The monetarization of medical care

Hospital Capital Assets, Community Health, and the Utilization and Cost of Inpatient Care: A Population-Based Study of US Counties

BACKGROUND

The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision.

OBJECTIVE

To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs.

RESEARCH DESIGN

We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders.

RESULTS

Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26).

CONCLUSIONS

The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.

On values and democratic policy making: the deceptively fragile consensus around market-oriented medical care

Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.

Financial management challenges for general hospital psychiatry 2001

Psychiatry programs are facing significant business and financial challenges. This paper provides an overview of these management challenges in five areas: departmental, hospital, payment system, general finance, and policy. Psychiatric leaders will require skills in a variety of business management areas to ensure their program success. Many programs will need to develop new compensation models with more of an emphasis on revenue collection and overhead management. Programs which cannot master these areas are likely to go out of business. For academic programs, incentive systems must address not only clinical productivity, but academic and teaching output as well. General hospital programs will need to develop increased sophistication in differential cost accounting in order to be able to advocate for their patients and program in the current management climate. Clinical leaders will need the skills (ranging from actuarial to negotiations) to be at the table with contract development, since those decisions are inseparable from clinical care issues. Strategic planning needs to consider the value of improving integration with primary care, along with the ability to understand the advantages and disadvantages of risk-sharing models. Psychiatry leaders need to define and develop useful reports shared with clinical division leadership to track progress and identify problems and opportunities. Leaders should be responsible for a strategy for developing appropriate information system architecture and infrastructure. Finally, it is hoped that some leaders will emerge who can further our needs to address inequities in mental health fee schedules and parity issues which affect our program viability.

Preserving community in health care

There are two prominent trends in health care today: first, increasing demands for accountabilty, and second, increasing provision of care through managed care organizations. These trends promote the question: What form of account-ability is appropriate to managed care plans? Accountability is the process by which a party justifies its actions and policies. Components of accountability include parties that can be held or hold others accountable, domains and content areas being assessed, and procedures of assessment. Traditionally, the professional model of accountability has operated in medical care. In this model, physicians establish the standards of accountability and hold each other accountable through professional organizations. This form of accountability seems outdated and inapplicable to managed care plans. The alternatives are the economic and the political models of accountability. In the economic model, medicine becomes more like a commodity, and "exit" (consumers changing providers for reasons of cost and quality) is the dominant procedure of accountability. In the political model, medicine becomes more like a community good, and "voice" (citizens communicating their views in public forums or on policy committees, or in elections for representatives) is the dominant procedure of accountability. The economic model's advantages affirm American individualism, make minimal demands on consumers, and use a powerful incentive, money. Its disadvantages undermine health care as a nonmarket good, undermine individual autonomy, undermine good medical practice, impose significant demands on consumers to be informed, sustain differentials of power, and use indirect procedures of accountability. The political model's advantages affirm health care as a matter of justice, permit selecting domains other than price and quality for accountability, reinforce good medical practice, and equalize power between patients and physicians. Its disadvantages include inefficiency in decision making, capture by extremists or experts, intractable value conflicts, fragmentation of community, and oppression of minorities. The political model is the model we should endorse. Its disadvantages can be minimized by proper institutional design. In addition, recent research on managed care plans suggests that the political model may be the best for a competitive marketplace because it can ensure that tough allocation decisions are addressed and improve health through changes in nonmedical aspects of community life.

Pediatric surgery--whither goest thou?

What I have attempted to do in this analysis is to give you my views of pediatric surgery as it stands today in terms of its original goals. I have also attempted to look ahead and to analyze the straws in the wind, hopefully offering some potential solutions for the issues we are currently facing. If we remember who we really are and what our purpose is, great opportunity lies ahead. To those of us who are not satisfied with the present outlook there is much to be investigated and much to be contributed.

Lessons from Elderly Physicians: Reflections on Practice, Changes in Medicine, and Retirement

To gain perspective on changes in medicine and learn about the later stages of physicians' careers, we surveyed Rhode Island physicians age 65 years or older. Despite their concerns about changes in the structure of medical practice and the doctor-patient relationship, these physicians reported satisfying careers and expressed few professional regrets. Those elderly physicians who remained in practice did so because they enjoyed patient care and the intellectual stimulation of medicine. They also felt a responsibility to their patients and wished to remain active professionally. Those who retired cited "hassles, "high costs associated with practice, and their personal health as important reasons.

A critique of the concept of MRI centers

A significant proportion of MRI units are being installed in MRI Centers that are free standing enterprises offering outpatient diagnoses separate from hospitals. The development of such Centers represents a challenge to more traditional arrangements and may have serious implications for physician responsibility that depend on their management and administration. In this review several legal and ethical issues arising from the proliferation of such Centers are analyzed and it is argued that regulatory attitudes may need to be altered to avoid major shifts of emphasis in the pattern of use of high cost imaging equipment.

Consultation-liaison psychiatry and the teaching of ethics

Medicine has undergone a technological explosion which presents physicians with an increased need to make difficult ethical decisions. This has been met by an equivalent development in American medical schools of efforts to teach the ethics of medical practice. The courses vary widely from school to school. It is recommended that a core curriculum of basic theory be taught in preclinical years, followed by case-centered teaching in clinical years and residency. Only with real cases can the influence of the doctor-patient relationship be appreciated. Teaching of ethics cannot be divorced from the clinical reality of the doctor-patient relationship. The emotional needs of both enter into all decisions. It is offered that consultation-liaison psychiatry, which addresses the needs of both, is an ideal focus for such teaching.

Building a helpful relationship: the foundation of effective patient education

To have a lasting impact on patients, patient educators need to build relationships that are characterized by trust and collaboration. Without trust, patients are likely to withhold intimate, often critical, information. Pa tients are not likely to give credence to or to carry out advice offered by health professionals they do not trust. In col laborative relationships, patients take an active role, have a sense of ownership of the changes they make, and assume responsibility for their own care to the extent they are able. Health pro fessionals who function in authoritarian ways can foster passivity and dependency in patients; postures that are counter productive to lasting change and growth.

Medical technology and health expenditure: an economic review and a proposal

This paper is an evaluative survey of the economic literature on the relationship between technology and/or innovation and health expenditures. Various types of analysis viz. econometric modelling; three residual approaches; the cost-of-illness approach; and the literature on supplier interests are contrasted, and the results presented. The paper concludes with a discussion of the policy and planning implications, and a simple, and conventional, proposal is made that could unambiguously determine this relationship in the case of process innovations.

HMOs: America today, Britain tomorrow? Exit the white coat, enter the pinstriped suit

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International perspectives on the health care crisis in the United States

The American health care system is confronting a crisis: one consisting of severe problems of cost and access, and the other consisting of significant qualitative changes in structure, systemic behavior and operation. Some of these factors may be understood better in comparison with how systems in other nations have responded to similar problems. The United States had adopted solutions which are significantly different from those of other countries, including more limited government involvement in health care and planning, and the development of corporatized medicine. These solutions pose significant ethical and operational problems.

The concept of Gemeinschaft in health planning and management: a Japanese perspective

The rationale for public involvement in the health sector lies mainly in realizing equity values. As the Gesellschaft relationship of utility maximization cannot be relied upon to arrive at a level of health care regarded as equitable in geographic and other terms, this article argues that there is need to focus on the Gemeinschaft relationship of humanitarian concern. Policy-makers would, firstly, have to define explicitly the objectives at each policy level; and, secondly, to convince and educate the public and the health providers that such is the way forward. At the operational level, the Japanese-style management with its emphasis on the mutual commitment of the management and the workers to the organization, would seem to offer a way to unify the fragmented interests within the hospital setting. A comparative study of the health systems of the UK, Japan and the US is made to evaluate the constraints and opportunities each country faces, or would face, in realizing the Gemeinschaft concept at the policy and operational levels. The conclusion reached is that, despite the difficulties, this concept appears to offer a viable alternative to the intensified conflict for resources in the health sector.