Providing good quality diabetes care is complex but achievable. Many aspects of the care do not require high tech medicine but, rather, good organisation. Diabetes is a costly disease, consuming 1500 pounds per diabetic patient per year versus 500 pounds on average for a non-diabetic member of the population in health service costs. Investment now in good quality diabetes care is sound: patients will benefit from a better quality of life associated with a reduced incidence of the complications of diabetes and the direct costs to the health service in treating these complications and the indirect costs to employers will be reduced. Physical and clinical assessments--measurements of blood glucose and glycosylated haemoglobin concentrations, weight, and blood pressure and assessment of eyes, kidneys, feet, and heart--are clearly important, but quality must include consideration of people and their reactions to life and diabetes--a lifelong entanglement--for which much more support should be provided. (+info
New directions in alcohol and drug treatment under managed care.
OBJECTIVE: To examine the potential effects of the introduction and expansion of managed care on the financing and organization of public and private alcohol and drug abuse treatment systems by reviewing studies on managed care and substance abuse. STUDY DESIGN: Spending on treatment for alcohol and drug abuse, the organization of treatment, treatment workforce composition, provision of services, and their implications for access and treatment outcome were examined by review of the treatment literature. RESULTS: Managed care has had major effects on the organization of service delivery, the workforce, and the provision of services. Most of the changes have occurred without the benefit of clinical or policy research. Although managed care has the potential ability to address longstanding problems associated with alcohol and drug treatment, it also presents additional barriers to access and improving treatment outcome. CONCLUSIONS: The review suggests that organizational approaches, particularly the settings in which treatment is placed, will differ in their impact on ties between treatment agencies and the medical community, and ties with other health and social service agencies. Also of importance is a new emphasis on accountability of treatment through the mechanisms of outcomes monitoring and performance indicators. It remains to be seen whether these innovations will be meaningfully linked with outcomes research. It is incumbent on researchers and clinicians to explore these issues. (+info
Managed public mental healthcare: issues, trends, and prospects.
OBJECTIVE: To describe the structure and status of public mental healthcare and the impact of managed behavioral healthcare on this system. STUDY DESIGN AND METHODS: The structure and financing of public mental health systems were reviewed. Because there are no controlled multisite studies of managed public sector behavioral healthcare, case examples were used to illustrate trends and issues. DISCUSSION: The methods, results, and impact of public managed behavioral healthcare are incomplete and uncertain. The complexity of the public sector system, the patients served in it, and the services provided are daunting. The variability of patient needs, the role of Medicaid versus state funding, and the variable governance structures of local systems in different states make managed care methods more complex than in private markets. CONCLUSIONS: The organization, structure, and financing of public mental health systems have developed rapidly in the past generation as care has been moved from hospital to community. Early efforts to apply managed behavioral healthcare methods used in the private, commercially paid sector have not been very successful, and most public sector managed care efforts have been limited to Medicaid-paid care. The trend in public mental health systems is to "unpack" managed care and use its tools selectively. (+info
Use of performance standards in behavioral health carve-out contracts among Fortune 500 firms.
OBJECTIVE: To determine the prevalence and nature of performance standards in specialty managed behavioral healthcare contracts among Fortune 500 companies. STUDY DESIGN: This was a cross-sectional survey of all companies listed on the Fortune 500 during 1994, 1995, or both. METHODS: From April 1997 to May 1998 we conducted a mailed survey with phone follow-up. Of the 68% of firms that responded, over one third reported carve-out contracts. The survey focused on whether companies had behavioral health carve-out contracts with specialty vendors and characteristics of these contracts, including the use of performance standards. RESULTS: More than three quarters of the Fortune 500 companies reporting specialty behavioral healthcare contracts used at least one performance standard. Most common were administrative standards (70.2%) and customer service standards (69.4%). About half of the companies used quality standards, whereas only a third used provider-related standards. Most (58.8%) companies using performance standards also specified financial consequences. Larger Fortune 500 firms were significantly more likely to use performance standards. Risk contracts and contracts that included all covered employees were also more likely to include some categories of standards. CONCLUSIONS: Administrative and customer service standards may be most common because companies find it easier to specify those standards, especially compared with clinical quality measures. To the extent that employers want to obtain the most value from their behavioral healthcare purchasing, we expect that more will begin to adopt quality standards in their contracts, especially as performance measures become more refined. Reliance on accreditation, however, is an alternative approach for employers. (+info
"Make or buy" decisions in the production of health care goods and services: new insights from institutional economics and organizational theory.
A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with expensive, complex and concentrated production forms such as hospital care require a stronger regulatory environment and skilled contracting mechanisms before governments can rely on obtaining these services from the private sector. Subsidiary activities within the production process can often be unbundled and outsourced. (+info
An analysis of hospital productivity and product change.
We developed a model to measure the contribution of changes in length-of-stay, service intensity, and productivity to the unusually low rate of growth in hospital costs per discharge in recent years. From 1992 through 1996 declining length-of-stay explained 97 percent of the decrease in real costs per discharge. Much of the drop was probably caused by care shifted from inpatient to postacute settings. Although complete data for our model are unavailable beyond that point, we cite several "leading indicators" that suggest that length-of-stay declines have played a smaller role in the continued low cost growth of 1997 and 1998 and that productivity may have risen sharply. (+info
A relational approach to measuring competition among hospitals.
OBJECTIVE: To present a new, relational approach to measuring competition in hospital markers and to compare this relational approach with alternative methods of measuring competition. DATA SOURCES: The California Office of Statewide Health Planning and Development patient discharge abstracts and financial disclosure files for 1991. STUDY DESIGN: Patient discharge abstracts for an entire year were used to derive patient flows, which were combined to calculate the extent of overlap in patient pools for each pair of hospitals. This produces a cross-sectional measure of market competition among hospitals. PRINCIPAL FINDINGS: The relational approach produces measures of competition between each and every pair of hospitals in the study sample, allowing us to examine a much more "local" as well as dyadic effect of competition. Preliminary analyses show the following: (1) Hospital markets are smaller than thought. (2) For-profit hospitals received considerably more competition from their neighbors than either nonprofit or government hospitals. (3) The size of a hospital does not matter in the amount of competition received, but the larger hospitals generated significantly more competition than smaller ones. Comparisons of this method to the other methods show considerable differences in identifying competitors, indicating that these methods are not as comparable as previously thought. CONCLUSION: The relational approach measures competition in a more detailed way and allows researchers to conduct more fine-grained analyses of market competition. This approach allows one to model market structure in a manner that goes far beyond the traditional categories of monopoly oligopoly, and perfect competition. It also opens up an entirely new range of analytic possibilities in examining the effect of competition on hospital perfomance, price of medical care, changes in the market, technology acquisition, and many other phenomena in the health care field. (+info
Frail elderly patients. New model for integrated service delivery.
PROBLEM BEING ADDRESSED: Given the complex needs of frail older people and the multiplicity of care providers and services, care for this clientele lacks continuity. OBJECTIVE OF PROGRAM: Integrated service delivery (ISD) systems have been developed to improve continuity and increase the efficacy and efficiency of services. PROGRAM DESCRIPTION: The Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is an innovative ISD model based on coordination. It includes coordination between decision makers and managers of different organizations and services; a single entry point; a case-management process; individualized service plans; a single assessment instrument based on clients' functional autonomy, coupled with a case-mix classification system; and a computerized clinical chart for communicating between institutions and professionals for client monitoring. CONCLUSION: Preliminary results on the efficacy of this model showed a decreased incidence of functional decline, a decreased burden for caregivers, and a smaller proportion of older people wishing to enter institutions. (+info