Using technology to reveal true costs

Healthcare leaders should address three important questions as they prepare to implement new costing systems: Do all providers in their organizations' systems, networks, or partnerships share the same definitions of unit of care and of fixed, variable, incremental, direct, and indirect costs? What are the maintenance processes and protocols for cost center and period matching of revenues and costs? If some providers within a network or partnership are not using costing systems, can an enterprise derive surrogate cost per unit of care?     

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.     

农村公共卫生服务效果分析和思考——基于海南省调查数据

当前村医的诊疗能力有一定提高。农村居民患者的就医意向和对村医服务态度的评价与其年龄和受教育程度密切相关,同时村医对疾病预防和控制知识的宣传不够,对微利的预防保健工作的重视不够。为更好地发挥三级医疗卫生服务网络“网底”的作用,农村公共卫生服务补偿力度应视不同地区经济发展水平而异,重点向贫困地区倾斜,建立权责分明的村卫生室绩效考核制度,明确各级财政对公共卫生服务项目的补偿比例,鼓励多元化筹资兴办村卫生室。     

Designing a guideline-based utilization management program

Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.     

The financial implications of ACOs for providers

To prepare for a future in which more and more patients will receive care in ambulatory settings, and acute care service capacity will likely need to be considerably downsized, hospitals should pursue five near-term strategies: Convert primary care practices to medical homes, Develop the IT capabilities required to manage and report on clinical and financial processes and outcomes, Integrate the clinical and financial interests with those of their physicians in improving value, Reduce cost per episode of care through bundled payment initiatives, Nurture key relationships with other providers.     

How to solve the cost crisis in health care

U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions--not organizational units or narrow diagnostic treatment groups--as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-cased costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Sch?n Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.     

Outlier detection in healthcare fraud: A case study in the Medicaid dental domain

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. Due to large amounts of claims submitted, estimated at 5 billion per day, review of individual claims or providers is a difficult task. This encourages the employment of automated pre-payment controls and better post-payment decision support tools to enable subject matter expert analysis. This paper presents how to apply unsupervised outlier techniques at post-payment stage to detect fraudulent patterns of received insurance claims. A special emphasis in this paper is put on the system architecture, the metrics designed for outlier detection and the flagging of suspicious providers which may support the fraud experts in evaluating providers and reveal fraud. The algorithms were tested on Medicaid data encompassing 650,000 health-care claims and 369 dentists of one state. Two health care fraud experts evaluated flagged cases and concluded that 12 of the top 17 providers (71%) submitted suspicious claim patterns and should be referred to officials for further investigation. The remaining 5 providers (29%) could be considered mis-classifications as their patterns could be explained by special characteristics of the provider. Selecting top flagged providers is demonstrated to be a valuable as an targeting method, and individual provider analysis revealed some cases of potential fraud. The study concludes that, through outlier detection, new patterns of potential fraud can be identified and possibly utilized in future automated detection mechanisms.     

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.     

Business in Richmond attacks health care costs

Like a fever that will not break, health care premiums continue to climb relentlessly, yet remedies have been hard to come by. Employers, for the most part, have accepted ever-rising expenditures as the price of good employee relations. And federal regulations designed to control medical costs have proven weak. The road to recovery begins, this author tells us, when a health maintenance organization, or HMO, enters a community, because its prepayment approach upsets the medical profession's conventional fee-for-service rules. Thus it quickly evokes competitive responses from other health care providers, who must become equally cost-conscious or lose their market share. HMOs need advocates, however, to spread as rapidly as their potential warrants. Drawing on recent events in Richmond, Virginia, the author shows how a city's business leadership can become the catalyst for changing the health care system.     

Redefining competition in health care

The U.S. health care system is in bad shape. Medical services are restricted or rationed, many patients receive poor care, and high rates of preventable medical error persist. There are wide and inexplicable differences in costs and quality among providers and across geographic areas. In well-functioning competitive markets--think computers, mobile communications, and banking--these outcomes would be inconceivable. In health care, these results are intolerable, with life and quality of life at stake. Competition in health care needs to change, say the authors. It currently operates at the wrong level. Payers, health plans, providers, physicians, and others in the system wrangle over the wrong things, in the wrong locations, and at the wrong times. System participants divide value instead of creating it. (And in some instances, they destroy it.) They shift costs onto one another, restrict access to care, stifle innovation, and hoard information--all without truly benefiting patients. This form of zero-sum competition must end, the authors argue, and must be replaced by competition at the level of preventing, diagnosing, and treating individual conditions and diseases. Among the authors' well-researched recommendations for reform: Standardized information about individual diseases and treatments should be collected and disseminated widely so patients can make informed choices about their care. Payers, providers, and health plans should establish transparent billing and pricing mechanisms to reduce cost shifting, confusion, pricing discrimination, and other inefficiencies in the system. And health care providers should be experts in certain conditions and treatments rather than try to be all things to all people. U.S. employers can also play a big role in reform by changing how they manage their health benefits.     

论互助保险公司在法国医疗保险制度中的作用

法国的医疗保险制度较好的保障了法国人民的健康状况和生活质量,在世界上享有良好的声誉。本文在介绍了法国医疗保险的财政支持的基础上,分析了互助保险公司在法国医疗保险制度运行中所发挥的重要作用,并以MGEN（法国最大的互助保险公司）为例,介绍了其建立原则、历史沿革、经济模型、覆盖的医疗服务及其发展的评估,探讨了其完善和促进法国卫生保障事业的功效,同时也缓和了社会不平等现象。基于互助保险公司非盈利、联盟和责任感的价值观,MGEN还在眼科医疗方面提供更多的服务。     

The ins and outs of outsourcing and insourcing: what have we learnt from the past 30 years?

This paper explores recent experience with outsourcing of public services. It highlights how approaches to outsourcing have evolved during the past 30 years, moving through phases of competitive tendering, partnership working, strategic commissioning, prime contracting and, more recently, insourcing. The paper finishes with 10 lessons for commissioners and service providers which can be drawn from these experiences.     

Managed care, consolidation among health care providers, and health care: evidence from mammography

We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.     

发达国家和地区空巢老年人长期照护的经验与启示

建立和完善老年人长期照护体系,是应对银色浪潮的必然选择.目前欧洲、美国、日本等发达国家以及香港、台湾等地区,老年人长期照护制度建设已比较完善,在空巢老年人长期照护体系建设方面积累了丰富的经验.目前我国空巢老年人长期照护体系建设还处于起步阶段.借鉴国内外的先进经验,我国空巢老年人长期照护体系应该是融经济供养、医疗照护、日常生活护理、精神慰藉于一体的综合服务体系.在这一体系的构建中,政府是主导,家庭、机构、社区是载体,社会服务组织是主力,专业人员是基础.只有充分发挥了这几个方面的作用,才能破解我国老年人长期照护体系建设的难题.     

Changing management roles in the Scottish NHS: implications for management learning and development

The UK government's austerity means that public service providers, such as the National Health Service (NHS), are looking for efficiencies from service integration and collaborative working. This paper highlights how NHS (Scotland) management is coping with these changes and how the role of the manager and the nature of management development is being transformed. New forms and processes of management learning and development are needed for collaborative partnership working in multi-agency public service environments.     

Das Geschäftsmodell des selektiven Kontrahierens — Eine Analyse wertschöpfender Aktivitäten gesetzlicher Krankenkassen

By establishing Integrated Care sickness funds are introduced the possibilities of signing individual contracts with single or a group of health care providers (selective contracting). So far, this topic has been discussed a lot from the health care system’s point of view. The research presented in this paper however focuses on business aspects from a single sickness fund’s point of view. By selective contracting of providers a sickness fund creates additional value for insurants. Besides the traditional payer function this is especially done by pre-selecting quality-proved providers, stipulating diagnosis and therapy methods, stipulating guarantees and negotiating remunerations. Customer-orientation requires identification of the patient’s different needs and preferences. To satisfy those individually varying demands a sickness fund has to choose carefully its contract partners. A sickness fund’s success depends on the quality of its contracted providers. As selective contracting means that only a chosen number of providers will be contracted, value is created for those by mediating patients with the opportunity of raising both income and utilisation. The value creation by selective contracting can be summarized both for patients as well as for providers as a strong reduction of transaction costs.     

Rationierung von Gesundheitsleistungen — Verfassungsrechtliche Maßstäbe der Kontingentierung

The compulsory health insurance must totally cover the medical needs of the insured while using the standards of todays medical cognition. This charge is restricted by the principle of economic efficiency which is concerned with the premium payer and the economy and has indeed been restricted by rationing measures as well as by ?open measures“ like the indemnification board, the ?set price system“ and hidden charges while consulting / visiting a doctor. The hope for protection of the standards of performance lie within the constitutional law. However, this doesn’t regulate the status quo. The warrantees obliged by law are accepted, with reservations, because of the financial possibilities. At the same time the constitutional law may dismantle the services to a certain degree to govern and to set priorities. The criteria are: The reservation of the law, the constitutional rights of the insured and of the care providers as well as the national objectives. Others are the ensurement of adequate coverage by the state considering the health care sector, protection of confidence, the systems’ justice, and the consequences.     

Can patients drive the future of health care?

As the traditional system of health care in the United States gives way to a regime run increasingly by the private sector, a powerful force is emerging: the patient. According to Harvard Business School professor Regina Herzlinger, health care is much like other service industries. Providers that hope to survive must cater to increasingly demanding and well-educated consumers. In a review of Herzlinger's book Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America's Largest Service Industry, Alexandra Wyke, managing editor at the Economist Intelligence Unit, argues that the path to consumerism in medicine will be longer and bumpier than Herzlinger suggests. Consumers of medicine don't simply want health care to be more convenient; they want cures for all ills. How can providers gratify this appetite for ever better medicine? Furthermore, patients are not always capable of making sound decisions about their medical care. And health care professionals, who emphasize the complex nature of decision making in medicine, are doing their best to keep patients from holding the health care steering wheel. Herzlinger has written a bullish book on the virtues of market-driven health care, but, Wyke contends, she has overlooked the far-reaching effects that emerging technology could have in shaping medicine--especially in reducing the need for specialists. She also has given short shrift to the young managed-care industry, which has succeeded in controlling costs and is now under competitive pressure to meet patients' needs better.     

Why General Mills mixes in health care.

When it comes to social responsibility, most companies are content to write out checks--often in large numbers--and let it go at that. General Mills is one company that likes to establish operating ventures that involve corporate officers and champion a cause. Such a venture is Altcare, a nonprofit organization designed to find more effective and less expensive ways of caring for elderly people who are getting frail but do not require acute care. In 1983, when the company chose this area as its next project, it realized it needed help from an organization with vast experience in the geriatric field. So it enlisted a nearby organization, the Wilder Foundation, and went into partnership as Altcare. The partnership has launched a service network for victims of Alzheimer's disease, a program with three other institutions to meet the myriad needs of chronically impaired people, and an unusual residence for physically impaired people, among other ventures. Altcare looks for advances and ideas that can be replicated, and the partnership often lends money to entrepreneurs who want to launch pioneering efforts or replicate Altcare initiatives. The cost to General Mills: about $80,000 a year after taxes, plus its share of any losses in project investments incurred by Altcare.