Dealing with Clinical Risk: Implications of the Rise of Evidence-Based Health Care

This article considers the nature of risk in health care and the use the National Health Service (NHS) makes of risk management. It explores how the concept of risk has been challenged by the rise of 'evidence-based' health care, accompanied and accelerated by a decline in professional prestige, status and mystique and much greater use of external measurement and controls as part of the New Public Management. The nature of evidence-based health care is outlined and the implications of the use of guidelines and other practice aids are explored. Finally, the article discusses how evidence-based health care is affecting our views of clinical risk.     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

Brain injury rehabilitation; the continuum of care

The continuum of care for individuals with traumatic brain injury has become quite complex. Medical technology has increased survival rates leaving many individuals with severe deficits. Quality treatment programs have been developed that are proving cost effective with good outcomes for many. To insure maximal recovery from traumatic brain injury, the patient should be provided the opportunity for treatment in the setting which is most conducive to maximal recovery. The acute hospital, the subacute program, the postacute program, the home program and the others should all be considered as part of the continuum of care for the brain injured individual. Timely movement to the appropriate setting will facilitate maximum recovery of a traumatic brain injured individual. Many patients have the potential to improve with quality treatment, appropriate setting and sufficient time to be treated. The article describes the levels of care that are available, with the goals and objectives of each level. It describes the patient that would best fit into each level. It further identifies assessment tools that are useful in measuring progress and outcomes.     

Frequent-user patients: reducing costs while making appropriate discharges

Homeless patients who lack access to the health resources they need to maintain their health on their own pose a challenge for hospitals: Premature discharge of such patients can result in their being readmitted to the hospital in a short time, leading to higher costs for the hospital. Hospitals can address this problem by developing clear, effective homeless discharge policies and by developing ongoing relationships with appropriate medical respite care providers. A hospital also can benefit from spearheading an initiative to develop a medical respite program, enlisting the assistance of other community stakeholders.     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

5 pillars of clinical integration

Implementing an effective clinical integration program requires deliberate investment of time and resources in five key areas: Physician leadership, Physician-led care management, Quality monitoring, Patient information and data sharing, Payer engagement.     

The hospital: how will it survive?

The federal government is under pressure to implement and enforce a program to provide economic and social relief from the rapidly escalating health care costs which now consume 8.5% of the Gross National Product. Glick predicts that within the next twenty years, the character of health care institutions will be reshaped and only the most adaptable hospitals, health maintenance organizations and health-related governmental organizations will survive. He urges hospitals to develop appropriate strategies to deal with the problems of cost-containment, state-operated cost review and control agencies, and the competition for limited health care resources. The author warns the health care industry that if it does not adjust to these changes, it runs the risk of becoming heavily rgulated. It is suggested that health care institutions be integrated into comprehensive health care systems and the article includes a model for assigning patients to medical care facilities on a regional basis. Glick forecasts that hospitals will enter into a competition for survival, resulting in mergers of some and the closing of others. He believes that as the number of health care institutions decreases, the remaining ones will become more specialized and geographically dispersed.     

How universal health care would influence decisions about work and retirement

The current U.S. health care system distorts individual decisions about work and retirement. After a brief explanation of how the current health care system works, this article reviews those distortions and considers how individuals would respond to the implementation of a universal health care system. The author argues that the likely adverse impacts of an employer health insurance mandate on low-skilled workers could be more than offset by a well-designed system of government subsidies.     

Managing the demand for health services by adopting patient-centered programs

Recently, the trend to managing the demand of health care services has become more prevalent. Standalone types of demand management programs are patient-centered and support appropriate health care decision making by the consumer. The author examines these types of programs including their benefits and risks.     

城乡居民医保逆选择的破解——一个基于不同人口年龄需求的设计

逆选择困扰了我国城乡居民医保事业的可持续发展.在原有的大病和重病保障之外,基于不同人口年龄需求设计一个有条件、有限度和有年龄差别的特殊医保待遇方案,让参保者在没有享受到大病重病医保待遇的情况下,也可获得一些与年龄相称的医保待遇.这一设计除了能增加参保的弹性,让各年龄群体都自愿积极参保,还可增强居民的健康意识,提高居民的健康水平,减少居民和医保的医药开支.此外,它还能促进基层医疗服务业的发展.     

DRG-based prospective pricing and case-mix accounting—Exploring the mechanisms of successful implementation

Escalating health care expenditures have brought on the need for restructuring health care delivery. A common response to this problem has been to seek market-based solutions. In the literature, however, increasing concern has been expressed that hospital management reforms will fail or will have only a limited impact. This longitudinal case study extends our understanding of the effects of implementing DRG-based prospective pricing and case-mix accounting systems for hospital management control in a specific health care setting. Moreover, this study contributes to current knowledge by focusing on the mechanisms explaining successful implementation of new accounting and control systems in the health care sector. A deep understanding of these mechanisms may help us to design better management control systems, and thus circumvent problems in implementing these systems. Our study suggests that successful implementation in the studied context is strongly dependent on the involvement of clinicians in this process. Integrated clinical and financial accountability, assigning responsibility for implementation to clinicians, freedom in choosing appropriate control tools, and flexibility in adoption all facilitated implementation. Furthermore, we argue that this process has also been advanced by the gradual implementation of these reforms and intensifying institutional pressures.     

Propuesta de un índice para evaluar la gestión del control interno

Derived from its humanitarian mission, to pay quality health care to the population, in hospitals and health facilities is needed reduce the occurrence of events that may threaten the physical and psychological integrity of the patients they serve. One of the strategies to consider to overcome this challenge is the proper implementation of the internal control system, to ensure the sustainability of insurers, by increasing efficiency in the care of people, feasible only within a care model that quantifies and management on population identified and addressed. The objective of this paper was to propose a coefficient to evaluate the internal control management for a hospital entity. This was conceived under the guidelines of the multi-criteria modeling in conjunction with the detection of critical points through Petri nets. For this, the order of importance and fulfillment of the components of Internal Control and in unison the unreliability of critical processes in the entity being identified practical application was determined.     

HMOs don't have to fail

One of the bright spots in the sometimes black picture that is painted of our national health care system is HMOs. Health maintenance organizations provide health services to an enrolled group of patients for a fixed, prepaid fee. This arrangement induces HMOs to try to keep patients healthy for a competitive rate. Because of its special nature, however, an HMO cannot be managed like a fee-for-service hospital or group practice. And because few managers fully understand them, more and more HMOs are failing. The authors of this article say, however, that some failures can be avoided. Good management techniques can help HMO managers-whether they are community-spirited citizens or seasoned executives-overcome many of the problems that plague HMO plans: out-of-control utilization rates, growth that can occur overnight, conflict between the values of HMOs and of the physicians that staff them, and competitors in the health field.     

Health information technology and patient outcomes: the role of information and labor coordination

Health information technology (IT) adoption, it is argued, will dramatically improve patient care. We study the impact of hospital IT adoption on patient outcomes focusing on the role of patient and organizational heterogeneity. We link detailed hospital discharge data on all Medicare fee‐for‐service admissions from 2002–2007 to detailed hospital‐level IT adoption information. For all IT‐sensitive conditions, we find that health IT adoption reduces mortality for the most complex patients but does not affect outcomes for the median patient. Benefits from health IT are primarily experienced by patients whose diagnoses require cross‐specialty care coordination and extensive clinical information management.     

Medicare on the critical list. Understanding the etiology of the disease will help in the search for a cure.

Medicare, and its companion program Medicaid, came into being as part of Lyndon Johnson's Great Society. Their purpose was to provide the elderly with equal access to high-quality medical care. Though the goals were laudable, the magnitude of the costs and of the effects was unforeseen. As the two programs made medical care available to a large segment of the population, the demand grew. At the same time, private industry became more generous with its health insurance plans. Because of their emphasis on hospital care, the governmental and private industry plans helped push hospital prices up. Now that both sectors are finding the cost of medical care unacceptably high, Congress is proposing remedial legislation and corporations are trying alternative health care plans. These authors explore how well the maladies of Medicare may respond to the various cures that are being proposed.     

Proposal of a coefficient to evaluate the management of the internal control

The objective of this article is to propose a management index for the Internal Control of care entities. This was conceived following the multicriteria modeling guidelines in conjunction with the detection of weaknesses through the Petri networks. For this purpose, the order of importance and compliance of the internal control components were determined, and the lack of reliability of the critical processes in the entity subject to the practical implementation was identified. Derived from its humanitarian mission – lending quality health care to the population – it is necessary to decrease the emergence of events that could infringe upon the physical and psychological integrity of the patients in hospitals. One of the strategies to consider to overcome this challenge is the adequate implementation of the Internal Control System, which guarantees the sustainability of the insurers through the increase in the efficiency of the care of the people, feasible only within a care model that quantifies the control over the population already identified and cared for.     

Perspectives Articles: Exploring Stakeholder Perspectives on What Is Affordable Health Care

Health care expenditures have accounted for increasing proportions of the U.S. gross domestic product, and the rate of growth of health care expenditures has increased over the past two decades. These two measures of assessing whether the level of health care expenditures is affordable may be appropriate in the aggregate for the United States but are not appropriate to assess whether individual stakeholder groups can afford their particular level of spending on health care. Health care is an economic good that differs from other economic goods, as it involves life and death issues, and invokes a call for a moral authority. This article explores definitions of what is affordable health care from the perspective of different stakeholders and suggests that other measures are needed to assess whether or not health care is affordable for stakeholders as one definition is not appropriate for all stakeholders.     

Stroke--incidence, mortality, morbidity and risk

In the United States, 700,000 strokes, responsible for 165,000 deaths, occur each year. Worldwide, stroke is the 2nd leading cause of death. Stroke is a major health problem; and as the population ages, its significance will grow. This paper reviews the epidemiology of stroke, the identification of modifiable risk factors, and some of the options for intervention that can reduce stroke-related mortality and morbidity. Though the diagnosis and care of stroke patients has improved, mortality resultant from stroke remains significant, with only 50% 5-year survival in some clinical studies. The risk of stroke following a transient ischemic attack (TIA) or initial stroke is also significant-approximately 30% following either event. Stroke severity at onset and patient age are the most important factors for predicting prognosis. Stroke prevention focuses on management of the traditional cardiovascular risk factors especially control of blood pressure and smoking cessation. The role of diabetes and lipid control in stroke prevention continues to be studied. The optimum use of anticoagulation to reduce stroke risk has been explored by the Stroke in Patients with Atrial Fibrillation (SPAF) studies. Carotid endarterectomy is effective in stroke prevention for those with symptomatic carotid obstruction of 70%, but its role in other scenarios is less certain. Antiplatelet drugs continue to be an important therapy for the prevention of recurrent stroke. Centralized stroke centers that specialize in stroke diagnosis and care along with rapidly rendering appropriate treatment can improve mortality and morbidity of stroke by 20%.