Managed care, quality of care, and patient rights

The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no persuasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.     

A second warning by the club of Rome

The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no persuasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.     

管理医疗模式的影响差异——来自加州医疗救助的经验证据

国际上越来越多的健康保险(医疗保险)采用了管理医疗的方式,目的在于保证健康服务质量并节约成本。尽管该方式在控制成本方面的效果有目共睹,但对于其保证健康服务质量方面的评价则颇为困难。本文使用独特的大样本数据,利用美国加利福尼亚州医疗救助项目(美国最大的公共健康保险之一)从传统按次偿付方式到多种管理医疗模式的转变,来识别不同管理医疗模式对健康服务的使用及服务质量的影响。这对于我国公共健康保险制度(如新型农村合作医疗)的探讨具有一定的借鉴意义。     

Does quality influence choice of general practitioner? An analysis of matched doctor–patient panel data

The impact of quality on the demand facing health care providers has important implications for the industrial organization of health care markets. In this paper we study the consumers' choice of general practitioner (GP), assuming they are unable to observe the true quality of GP services. A panel data set for 484 Norwegian GPs, with summary information on their patient stocks, renders the opportunity to identify and measure the impact of GP quality on the demand, accounting for patient health heterogeneity. We apply a multi-equation model in the LISREL format, with GP quality and patient health as latent determinants of demand for GP services. Patient excess mortality rate at the GP level is one indicator of quality. Our results indicate that GP quality has a clear positive effect on demand, even when patient heterogeneity is accounted for.     

Why managed care has gone too far

Managed care has not solved employers' problems with rising health care costs; instead, it has created another set of problems, this author maintains. She suggests steps that employers can take to enhance the quality of health care for their employees and prevent further damage from the excesses of managed care.     

The future of the Affordable Care Act: will we abandon health care reform?

With obstacles to the Affordable Care Act (ACA) growing, nurses need to continue to educate themselves about the ACA and the issues it is designed to address. While it has many shortcomings, the ACA invests in creating a new infrastructure that holds the potential to improve care quality and contain costs. Health economist Victor Fuchs suggests three areas must change if we are to have a health care system that is quality focused: information, infrastructure, and incentives. The current health care legislation is noble and lays a basis for future structural cost containment. The health care system continues to unravel as our politicians remain polarized over reform efforts. We must engage or we will never find solutions, never see reform.     

Focus on quality assessment: the need for evaluation

There is growing concern among purchasers and consumers of health care as well as among regulators that managed care has meant that quality has been sacrificed in the name of cost saving. Employers, as major purchasers, should demand that the managed care organizations they utilize demonstrate high-quality/low-cost care.     

INVESTMENT IN HOSPITAL CARE TECHNOLOGY UNDER DIFFERENT PURCHASING RULES: A REAL OPTION APPROACH

Quality of health care is the product of several factors as the literature has long recognized. In this paper we focus on the relationship between quality and investment in health technology by analysing the optimal investment decision in a new health care technology of a representative hospital that maximizes its surplus in an uncertain environment. The new technology allows the hospital to increase the quality level of the care provided, but the investment is irreversible. The paper uses the framework of the real option literature to show how the purchaser might influence the quality level by setting a quality‐contingent long‐term contract with the hospital.The investment in new technology is in fact best incentivated within a long‐term contract where the number of treatments reimbursed depends on the level of investment made when the technology is new. In this way, asymmetry of information does not affect the outcome of the contract. In our model in fact the purchaser can verify the level of the investment only at the end of each period but the purchasing rule has an anticipating effect on the decision to invest.     

Cost-effectiveness of a symptom management intervention: improving physical activity in older women following coronary artery bypass surgery

Older women have lower levels of physical functioning and higher associated health care costs than men after coronary artery bypass surgery (CABS). Clinical trials have demonstrated that interventions to increase physical activity levels can reduce the risk of recurrent cardiac events, reduce health care expenditures, prolong life, improve functional capacity, and increase quality of life in the elderly cardiac population. It is important for the patients, providers, health care payers, and policymakers to identify a cost-effective recovery intervention that has the potential to increase women's physical activity and functioning during their early recovery from CABS, especially in this time of limited health care resources. This home-based symptom management intervention has the potential to reduce the risk of recurrent cardiac events and health care cost by improving women's physical activity level after surgery. This information is vital to nursing leaders in making resource decisions regarding followup care of women who have had heart surgery.     

Maintaining quality in a changing environment

The turbulent health care environment has led to an increasing interest in assessment of quality of care, with a primary focus being outcomes analysis. The emphasis on organizational and clinical outcomes demands a total commitment to quality improvement and restructuring of the hospital environment.     

Socio-economic evaluation of mental health as a basis for financing health care in Sweden

The objective of this paper is to examine hypotheses about the relationships between socio-economic factors, risk factors in working life, and the occurrence of mental illness, together with the degree of quality of life and consumption of health care, costs for health care, and costs for social insurance. This is a prospective and longitudinal study of 1,347 individuals of an active working age, 18–64 years, who have been on sick leave for more than 30 days. The group is characterized by the prevalence of risk factors in their work environment and welfare losses, such as multiple health problems, poor quality of life, inability to work, and dependency on society's support from health care and social insurance. The costs for health care were just over 2.8 million SEK, or 30 percent higher for those with psychological distress as compared to the group without. The payments from social insurance also increased by approximately 15 percent. The relatively greater weighting of health care costs and sickness cash benefits were motivating factors to study whether this group had an optimal amount and quality of health care, or if the resources available for health care should be distributed in another way that better satisfies the needs of the group.     

Praising Arizona

Out west in the Grand Canyon State, Arizona has accomplished what many health care experts said was impossible. The state has slashed the costs of long-term care for the elderly and the disabled, the most expensive part of its medicaid program, and improved the quality of care.     

Building a case for using technology: health literacy and patient education

The interplay of a mobile population can affect the quality of patient outcomes and the economics of health care delivery significantly. Helping patients with limited English proficiency understand the basics of self-care for optimal health will continue to be a challenge in the delivery of the highest quality nursing care. Becoming familiar with high-quality, peer-reviewed, and reliable health education materials and Web sites is the responsibility of every health care provider so that patients receive culturally and linguistically appropriate resources to support healthy lifestyles and choices.     

Governing for improved quality and patient safety

Board members have a critical oversight role to play in monitoring and providing direction to improve health care quality and safety. In the emerging environment of health care reform, the board's role in overseeing quality and safety on behalf of stakeholders will become as or even more important than its financial oversight role. Nurses can expand their impact by joining the ranks of health care organization governing boards to lead and guide the entire health care enterprise to realize the goal of improved care and outcomes for all patients.     

Envisioning and implementing new directions for health care

Across the entire health sector, federal analysts indicate that in 2006 approximately $2.1 trillion were spent on health care, over $7000 per person. With expenditures at this level, it is no surprise that people are asking whether the public receives value commensurate with the financial investment. While strides are being made on a number of quality of care fronts, given the financial resources being consumed, overall forward momentum is glacial. Educating the public is a particular challenge given amplified sound bites and attack ads designed to preserve the status quo. All of this underscores that nursing has a role not just in implementing new directions in health care but envisioning them as well.     

Does contracting out increase the efficiency of government programs? Evidence from Medicaid HMOs

State governments contract with health maintenance organizations (HMOs) to coordinate medical care for nearly 20 million Medicaid recipients. Identifying the causal effect of HMO enrollment on government spending and health care quality is difficult if, as is often the case, recipients have the option to enroll in a plan. To estimate the average effect of HMO enrollment, this paper exploits county-level mandates introduced during the last several years in the state of California that required most Medicaid recipients to enroll in a managed care plan. The empirical results demonstrate that the resulting switch from fee-for-service to managed care was associated with a substantial increase in government spending but no corresponding improvement in infant health outcomes. The findings cast doubt on the hypothesis that HMO contracting has reduced the strain on government budgets.     

Health IT adoption,productivity and quality in primary care

Within the last decade, there has been a growing push towards the use of electronic medical records and health information technology (IT) within primary care physician practices. Despite financial subsidies, smaller practices remain reluctant to adopt these information systems. Using a nationally representative survey of physicians, this study explores the relationship between physician, practice and area attributes and the adoption of health IT systems. Controlling for these attributes, the analysis subsequently studies the relationship between health IT, physician productivity and perceived quality of care. It finds that smaller practices and physicians with lower incomes are less likely to adopt health IT systems and that adoption varies with the type of medical conditions the practice typically treats. With regards to productivity, health IT adopters are more likely to see fewer patients and spend a larger amount of time on each visit with marginal increases in time on administrative tasks and no differences in perceived ability to deliver quality health care.     

Forecasting requirements for health care personnel

Accurate forecasting of requirements for health care personnel is an important part of avoiding significant imbalances that create costly inefficiencies in health care markets. Manpower shortages threaten access, quality, and costs of health care. This article reviews five general approaches previously used to determine manpower requirements. Suggestions are made for the analytic components of a comprehensive model for identifying significant imbalances in supply or demand for health care workers.     

A nurse-run business to improve health care for nursing home residents

The costs of health care for the rapidly growing segment of our population over age 75 are staggering. EverCare is a nurse-run business that seeks to improve cost-effectiveness and quality of health care for nursing home residents enrolled in a health maintenance organization.     

Medicare--where is its future?

Canadian health care policy is in a period of transition. Continuing reform is necessary to ensure quality; to evaluate health outcomes; and to promote efficiency, effectiveness and appropriateness of care.