Effects of providing comprehensive ambulatory services to children with chronic conditions

OBJECTIVE

To document the effects of a comprehensive program of care on the resource utilization and cost of care for children with chronic conditions.

DESIGN

Descriptive study of 10715 admissions between 1984 and 1995 with analyses of costs based on charges. Comparisons were made with data from a national consortium of academic medical centers and from a national survey of hospitals. A 2-week survey of staff was conducted to identify their use of time in the care of these patients.

PATIENTS

Children aged birth through 18 years meeting International Classification of Diseases, Ninth Revision, Clinical Modification criteria for chronic conditions. Patients with acute conditions were used as controls.

INTERVENTION

A program of expanded care funded since 1989 by a regional insurance company.

RESULTS

Between 1984 and 1995, mean length of stay for children with chronic conditions decreased from 83.9 to 10.6 days; mean annual admissions decreased from 2796 to 1622. Median hospital inpatient charges, adjusted for cost of living, decreased from $26.1 to $14.6 million. A $77.7 million savings occurred for inpatient care, with total expenditures from the insurance program of $3.6 million (a 21:1 ratio). Almost half the professional activities provided for these children were for services that could not be reimbursed in a fee-for-service model. Median adjusted inpatient charges were lower in Rochester, NY ($8746) than in other academic medical centers ($12773) or in a national survey of hospitals ($12462), and fewer children were readmitted within 30 days in Rochester (12.7%) than in other academic medical centers (15.0%).

CONCLUSIONS

An investment of funds by a regional insurance company was associated with reduced costs, admissions, and lengths of stay for children with chronic conditions, and resulted in significant savings for the company. This model may be applicable to other centers.

Deep pockets or blueprint for change: traumatic brain injury (TBI) proactive strategy

The Pacific Conference scheduled for October 1-3, 1988, is a critical event in the development of an integrated community-based plan for a comprehensive continuum of services to address the "silent epidemic," Traumatic Brain Injured (TBI). This paper provides insights of the complex nature and the special problems faced by the TBI survivors; their families, natural supports and caregivers, as well as the health, social and educational care providers in Hawaii. Process for the development of the community plan is presented.

Coordinated system of care cuts costs, maintains quality for persons with AIDS

Coordinated HMO care reduces costs for patients with AIDS. Although HMOs get a bad rap, a surprising study from Boston University found that a comprehensive system of managed care can do a better job of avoiding hospitalization and reducing health care costs than traditional fee-for-service plans--without negatively impacting patient satisfaction, health status, or level of function.

Clinical and economic impact of implementing a comprehensive diabetes management program in managed care

Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America's Diabetes NetCare, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCare achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbAlc tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program. These data suggest that implementation of a comprehensive healthcare management program for people with diabetes can lead to substantial improvements in costs and clinical outcomes in the short-term. It is expected that improvements will increase over time, with continuing improvements in health status and a reduction in the number of future diabetic complications.

Can we afford comprehensive, supportive care for the very old?

OBJECTIVE

To address the question, "Is there enough overuse of Medicare reimbursement to hospitals that reallocation of excess could provide sufficient funds to enhance home care and community services?"

DESIGN

Simulation using data from the Medicare Current Beneficiary Survey (MCBS) to estimate dollars that might be reallocated from hospital reimbursement.

PARTICIPANTS

A total of 3577 persons aged 80 and older in a stratified sample of Medicare beneficiaries interviewed in September 1992 in the MCBS.

MEASUREMENTS

We ranked the United States hospital service areas' (HSAs) Medicare hospital discharge rates. We assigned the beneficiaries in the MCBS to the HSAs based on their residence zip codes. The hospitalization expenditures and mortality rates of MCBS respondents living in HSAs in each quartile were compared.

RESULTS

By reducing hospital utilization to the mean level now used by the lowest quartile of HSAs, $560 would be saved per Medicare beneficiary aged 80 or older (P=.004) with no difference in mortality rates. These savings could purchase 40 visiting nurse visits per year for those in need. Potential savings would be $152 per Medicare beneficiary if hospital utilization were reduced from that used by the highest quartile to the level of the lower three quartiles of HSAs, enough to purchase about 11 additional visiting nurse visits.

CONCLUSION

This simulation suggests that the very old might safely receive less hospital care. Because relatively few older people need home and community services in a year, these per capita savings could be reallocated to purchase many services for those having the greatest need.

State funding of comprehensive primary medical care service programs for medically underserved populations

OBJECTIVES

This study examined the availability of state funding for comprehensive primary care programs and the need for primary care subsidies for medically underserved communities.

METHODS

A brief questionnaire was used to ask health agencies in all 50 states whether their state funded a program that met our definition of comprehensive primary medical care practice programs. An in-depth written survey instrument was then administered to the states with programs.

RESULTS

Almost half of all states provide some funds for the development and/or operation of comprehensive primary medical care practices. Expenditures in most states were found to be relatively modest in comparison with both federal funding and the total level of unmet need for primary care. States that subsidize primary care practices tend to follow the model established under the federal health centers program.

CONCLUSIONS

The findings suggest the continued viability of the health center model of care, as well as the presence of some state support for such a program. However, in light of limited state resources for the development and operation of comprehensive practices, a continued and significant federal effort is imperative.

The emergency department under managed care: exploring an alternative model

An obvious emphasis by managed care organizations is to limit emergency department care to only the most emergent patients. The result? A "lean & mean" department. However, another approach would be to encourage emergency department care--it offers more comprehensive services to both the managed care organization and the patient. And this professional paper explains how it's possible.

Behavioral medicine, complementary medicine and integrated care. Economic implications

Health care concepts and practices are changing dramatically because of demographic and economic factors. The routine integration of behavioral and biomedical care is completely compatible with these changes and such integration would provide clinical and economic benefits to patients and to society.

Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure

OBJECTIVES

To assess the impact of a comprehensive heart failure management program, functional status, hospital readmission rate and estimated hospital costs were determined and compared for the 6 months before and the 6 months after referral.

BACKGROUND

The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost.

METHODS

Over a 3-year period, 214 patients were accepted for heart transplantation and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per min and a total of 429 hospital admissions in the previous 6 months (average 2.0 per patient). Changes in the medical regimen included a 98% increase in angiotensin-converting enzyme inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling also regarding diet and progressive exercise.

RESULTS

During the 6 months after referral, there were only 63 hospital readmissions (85% reduction), with 0.29/patient (p < 0.0001). Functional status improved as assessed by functional class (p < 0.0001) and peak oxygen consumption (15.2 vs. 11.0 ml/kg per min, p < 0.001). The same results were seen after excluding the 35 patients without full 6-month follow-up (9 deaths, 14 urgent transplant procedures during hospital readmission, 12 elective transplant procedures from home); 34 hospital admissions occurred after referral, compared with 344 before referral. Even when adding in the initial hospital admission after referral for these 179 patients, there was a 35% decrease in total hospital admissions in the 6-month period. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient.

CONCLUSIONS

Comprehensive heart failure management led to improved functional status and an 85% decrease in the hospital admission rate for transplant candidates discharged after evaluation. The potential to reduce both symptoms and costs suggests that referral to a heart failure program may be appropriate not only for potential heart transplantation, but also for medical management of persistent functional class III and IV heart failure.

Economic reforms and the acute inpatient care of patients with schizophrenia: the Chinese experience

OBJECTIVE

This study compared insured and uninsured schizophrenic inpatients in China and examined changes in the acute inpatient care of schizophrenic patients during China's economic reform era.

METHOD

Detailed chart reviews of 50 randomly selected inpatients discharged from a hospital in central China each year from 1984 through 1993 identified 321 patients with schizophrenia. Demographic, insurance, treatment, and cost data of these patients were collected from the charts.

RESULTS

With logistic regression models to control for confounding variables, the analyses showed that the 129 insured patients were significantly more likely than the 192 uninsured patients to be urban residents, to be older, to have had 7 or more years of schooling, and to have had more psychiatric hospitalizations; moreover, their index admissions were longer and were more likely to include use of traditional Chinese medications. The estimated 19% of schizophrenic individuals in the community with health insurance receive inpatient treatment 2.8 times more frequently than the 81% without insurance. Compared to admissions in 1984-1988, admissions in 1989-1993 were significantly shorter and involved longer periods of polypharmacy with multiple antipsychotic medications but included lower mean chlorpromazine-equivalent doses of medication. The relative cost of inpatient care for an acute episode of schizophrenia increased 3.5-fold over the 10-year period, from 11% of mean annual household income in 1984 to 37% in 1993.

CONCLUSIONS

Changes in the incentive system for care providers and rapid increases in the cost of care during the economic reform era have resulted in increasingly restricted availability of services for the many schizophrenic patients without health insurance.

The economics of managing healthcare delivery systems by service lines

In their continuing quest for greater efficiency and lower costs without compromising quality of care (and preferably while improving quality), some health system leaders have adopted what is called the "service line" or "product line" approach to healthcare delivery.

Taiwan's 1995 health care reform

Under considerable domestic political pressure, the Taiwan government inaugurated a compulsory universal health insurance scheme on 1 March 1995. This new scheme is financed mainly by payroll tax and provides comprehensive health care benefits with a moderate cost sharing. In order to gain efficiency in delivering health services, the scheme enters contracts with health care providers and has been developing a prospective payment system. Meanwhile, the scheme uses a uniform fee schedule and makes all payments through a public single-payer system to control health care costs. By the end of the inaugural year, the scheme covered 92% of the population and the utilization pattern of the newly insured became close to that of the previously insured. However, there is the beginning of a financial crisis because the payments of the scheme are rapidly increasing and expect to exceed the premiums in the coming year. Besides, the scheme did not bring in the efficient use of health care resources and probably caused it to worsen. Taiwan's health care reform has an unfinished agenda.

Total partnership for primary health care provision: a proposed model: Part I

Presents the first of a two part paper, based on a study which examined the dynamics of primary health care provision. The study examined 49 general practices in the Kirklees area, UK, through a detailed questionnaire mode. The response was 67 per cent covering the views of 106 doctors. To capture further input for the study, an in-depth seminar with nine doctors from a range of practices was conducted. Examines internal factors for managing general practices and the levels of competence in addressing financial, strategic, quality issues and whether general practices get involved in any external activities for new learning and benchmarking. Comprehensively covers common areas of concern and areas where expertise may be inadequate or lacking.

Battling drug use in pregnancy

Holy Spirit Hospital, Camp Hill, PA, established the Capital Region Maternal Assistance Program (MAP) to reduce the incidence of substance abuse in pregnant women and new mothers by creating a bridge between perinatal and substance abuse services in the community. Two nurses at Holy Spirit developed the idea of setting up a program in the community and obtained permission from the hospital administrators to pursue the project. They drew in staff from an inner-city obstetrical clinic in nearby Harrisburg, PA, and formed a work group to plan and build a consortium of agencies. Another hospital joined the consortium within a year. With several grants, the team hired an MAP coordinator, who in turn hired care managers, leased vans, and started the MAP in an office on the campus of Holy Spirit Hospital. The program focuses on case management (facilitating access to available community (resources) as opposed to direct service delivery. Referrals come from a variety of healthcare providers, county courts, probation and parole offices, and Children and Youth Services. Care managers visit clients weekly in their homes; coordinate services provided by multiple hospitals, clinics, and agencies; help clients set goals and become self-reliant; and address problems with transportation and babysitting.

The cost of comprehensive care of people with schizophrenia living in the community. A cost evaluation from a German catchment area

BACKGROUND

In community mental health care, knowledge about costs of care is very limited. Only few studies have related costs to outcome measures.

METHOD

This German study assesses the cost of psychiatric care of 66 schizophrenic patients during one year of living in the community. Predictors of high cost were identified.

RESULTS

The average cost of comprehensive community care of one patient of the cohort was US$ 363 per week. This was only 43% of the cost of constant long-term care in a psychiatric hospital. Significant predictors of total cost of community care were the number of rehabilitative problems at the beginning and at the end of the study period, the type of accommodation before index hospitalisation and the gender of patients.

CONCLUSIONS

Results must be understood in terms of the characteristics of the special patient group and the catchment area we studied and are of high relevance in planning future care.