Need cardiac rehabilitation be cost-effective?

In this article, the available health-economic literature in the field of comprehensive cardiac rehabilitation is reviewed. The effects of cardiac rehabilitation are well known, but cost-effectiveness studies are lacking in several important areas. The long-term effect on the number of life-years saved indicates that cardiac rehabilitation is a cost-effective use of health care resources, provided that cost-containing principles are applied in comprehensive programmes.

The quality journey in a comprehensive mental health center: a case study

BACKGROUND

In early 1992 the chief executive officer (CEO) and consequently the senior leadership of Shawnee Hills, a mental health care organization comprising more than 65 facilities in West Virginia, decided to begin the journey toward total quality management (TQM). TQM provided guidance for establishing an infrastructure for planned organizational change and continuous improvement while maintaining the CEO's responsibility to set the vision and provide direction. TQM'S IMPACT: Absenteeism and turnover rates have decreased, which are felt to reflect increasingly high levels of staff satisfaction. The tripling of the operating budget from 1993 to 1995 is also considered a byproduct of TQM. TQM has increased the potential for this organization's success in the new health care environment by providing an infrastructure for "managing" managed care.

IMPLEMENTING TQM

Setting forth the vision, purpose, mission, and goals required a focus on customer satisfaction and the development of partnerships, empowerment, and teamwork. The leadership identified strategic indicators for critical success factors--customer satisfaction, positioning for future success, financial viability, and safe and professional environments--and teams were formed to address how improvements can be made.

BENCHMARKING AND REENGINEERING

If a problem is minimal or average, processes are improved. If it is severe, reengineering is indicated. For example, each program at Shawnee Hills had its own intake procedure. To simplify access to service, it was determined that a single point of entry was needed, requiring a total redesign of current operations.

CONCLUSION

Although not a panacea for all the problems an organization might be experiencing, TQM does provide guidance and direction to organizations in an ever-changing environment.

Evaluating long-term care demonstrations in real time with study design and plan performance interactions

The evaluation of long-term care demonstrations has to deal with complex organizational entities, with large, heterogeneous client populations that, during the course of study, may have to change features of their organization or operation. The implications of such "real-time" changes are discussed for analyses of the operation and performance of Social/Health Maintenance Organizations over a 5-year period (2 years of start-up and enrollment and 3 years of follow-up). Analyses conducted of the plans in the context of real-time changes have to be based on different statistical models than for classic experimental study designs, where treatment factors are fixed rather than dynamic. A number of issues that may arise are identified, and possible approaches to their solutions described. Key words: long-term care; demonstrations; evaluations; study design; capitation.

The cost of comprehensive preventive medical services for adolescents

OBJECTIVES

To address the need for clinical preventive services for 11- to 21-year-old males and females and provide cost estimates for those services under a fee-for-service system. Preventive services include screening, health promotion, and immunizations.

DESIGN

The prevalence of adolescent morbidities was derived from national surveys. Estimated costs of these morbidities were obtained from published data and adjusted for 1992 dollars using the Consumer Price Index. The estimated costs of preventive services for adolescents under a fee-for-service system were derived from a 1993 survey of nine Blue Cross and Blue Shield plans and four insurance companies.

MAIN OUTCOME MEASURES

The cost of adolescent morbidities includes only direct medical costs for a single year and excludes long-term and indirect costs. The cost of clinical preventive services is calculated at 100% participation levels.

RESULTS

Each year, an estimated $33.5 billion is spent on medical treatment for select adolescent morbidities, approximately $859 per adolescent per year; this is a conservative estimate. The average cost of clinical preventive services per adolescent per year would be approximately $130 in a fee-for-service system, although these are not entirely "new" costs because payers already incur screening costs for some conditions.

CONCLUSION

The cost-effectiveness of clinical interventions for various health risk behaviors among adolescents is unknown. It appears that preventive interventions would have to eliminate 15% of adolescent morbidities overall to break even in economic terms.

The effectiveness of traumatic brain injury rehabilitation: a review

The rehabilitation of traumatic brain injury (TBI) has undergone tremendous development over the past 20 years. A much more aggressive, extended and comprehensive approach is now common and clinically accepted. Multiple new forms and sites of treatment are utilized such as cognitive, behavioural, sub-acute and post-acute rehabilitation programmes. While there has been widespread clinical acceptance of these treatments the appearance of well-designed experimental or quasi-experimental studies actually evaluating the results of such treatment have been, until recently, generally lacking. This review article selects, analyses, and critiques the most salient of recent studies published regarding the overall clinical benefit, and to some extent the cost benefit, of TBI treatment programmes in their multiple forms. A conclusion which is reached following this survey is that while truly randomized controlled studies still have not been achieved, an impressive variety of studies of quasi-experimental design have been completed. The overall conclusion from these studies is that the efficacy (and cost-effectiveness) of TBI rehabilitation is strongly supported.

Preventing restrictive placements through community support services

A policy evaluation of Community Support Services, an assistance group created by the Minnesota Department of Human Services to prevent admission of individuals with developmental disabilities to large state facilities, was presented. The model of these out-reach services was described. Program evaluation data were presented. The possible effect of Community Support Services on admissions to large state facilities, characteristics of individuals served compared to those waiting for these services, cost-benefit issues of operating Community Support Services, and community service providers' satisfaction with these services were discussed. Issues related to the establishment and operation of Community Support Services were also presented.

Federal tax concerns in structuring integrated delivery systems. Part I: Background, tax rules, and exempt systems

As health care providers develop integrated delivery systems, they need to be aware of the Internal Revenue Service's careful scrutiny of these systems. In the first installment of this two-part article, the author reviews the current tax rules for exempt health care providers.

The pathologist and managed care. Integration into the new health care delivery system

As the health care system evolves, managed care plans are expanding rapidly, and pathologists face radical changes in contractual relationships and payment methodology. As a result, entirely new relationships will often need to be negotiated to adapt successfully. The experience of pathologists in areas where there is already high market penetration by managed care plans can be used in strategic planning, learning to gain entry to negotiations, and planning what and how to negotiate. Proper preparation is critical to successful negotiations in our new health care system and requires an understanding of capitation, contracting risks, and opportunities.

Managing opportunities under managed care

Health care reform is driving significant changes in associations between physicians, hospitals, insurers, and patients. This restructuring of the delivery of care will affect the practice of pathology. At these crossroads, practices have to decide to continue without change or to adopt new approaches. Horizontal mergers between pathology practices offer one opportunity under health care reform. Such mergers reflect the general trend toward consolidation of operations as a cost-effective approach to health care delivery. They will require a reevaluation of the manpower needs in pathology. The move to consolidated health plans also suggests that pathology practices should consider vertical integration with other physicians. Restructuring of practices is not the sole answer to addressing health care reform. Practices must become involved in cost-saving strategies in the systems.

Are you ready for the computer-based patient record?

Moving to a computer-based patient record (CPR) involves much more than simply putting computers in clinical offices. To achieve success, a health care organization must rethink and revise traditional workflows and organizational structures. Diverse constituencies within an organization must be targeted to gain buy-in to the process. Other considerations include cost justification and implementation strategies. Current market dynamics suggest that organizations should be contemplating the move to a CPR in order to gain competitive advantage or even to maintain the status quo.

Are the Twin Cities a Stage V marketplace?

The Twin Cities continues to be an outstanding laboratory for discovering what could be the future in many other markets. Over the last year or two it has been the site of massive consolidation among hospitals, physicians and health plans. Even as the entire infrastructure for healthcare financing and delivery has changed, the state has turned in a good performance in comparison with national cost averages. It is hard to beat premium levels that are 25%-35% lower than national benchmarks. And, these have been achieved by the marketplace, not by government. Nevertheless, employers aren't completely satisfied and the sources of discontent are very instructive. The natural course of market change throughout the country is consolidation from many fragmented competing groups down to a handful of large integrated systems. From an employer/consumer perspective, this natural evolution will reduce competition, concentrate power, eliminate choice, weaken the employer's negotiating leverage, discourage innovation, and reduce the responsiveness and sensitivity to customer service needs. Strategies have to be devised by those engaged in integrated health systems development to counter the perception that consolidation is only an attempt to grab market share. True integration should produce demonstrable improvements in the quality, coordination and delivery of care. But, the trick is understanding the employer and consumer perspective on "improvements". The financing and delivery of healthcare has literally been hidden inside a "black box" for as far back as anyone can remember.(ABSTRACT TRUNCATED AT 250 WORDS)

The first 18 months of mental health reform in Kansas

OBJECTIVE

The effects of the first 18 months of implementation of the Kansas Mental Health Reform Act were evaluated. The act designated community mental health centers as gatekeepers for admission to mental health services, created screening and diversion services for state hospital admission, allocated state hospital bed days to each center, and reallocated funds from hospitals to communities.

METHODS

Data from the catchment area in which reform was implemented in the 18-month study period, January 1991 to June 1992, were compared with data for that area before reform, and with data for the two state hospital catchment areas in which reform was not yet implemented.

RESULTS

In the catchment area in which reform was implemented, state hospitalization decreased by about 29 percent, and state mental health funds allocated to the area's mental health centers almost doubled. Service utilization by patients discharged from the state hospital was higher than in the other two catchment areas, and most indicators of living status and vocational or educational involvement reflected improvement.

CONCLUSIONS

The first 18 months of implementation suggest that state-level systems change can decrease state hospitalization and improve the utilization of community services while improving the quality of life for people with severe and persistent mental illness.

EFT (electronic fund transfer) is low on automation priority lists

Electronic funds transfers are taking a back seat to other automated health care transactions. Providers, payers and bankers say the health care industry is focusing on automating claims, eligibility verification and other transactions that logically precede electronic payments.

Core and comprehensive health care services: 4. Economic issues

This article reviews the economic dimensions of the CMA's decision-making framework on core and comprehensive services. The framework was developed in a policy context characterized by three government objectives: reduction, reallocation and reassignment of health care resources. One economic-evaluation tool for the determination of core services is cost-effectiveness analysis. Some of the critical demand-side and supply-side considerations include the perceived value of medical services, the availability of private insurance and the supply of health care providers. The article concludes that shifting services to the private sector should not be viewed as a panacea for reducing the costs and improving the economic efficiency of the health care system, or for increasing patient access to, or the cost-effectiveness of high-quality care.

Core and comprehensive health care services: 3. Ethical issues

The CMA's Working Group on Core and Comprehensive Health Care Services recognizes ethics to be one of the three key factors in determining which services should be publicly funded. The role of ethics is to identify and make explicit the principles and values, at individual and societal levels, that lie behind judgements and positions. Two types of ethical issues are addressed: one deals with the criteria for these services and the other with the process to be followed. The five ethical criteria discussed are fairness, age, lifestyle, the identifiable versus the statistical patient, and futility. An ethical process incorporates appropriate roles for the public physicians and payers (government) and accountability of all participants. A provided checklist for determining a fair process asks such questions as Do potential users of a service, its providers and the public have an adequate say in the decision about whether the service should be publicly funded? Are the reasons for the decision communicated to those affected by it? and is the service being denied to potential users on the basis of unfair discrimination or lifestyle?

MediCaring: comprehensive support services as a Medicare option

MediCaring is a feasibility project that aims to develop an alternative benefit for comprehensive, supportive, home-based care to individuals who are enrolled in Medicare. Will Medicare-eligible consumers be willing to relinquish acute care benefits to finance supportive, home-based care?