Accounting and Medicine: An Exploratory Investigation into Physicians’ Attitudes Toward the Use of Standard Cost-Accounting Methods in Medicine

Research studies demonstrate wide variation in how physicians diagnose and treat patients with similar medical conditions and suggest that at least some of the variation reflects inefficiencies and unnecessary medical costs. Health care researchers are actively examining ways to reduce variations in practice through standardization of medicine to reduce the cost of treatment and ensure the quality of outcomes. The most widely accepted form of this standardization is Evidence Based Best Practices (EBBP). Furthermore, financial health care providers such as hospitals and managed care organizations are investigating methods to tie resource usage to medical protocols in their efforts to monitor and control health care costs. Such proposals are contentious because they report on physicians’ medical practice behaviors (such as the number of tests ordered, use of specific therapies, etc.) and such reports could potentially be used to influence their clinical behaviors. The intent of this exploratory study was to examine physicians’ perceptions about linking a standard costing system to EBBP guidelines. The authors interviewed nine practicing physicians asking each physician to respond to the question, ‘As a physician working in a hospital environment, what are your reactions to and concerns with combining standard costing techniques with EBBP?’ The interviews were in-depth and free form in nature. The physicians’ responses were recorded and analyzed using Grounded Theory Methodology. Using this methodology the field data was categorized into two major themes. The most important theme centered on ethics and the second theme was concerned with the implementation and use of a standard cost system in regard to EBBP. If physicians’ worries about ethical dilemmas and implementation issues are not resolved, then it is likely that doctors would be unwilling to participate in any efforts to develop or use a standard cost-reporting system in medicine. While this study was exploratory in nature, it should provide future guidance to accountants, health care researchers and health care providers about physicians’ issues with the use of standard costing methods in medicine.     

The cost of childhood injury in France

Injuries are a major public health problem worldwide. In the USA, injuries cause 146, 400 deaths annually, with 31 million non-fatal injury visits to emergency departments (EDs). EDs thus represent an important source of injury data. The primary objective of the current study was to describe the epidemiology of injury-related ED visits and assess injury-related utilization of health care resources in an inner-city hospital in Indiana, using data stored in a computerized medical record system. It involved a retrospective review of the records for injury visits to EDs and injury admissions over a 3-year period. The variables extracted and analysed included patients' demographics, external cause of injury, diagnosis, length of stay, ED and hospital charges. A total of 60,470 injury-related ED visits were made, the majority of patients were male (61.6%), uninsured (63.1%), treated in ED and discharged (98.4%). The leading causes of injury were falls (18.8%), motor vehicle crashes (18.4%), assaults (17.6%), being struck (11.2%) and overexertion (10.6). Firearms caused most injury deaths (32.4%; n = 314); motor vehicle crashes were the leading cause of hospitalization (26.6%; n = 642) and also the most expensive to treat as inpatients (mean charge $19,190). The mean charge per patient treated and discharged was $150 compared to $11,116 for patients admitted. These findings demonstrate the value of computerized medical records in capturing and storing E-coded injury data. The system generates data that can be used for epidemiological surveillance and injury prevention at the local level, and for assessment of impact of specific injuries on health care resources.     

Consumer use of the internet for health information: a survey of primary care patients

An increasing number of patients use the internet to obtain information about health. Although some information is available about how health professionals use the internet, little is known about how patients utilize this information. Some patients may actively seek information to assume more responsibility for their health. However, others may feel obliged to do so because of failing confidence in health care provision. Health professionals have the potential to assist patients to make sense of health information from the internet; however, they may not necessarily welcome this role. This study aims to evaluate patients’ use of such information in a primary care setting. The sample consisted of adult patients (n = 851) from two general practice populations at different levels of the socio‐economic spectrum in South Wales (UK). Patients were surveyed by questionnaire about the health information they use, including the internet. The majority of patients preferred to use their general practitioner as the main source of health information. The internet was jointly the second preferred source for information about an illness (6%). Just over half (51%) of patients in this study had access to the internet, of which about half use it to access health information. Just under a quarter (24%, n = 55) of health internet users had discussed information accessed from the internet during a subsequent consultation with a health professional. Of these, three‐quarters felt more prepared and able to participate in decision‐making about treatments. This study provides a greater understanding of how patients are making use of health‐related information from the internet. These findings can be used to help prepare health care professionals for dealing appropriately with internet‐informed patients.     

Working with risky consumers: multi‐professional care for substance‐using pregnant women

Substance use is increasingly common in many countries. Consumption and lifestyles associated with consumption often involve a number of specific health and legal risks for users. For pregnant women, the risks extend to the health and care of their unborn children. A multi‐professional approach to the management of substance use in pregnancy is recommended as best practice but, as with all strategies, effectiveness depends on the way that professional workers implement policy. This study evaluated evidence of multi‐professional working within local maternity services in and around a Scottish city by (a) collating and analysing data from the maternity records of 163 substance‐using women, who delivered between January 2001 and December 2003; and (b) conducting a questionnaire survey in 2004 with 120 midwives and neonatal nurses for their views on maternity care for substance‐using women and their babies. Despite the importance placed on multi‐professional working by midwives and neonatal nurses, maternity records indicated operational inconsistencies with implementation in some cases and not in others. Policy was not yet to be seen embedded in everyday practice.     

Why People Do Not Always Follow the Doctor's Orders: The Role of Hope and Perceived Control

The lack of adherence to medical advice is a widely recognized health care concern with important implications for consumer well‐being. This study advances a model for better understanding adherence behaviors by incorporating the positive emotion of hope and consumer perceptions of control. Empirical testing of the model in the context of type 2 diabetes, a lifestyle‐changing chronic illness, shows that hope generates more patient adherence. Furthermore, individuals have higher hope when they believe they are capable of performing the actions their treatment requires, and/or that their health outcomes are under their physician's control. The results indicate that health care providers can play an important role in encouraging adherence behaviors by cultivating hope and customizing their interactions with patients. Interventions aimed at increasing patient self‐efficacy or promoting patients' beliefs that health outcomes are under their physician's control are two routes to building hope. Health initiatives aimed at increasing diabetes treatment adherence should consider alternatives beyond asking patients to “take control” of their diabetes.     

Hope across the seas: the role of emotions and risk propensity in medical tourism advertising

Rising US medical costs as well as more competition in the health care industry have led many Americans to pursue health care in foreign destinations. As a result, leading countries in medical tourism have begun launching international advertising campaigns. A growing trend in much of this advertising is the use of emotional appeals. The purpose of this research is to examine whether the use of emotional appeals by non-domestic health care providers contributes to more favourable evaluations of the target health care provider than rational appeals. Specifically, two experimental studies investigate the efficacy of advertisements that induce the emotion of hope to determine whether these advertisements increase trust perceptions and reduce perceived risk, given an individual's level of risk propensity. Implications for public policy makers and marketing managers who work in health care are discussed.     

A Synthesis Model of the General Health Care System

A synthesis model of the general health care system is developed based on literature from a variety of disciplines. The synthesis model is then used to create a theoretical framework of fundamental laws and derivative propositions. The integrated synthesis model and the theoretical framework should provide opportunities for future research. For the practitioner, they provide a macro-oriented understanding of the general health care system and the activities that are crucial within the system. Several practical examples that are based on interviews and case studies with health care providers are used to explain the elements in the synthesis model.     

Beyond Technology Adoption: An Embeddedness Approach to Reduce Medication Errors

Medication errors are causing harm, and even death, to hospital inpatients. These preventable errors occur at the hands of the same individuals who are charged to protect and provide care to patients—health care professionals. While decision support technologies are available to assist health care providers, patients continue to experience incorrect medications, inaccurate doses/rates of medication, duplicate doses, medication interactions, and other medication errors. This article investigates the reasons that health care professionals in hospital environments underutilize medication administration technologies and argues that a fusion view can provide guidance to increase their use. A Fusion Model is developed using the concept of embeddedness, the Technology Acceptance Model, the Task-Technology-Fit Model, and drawing on ethnographic fieldwork conducted at a modern hospital in the United States. The most important findings of this research are: (1) the concept of embeddedness can be used to study and frame fusion of technology in an environment; (2) four constructs (i.e., task characteristics, technology characteristics, individual use behavior, environmental characteristics) are identified and used to describe system characteristics needed to support medication decisions; and (3) guidance is provided for design and evaluation of decision support technologies for medication administration in hospitals.     

Process Coordination Within a Health Care Service Supply Network

There are two manifestations of supply chains in health care. One involves the supply of equipment and materials used in health care delivery. The other supply chain involves the delivery of health care itself, wherein patients supply their physical conditions and service suppliers deliver health care services. This article considers the latter supply chain, analyzing a case study in which patients have comorbidities and thus require the services of a network of multiple health care providers. In the case study, we examine three schemes for coordination of care. In the first scheme, the patient herself is expected to manage the coordination. In the second scheme, physicians are expected to coordinate the care. In the third scheme, a third‐party coordinator manages care across network members. We examine these three possible coordination alternatives using a technique known as Process‐Chain‐Network (PCN) Analysis. PCN Analysis helps us document how coordination schemes are implemented and where they may fail. Our analysis of the case study leads us to the development of ex post theory about who should initiate coordination and how it should take place under conditions of comorbidities. Empirical data coming from the case study support the theory. We describe possible applications of the theory inside and outside of health care, and show how the PCN approach can guide process innovation.     

An integrative model of customers' perceptions of health care services in Taiwan

As the health care service gets more competitive, health care practitioners and academic researchers are increasingly interested in exploring how patients perceive the quality and value of their care before building up their satisfaction levels and generating behavioural intentions. Drawing some theories from marketing and health care service literature, this study tries to propose an integrative model of customers' perceptions of health care services based on the established relationship among four key constructs (service quality, perceived value, satisfaction, and behavioural intentions). Structural equation modelling is then used to validate the model. As Taiwan's universal health insurance offers every citizen equal financial access to all health care providers, Taiwan offers a good opportunity to study how the patients' perception model is structured. The findings reveal both perceived quality and value as antecedent variables in this model illustrating direct and indirect paths from perceived quality and value to patient satisfaction and behavioural intentions.     

Towards an understanding of health care purchasing: The purchasing behaviour of general practice fundholders 1

In the last few years there have been considerable changes in the National Health Service. Perhaps the most significant of these has been the introduction of competition into health care, that is the split of the health service into purchasers and providers of care. Central to this development has been the introduction of general practice fundholding, whereby practices are able to purchase health care for their patients directly from competing suppliers. Those pradices which have become fundholders have faced considerable challenges in developing their purchasing function. At the same time, provider units in areas where fundholding has become established face an increasingly fragmented purchasing base.

Building on existing theoretical work into the nature of organizational purchasing behaviour and current knowledge of the health care market in Britain, this paper attempts to develop an understanding of the dynamics of GP fundholder purchasing behaviour.     

Improving Incentives in Health Care Spending

Although U.S. economic growth is likely to continue to be robust, the growth of private and public spending on health care presents long-run public policy challenges. To meet these challenges health care resources must be used more efficiently. Currently, there are few incentives to put health care dollars to the highest value use. This is true in both public and private spending. An important element of the problem lies in the tax-preferred treatment given to employer-provided insurance but not to out-of-pocket spending. The resulting bias towards first-dollar insurance coverage means that consumers are insulated from the real costs of the health care that they consume and have little reason to evaluate whether the benefits are greater than those costs. Moreover, they seldom have sufficient price and quality information to make informed decisions. Health Savings Accounts (HSAs) are a promising way to remove the tax-penalty for enrolling in catastrophic insurance and paying for routine care out of pocket. Given the information that they need, consumers would then have more choices and more control, strengthening their role in reducing waste, improving efficiency, and promoting competition. Coupled with other policies, HSAs can be a critical component in moving toward an efficient and equitable health care system. JEL Classification I11     

The promises and constraints of consumer-directed healthcare

Consumer-directed healthcare promises to reduce costs and increase quality by expanding provider choice for prospective patients. High-deductible insurance, employer- or government-subsidized health savings accounts, transparent pricing, and accurate information on clinical performance help generate millions of patients shopping for healthcare. As in any other well-behaved market, when patients shop, there is a link between financial reward and value for the individual patient. Absence of price competition, agency problems, and high barriers to entry in local markets are market failures that currently break this link in U.S. healthcare. Consumer-directed health plans are already popular among many employers and have established a momentum that indirectly shapes discussion of reform by the Obama administration. Complexity of reporting clinical results, dependence of treatment success on at-home patient behavior, and scientific ignorance among consumers threaten delivery of results promised by theory. Successful implementation requires regulator attention to sophisticated data reporting that adjusts for clinical risk, avoidance of patient-focused marketing that leads to over-consumption, and adequate subsidy of health savings accounts. In the end, implementation shifts the locus of healthcare system control from cost-shifting negotiations between employers, providers, and payers to new-found purchasing power of prospective patients.     

Patterns of inter-organizational purchasing: Evolution of consortia-based purchasing amongst GP fundholders

In the last few years there have been considerable changes in the National Health Service in the United Kingdom. Arguably the most significant of these has been the introduction of competition into health care with the split of the health service into purchasers and providers of care. Central to this development has been the introduction of General Practice fundholding, whereby practices purchase health care for their patients directly from competing suppliers. Those practices that have become fundholders have faced considerable challenges in developing their purchasing function given the complexities of contracting within the context of the NHS internal market. Although one of the original aims of GP fundholding was to facilitate locally responsive purchasing, such have been the complexities of contracting that many fundholding practices have attempted to reduce the managerial demands of purchasing through membership of purchasing consortia. Based on an in-depth study of GP fundholders across Scotland, this paper explores the development of consortia-based purchasing in terms of the managerial implications for the participant practices of purchasing through such inter-organizational networks.     

Ownership Sentiments Towards the Customer Care Function in E-Business Situations

ABSTRACT

Effective management of customer care is critically important for successful electronic commerce. The executive in charge of the customer care function in a business based on e-commerce might have a technical IT background, a marketing background, or be from general management. This empirical study examined the degrees to which a sample of 86 marketing and IT managers responsible for customer care in e-commerce environments felt they “owned” the customer care function, and the antecedents and consequences of powerful ownership sentiments. It emerged that heads of department with marketing backgrounds reported significantly stronger feelings of ownership of customer care than heads with IT backgrounds. The level of ownership sentiment varied with respect to the extent of the personal investment a manager had devoted to developing the customer care function, the belief that he or she was an expert in customer care, the person's commitment to the organisation as a whole (rather than to a specific function within it), and the degree of centralisation of the firm's decision making. People who felt strongly that they owned their company's customer care function experienced a heavy sense of responsibility for its effective management. However, the same individuals were more likely to be in conflict with managers of other departments and to resist change.     

Are Patients Traveling Further?

Managed care has been hypothesized to increase patient travel for health care services by steering patients to more distant providers. This raises access concerns. However, if the result is to expand the geographic extent of provider markets, this may ease antitrust concerns about mergers. This research compares travel distances for patients discharged from California hospitals in 1985 and 1991 controlling for payor, diagnosis, and local market conditions. Privately insured patients were more likely to be in managed care than Medicare patients during this period. We expect travel distances to increase for private patients relative to Medicare patients if managed is leading to greater travel. However, for a random sample of patients excluding births and neonatal discharges, we find no evidence relative travel increased. Nor do we find a systematic pattern of increase when we examine travel for specific diagnoses selected on the basis of the urgency and complexity of care.     

Purchasing health care services: Information sources and decisional criteria

The introduction of a market mechanism into the National Health service in the UK was underpinned by the belief that decentralised purchasing would both improve the quality of health care provision and restrain spiralling costs, through purchasers exercising their ability to choose between alternative providers. Focusing on budget holding General Practitioners, that is those practices responsible for purchasing hospital services for their practice populations, this paper explores the evolving purchasing behaviour of these professional intermediaries. Drawing on empirical evidence gathered as part of a broader study of the purchasing behaviour of GP Fundholders in Scotland, specifically it examines the key information sources and decisional criteria utilised by these professional intermediaries in selecting health care providers for their practice population. Utilising relational models of market behaviour, it addresses both the contextually specific issue of whether the market mechanism within the NHS is achieving the twin objectives of improving health care provision and restraining cost pressures, and the broader conceptual issue of the purchasing behaviour of professional intermediaries within a service sector environment.     

Therapy,Enhancement, and Medicine: Challenges for the Doctor–Patient Relationship and Patient Safety

There are ethical guidelines that form the foundation of the traditional doctor–patient relationship in medicine. Health care providers are under special obligations to their patients. These include obligations to disclose information, to propose alternative treatments that allow patients to make decisions based on their own values, and to have special concern for patients’ best interests. Furthermore, patients know that these obligations exist and so come to their physicians with a significant level of trust. In this sense, therapeutic medicine significantly differs from straightforward business practices such as the buying and selling of houses, cars, cell phones, etc. However, we argue that this relationship differs when medicine is used for enhancement rather than therapy. When patients seek enhancements they are not as vulnerable as when they are ill. And in an enhancement setting, physicians have little role outside of medical risks to discuss motivation and alternatives. Therefore, we conclude that a more reasonable alternative may be for doctors and patients to use ethical norms associated more with straightforward business practices, specifically sales. We believe that full disclosure of this different set of norms will benefit both physicians and patients.     

Financing the correct rate of growth of medical technology

This article suggests ways to preserve innovation while partially restraining the impressive growth rate in new medical technology. Health care will soon consume 12 percent of GNP. There is a wide range of opinions as to whether medical technology is a major or minor source of rising health care expenditures. Given our current fiscal problems, health care providers will be in direct competition with education and other domestic programs for a limited supply of R&D funds. More funding will have to come from the private sector. The challenge for prudent buyers of health care services is to control costs without eroding the biomedical capacity of the nation.