost Report data shows that employment increased steadily during 1982-1994. There is no evidence that hospitals responded to growing competition by altering the rate of growth in hospital personnel and only weak evidence that they altered the mix of personnel by hiring a greater proportion of nonclinical staff. We conclude that increased competition had only a minor effect on hospital employment decisions.     

EPR evidence for the involvement of free radicals in the iron-catalysed decomposition of qinghaosu (artemisinin) and some derivatives; antimalarial action of some polycyclic endoperoxides

The role of pharmacies that specialize in the treatment of specific chronic diseases in the alternate-site health care setting is discussed. The optimal use of medications through disease management programs can improve patient outcomes and lower overall health care costs. The increase in disease management programs has spawned the growth of disease-specific pharmacies in the home care and other alternate-site health care settings. These pharmacies usually operate from a single location or are regionalized operations that deliver pharmaceutical products to patients throughout the United States. The pharmacies employ clinicians who specialize in a particular disease. These clinicians conduct comprehensive patient education programs, drug-use review, and compliance monitoring. Disease management pharmacies focus on chronic, expensive diseases; costs related to inventory, equipment, and storage can be very high. Many disease management pharmacies are involved in preferred-distribution or closed-distribution arrangements with pharmaceutical manufacturers. Pharmacists involved in disease management programs routinely send compliance information about their patients to pharmaceutical companies, managed care organizations, or prescribing physicians. Disease management pharmacies act as advocates for patients with particular chronic diseases. Various foundations and patient advocacy and research groups have created their own disease management pharmacies. Disease management has also reached the community pharmacy practice setting. Pharmacies specializing in the treatment of specific chronic diseases in the alternate-site health care setting can improve health care and promote efficient use of health care dollars.