What is driving health system change?

Quality trends in healthcare and their impact on anesthesiology

The new approach of a patient-centred, appropriate and timely care that was at the heart of the Institute of Medicine (IOM) initiative is changing the face of the healthcare industry in general and, in particular, of anesthesiology as a speciality. The drivers of this change are better quality and decreased healthcare costs, since despite a large expenditure for healthcare, the quality of care has not changed tremendously. Metrics have been identified, derived from the cybernetic model first described by the quality "parent". Donabedian and each of those metrics have both advantages as well as disadvantages. Ultimately the outcome measures are the ones that CMS will hold hospitals accountable for financially as well as from a safety standpoint. The culture of safety and quality as well as methodologies to improve that culture will shape the future of quality of care and improve outcomes and patient satisfaction.

Health care coalitions: from joint purchasing to local health reform

For several decades, business and health coalitions have played an important role in representing the interests of business in the health care arena. During the 1990s, these coalitions focused their efforts on supporting purchasing activities related to health insurance benefits and direct health care. Based on a national survey conducted in 2006, and prior similar surveys, we find that business and health coalitions have invested in pooling regional health care data, promoting public reporting of quality and cost information, and coordinating pay-for-performance initiatives. In addition, many business and health coalitions are broadening their membership to include other stakeholders and to support community health reform efforts with far-reaching benefits. Through this work, coalitions increasingly are recognizing and embracing their role as catalysts for local market reform.

The role of early newborn discharge legislation in influencing policy development: understanding the Kansas experience

Early newborn discharge legislation began a movement in health policy towards incremental changes in how medical consumers receive services. While well intentioned, these initiatives may undermine national efforts to address problems through more comprehensive reform, while stifling smaller efforts to address the problems locally. This paper discusses early newborn discharge legislation in Kansas: its origins, apparent impact, and implications. Findings from a hospital survey and two-year follow-up suggest a minimal effect of the legislation on health services in the state. Though acute hospital care appeared to replace home-based programs in many hospitals we spoke with, the more longstanding impact of the legislation seems to have been its precedent in how health policy is now made.

Business ethics and health care: a stakeholder perspective

This article examines the recent controversy in health care delivery about whether it should be conceptualized as a business. The current debate implicitly appeals to a common understanding of business and business practices that is no longer very useful. This common notion, which the authors call "cowboy capitalism," conceptualizes business as a competitive jungle resting on self-interest and an urge for competition in order to survive. The authors suggest that stakeholder capitalism offers a more useful framework for the dialogue about health care reform.

Managed care and the US health care system a social exchange perspective

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.

Bounceback: Blues thrive as markets cool toward HMOs

Enrollment in Blue Cross and Blue Shield (BCBS) plans has grown by almost seventeen million since 1994, and recent financial performance indicators are positive for most plans in the Blues system. These gains have been achieved by for-profit, nonprofit, and mutually owned plans. A journalistic analysis of distinctive features contributing to recent successes is offered, combining observations of financial analysts, health services researchers, and BCBS officials. Long-term stability, broad provider networks, and conservative financial management have given the Blues advantages vis-à-vis many managed care organizations that have lost market share in the same period.

The social roles of Medicare: assessing Medicare's collateral benefits

The Medicare program incorporates a number of functions that go beyond providing health insurance to its beneficiaries. These activities, which we refer to as "collateral" functions, may have important health consequences but are also an increasing source of controversy. In this essay we develop a conceptual framework for categorizing these involvements, introduce some additional options that might complement Medicare's current collateral functions, assess the reaction of policy elites and Medicare's current beneficiaries to these alternatives, and evaluate the role that collateral activities play for Medicare's core mission. A case can be made for expanding some collateral involvements, but only if the Health Care Financing Administration has the strategic direction and administrative capacity to effectively implement these activities.

Humanism in health care service: the role of stakeholder management

In the era of technological proliferation the potential for the holistic intention and practice of nursing to become overshadowed is immense. This article presents an overview of the stakeholder theory of management as a useful and important management model for the creation of health care delivery environments where the human condition is celebrated, exemplary service is cultivated, and human caring becomes an enterprisewide value.

Beyond managed costs

Managed care organizations (MCOs) face an uncertain future. While consolidation and price competition have expanded their market share, health care expenditures are expected to rise in the near future, and the cost containment premise--and promise--of MCOs is being threatened by mixed blessing and nonsupportive stakeholders. To shed light on MCOs' situation, we discuss four drivers for change in health management in the U.S.: technology, regulation, consumerism, and demographics. Using those four drivers, we then assess the various stakeholders in the industry through a competitive analysis and a stakeholder analysis. These analyses suggest that the munificence of the MCO business environment has significantly declined, especially among supplier and buyer stakeholders. Hence, MCOs cannot continue to manage health care costs alone as this will no longer generate sufficient support among buyer and supplier stakeholders. Instead, MCOs must tackle five critical health care issues by working closely with other stakeholders and also by learning what they can from innovative health care initiatives both inside and outside the United States.

Health maintenance organizations and hospital quality for coronary artery bypass surgery

This study uses hospital discharge data for 1992-1994 to assess differences between HMO and insured non-HMO patients in California and Florida with regard to the quality of the hospitals used for coronary artery bypass graft (CABG) surgery. The authors found that commercially insured HMO patients in California used higher quality hospitals than commercially insured non-HMO patients, controlling for patient distance to the hospital. In contrast, commercially insured HMO and non-HMO patients in Florida were similarly distributed across hospitals of different quality levels, whereas Medicare HMO patients in Florida used lower quality hospitals than patients in the standard Medicare program. The authors conclude that the association between HMO coverage and hospital quality may differ across geographic areas and patient populations, possibly related to the maturity and structure of managed care markets.

Depressive symptoms and plan switching under managed care

OBJECTIVE

A central assumption underlying managed care is that plan switching is a viable option for enrollees when they are dissatisfied. The authors used a national employee survey to test the hypothesis that this mechanism is less effective for enrollees with high levels of depressive symptoms than for the remainder of the population.

METHOD

The study used data from the Employee Health Care Value Survey, a 1993 survey of 20,283 employees of three major corporations. The authors used the Medical Outcomes Study 36-Item Short-Form Health Survey to identify individuals with the highest decile of depressive and physical symptoms. They examined the relationship between symptoms and dissatisfaction and, for dissatisfied individuals, how symptoms predicted plan switching. Multivariate models were used to control for potential demographic, health, and health coverage confounders.

RESULTS

Depressive and physical symptoms were both associated with dissatisfaction with care. Unlike physical symptoms, depressive symptoms were associated with a significantly lower likelihood of actually disenrolling among people who were dissatisfied or who intended to disenroll. This effect was most pronounced for satisfaction with administrative aspects of care (e.g., gatekeeping, utilization review).

CONCLUSIONS

People with high levels of depressive symptoms appeared to be less willing or able to act on their dissatisfaction by switching plans. In particular, they were willing to tolerate higher rates of dissatisfaction with the administrative aspects of their health coverage without disenrolling. Plan switching is an essential mechanism underpinning a health care system predicated on competition; it may be less effective for people with depressive disorders.

Overall survival of the medical oncologist: a new outcome measurement in cancer medicine

BACKGROUND

Changing patterns of patient referral, decreasing payments for service provision, confusing network participation and reimbursement, as well as challenges to autonomous clinical decision-making jeopardize the traditional role of the oncologist in delivering cancer care. The cancer patient also may be at risk with unproven cancer delivery systems that displace the oncologist as decision-maker and care provider. The authors have constructed a model that preserves the oncologist's clinical and financial autonomy while meeting marketplace demands for improved access, decreasing costs and preserved quality of care.

METHODS

During a 4-year period, a group of private practice medical oncologists initiated a formal business plan to evaluate marketplace needs, then designed and implemented a novel cancer care delivery model. The model required reconfiguring the practice into an integrated Joint Commission on Accreditation of Healthcare Organizations-certified cancer service corporation, providing medical, radiation, and gynecologic oncology. Palliative care, pain management, psychologic, and nutritional services were instituted as well as the vertical integration of home health and hospice care. Clinical pathways and treatment protocols were designed to enhance patient care and facilitate cost-of-care projections in designated populations using a cancer incidence forecasting model. Outcomes analysis are performed as part of ongoing continuous quality improvement, which continues to change this health care delivery system.

RESULTS

In the 3 years since implementation of the model, the practice has increased from 16 to 24 physicians, and the number of offices has increased from 12 to 17. Patient encounters, both new and established, have doubled. Cost of services, specifically hospitalization, have been reduced by 50%. Clinical research referrals have increased 300%. Physician compensation has improved >20%.

CONCLUSIONS

The model created a low cost, high value provider not burdened by allocated overhead. Decentralized care enhanced community access, which improved patient compliance, enhanced patient satisfaction, decreased hospitalization, and thereby decreased cost. The horizontal structure permited the flexibility for varied purchaser products and politically sensitive physician and hospital provider panels. Consensus-based protocol and pathway determination achieved maximum physician participation, which preserved clinical and financial autonomy, decreased variance, and facilitated clinical research.

Managed care and physician referral

In the era of managed care, fundamental changes are occurring in the American health care system that are altering physician referral patterns. Faced with higher premiums that erode profits and competitiveness, employers, government, and nonprofit agencies are contracting with managed care organizations, which control costs partly by imposing constraints and incentives on physician referral behavior. As more and more Americans are covered by managed care plans, it becomes more important to understand how managed care organizations control access to specialists and how these controls affect health outcomes. The authors present a model defining the expected influence of managed care on physician referral based on social exchange theory and the empirical literature. They conclude with a discussion of the future research implications of the model.

Managed care. Evolution and distinguishing features

Managed care as a system of health care delivery has grown tremendously in popularity in the United States during the past decade in response to demands by employers and government for cost containment, enhanced access, and improved quality. Managed care took root in the 1800s as prepaid health services provided by employers for immigrants coming to the United States to work. The forerunner of modern managed care, prepaid group practice, later was dwarfed by the unbridled development of FFS medicine under indemnity insurance in the post-World War II period and stunted by early reactions of organized medicine. The early health care reform years of the 1960s spawned HMO legislation in the 1970s, which prompted ever-escalating growth in HMO enrollment. Market-driven health reform has prompted the evolution of health care delivery to the modern-day version of managed care. In this system, health care is provided by a limited number of contracted providers at reduced rates of reimbursement. Patients are channeled to these contracted providers, and clinical decision making of these providers is influenced by the MCO through utilization management and quality assurance. Financial risk is shifted from payers and insurance companies to providers to influence further clinical decision making. All of these characteristics of managed care pressure providers toward higher levels of integration and foster greater reliance on management information systems. Gaining a perspective from the history of managed care, understanding managed care's distinguishing features, and dealing effectively with the pressures of these unique characteristics are important in successfully caring for patients, managing the risk structure, and succeeding professionally in this current environment for health care delivery.

The current health care environment and stages of market development

The history of medical payment strategies is reviewed with a historical perspective on the development of the health care system in the United States. The growth of managed care is discussed with sections detailing the effects on and responses of health care providers, the insurance industry, government, consumers, and employers. Current status and future market trends are discussed.